Volume 1 Guidelines Lipid Lowering in the prevention of Coronary Heart Disease

LIPID LOWERING IN THE PREVENTION OF CORONARY HEART DISEASE

Hyperlipidaemia

Hyperlipidaemia may be of primary or secondary origin.

Where secondary hyperlipidaemia has a treatable cause (e.g. hypothyroidism, alcohol overuse, diabetes, a therapeutic drug), this is first dealt with. Treatment as for primary hyperlipidaemia is sometimes appropriate.

Primary hyperlipidaemia is classified as follows:

hypercholesterolaemia

combined (mixed) hyperlipidaemia

hypertriglyceridaemia

Primary hyperlipidaemia is treated according to its type and severity, in the context of the patient’s global risk of coronary disease.

A minority of patients have major genetic hyperlipidaemias.

The features of major genetic hyperlipidaemias include:

hyperlipidaemia in the family

early onset of coronary disease in the patient and/or family

physical sings (xanthomas, arcus senilis, etc.)

severity of the hyperlipidaemia

These features are not necessarily all present in individual patients.

Lipid measurements

Cholesterol measurement is an essential part of coronary risk assessment. Without it, many patients with major familial hyperlipidaemia will be missed. Such hyperlipidaemias, for which treatment is mandatory because of their very high risk, are by no means uncommon.

The full lipid profile (cholesterol, triglyceride, LDL cholesterol, HDL cholesterol), measured in the fasted state, is the preferred investigation in all adults.

In risk assessment, measurement of non-fasting serum cholesterol alone is less informative than the full lipid profile; but it will detect the presence of severe, usually genetic, hypercholesterolaemia. A full lipid profile provides a more accurate means of assessing risk.

Since treatment costs far exceed those of initial diagnostic tests, the full profile, by assisting precise targeting of treatment to patients at high risk, adds little to the overall costs of a prevention programme.

Diagnosis of hyperlipidaemia requires a minimum of two consistent analyses.

A full profile should be measured in patients with cardiovascular disease and those with plasma cholesterol >6.5 mmol/l (>250 mg/dl).

A full lipid profile is desirable in those with cholesterol >5.2 mmol/l (>200 mg/dl) plus non-lipid risk factors, and in diabetes and hypertension.

The full profile is mandatory if drug treatment is being considered, but need not be repeated on each occasion when therapy is being monitored.

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