Diagnosis and Treatment of Dyslipidemia

 Diagnosis and Treatment of Dyslipidemia: A Step-by-Step Approach for Physicians

Dr Neeraj manikath ; claude.ai

Diagnosis Phase

Step 1: Screen Appropriate Patients

- Primary Prevention: Screen adults aged 40-75 years for cardiovascular risk assessment

- Secondary Prevention: Screen all patients with established atherosclerotic cardiovascular disease (ASCVD)

- Special Populations: Screen patients with diabetes, family history of premature ASCVD, family history of hyperlipidemia, or clinical signs of dyslipidemia (e.g., xanthomas)

Step 2: Order Appropriate Laboratory Tests

-Standard Lipid Panel(after 9-12 hour fast):

  - Total cholesterol

  - LDL cholesterol (directly measured or calculated)

  - HDL cholesterol

  - Triglycerides

- **Additional Testing** (if indicated):

  - Apolipoprotein B (ApoB)

  - Lipoprotein(a) [Lp(a)]

  - Non-HDL cholesterol (calculated as total cholesterol minus HDL)

 Step 3: Evaluate for Secondary Causes

- Review medications (e.g., thiazides, beta blockers, estrogens, glucocorticoids)

- Screen for endocrine disorders (e.g., hypothyroidism, diabetes, Cushing's syndrome)

- Assess for renal disease (nephrotic syndrome, chronic kidney disease)

- Consider liver disorders (.!cholestasis, hepatitis)

- Evaluate lifestyle factors (alcohol use, diet high in saturated/trans fats)

 Step 4: Risk Assessment

- Calculate 10.-year ASCVD risk using Pooled Cohort Equations for patients without established. ASCVD

- Consider enhancing risk assessment with:

  - Coronary artery calcium (CAC) score

  - Family history of premature ASCVD

  - High-sensitivity C-reactive protein (hs-CRP)

  - Ankle-brachial index (ABI)

Treatment Phase

 

Step 5: Implement Therapeutic Lifestyle Modifications for All Patients

- Dietary Recommendations with Indian Food Guidance:

  - Reduce saturated fat to <7% of total calories

    - Choose low-fat dairy (skim milk, low-fat curd/yogurt) over full-fat paneer or malai

    - Replace ghee and coconut oil with mustard oil, rice bran oil, or olive oil for cooking

    - Limit fried snacks like samosas, pakoras, and vadas

    - Choose tandoori or grilled preparations over curry-based dishes with heavy cream

  

  - Eliminate trans fats  - Avoid commercial bakery products like puffs, rusk, and packaged namkeens

    - Check labels for "partially hydrogenated oils" in packaged foods

    - Prefer homemade snacks over commercial deep-fried options

  

  - Increase soluble fiber (10-25g daily)

    - Include whole grains like brown rice, whole wheat atta, barley (jau), and jowar

    - Add legumes such as rajma, chole, moong dal, and masoor dal regularly

    - Incorporate oats (daliya) in breakfast porridge or savory preparations

    - Include psyllium husk (isabgol) in buttermilk or sprinkled on curd

    - Ensure daily intake of seasonal fresh fruits with edible peels

  

  - Plant stanols/sterols (2g daily)

    - Include plenty of seasonal vegetables like lauki (bottle gourd), tori (ridge gourd)

    - Add methi (fenugreek) seeds and leaves to diet

    - Use amla (Indian gooseberry) regularly in diet or as juice

    - Include flaxseeds (alsi) in raita or mixed with dry fruits

  

  - Heart-healthy Indian dietary patterns

    - Follow traditional sattvic diet principles emphasizing fresh, seasonal foods

    - Consider regional plant-based diets like South Indian cuisines rich in fermented foods

    - Prepare dal-roti-sabzi as daily staples rather than rich restaurant-style dishes

    - Use traditional spices like turmeric, garlic, ginger, and cinnamon which may have cardioprotective properties)

- Physical Activity:

  - Recommend 150 minutes of moderate-intensity aerobic activity per week

  - Include resistance training 2-3 times weekly

- Weight Management:

  - Target BMI of 18.5-24.9 kg/m²

  - Waist circumference <40 inches (men) or <35 inches (women)

- Other Lifestyle Factors:

  - Smoking cessation

  - Limit alcohol consumption

 Step 6: Determine Treatment Goals Based on Risk Category

Very High Risk (ASCVD or diabetes with target organ damage):

- LDL-C reduction ≥50% from baseline AND

- LDL-C goal <55 mg/dL (<1.4 mmol/L)

High Risk (Multiple risk factors or diabetes without target organ damage):

- LDL-C reduction ≥50% from baseline AND

- LDL-C goal <70 mg/dL (<1.8 mmol/L)

Moderate Risk:

- LDL-C goal <100 mg/dL (<2.6 mmol/L)

Low Risk:

- LDL-C goal <116 mg/dL (<3.0 mmol/L)

 Step 7: Initiate Pharmacotherapy When Indicated

Statins (First-line therapy):

- High-intensity (lowers LDL-C by ≥50%): atorvastatin 40-80mg, rosuvastatin 20-40mg

- Moderate-intensity (lowers LDL-C by 30-49%): atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin 20-40mg, pravastatin 40-80mg

- Low-intensity(lowers LDL-C by <30%): simvastatin 10mg, pravastatin 10-20mg

Non-statin Therapies (Add if inadequate response to statins):

- Ezetimibe: 10mg daily

- PCSK9 Inhibitors: evolocumab or alirocumab (for very high-risk patients not at goal)

- Bempedoic Acid: 180mg daily

- Bile Acid Sequestrants: cholestyramine, colestipol, colesevelam

- Icosapent Ethyl: for hypertriglyceridemia in ASCVD patients

Triglyceride-Lowering Therapies(for TG >500 mg/dL):

- Fibrates (fenofibrate, gemfibrozil)

- Omega-3 fatty acids (2-4g daily)

- Niacin (extended-release)

 Step 8: Monitor Response and Adjust Therapy

- Check lipid levels 4-12 weeks after initiating or changing therapy

- Assess liver function tests at baseline, 4-12 weeks after starting therapy, then annually

- Monitor for muscle symptoms and check CK if symptomatic

- Adjust therapy based on response and tolerability

 Step 9: Address Statin Intolerance

- Attempt statin rechallenge (lower dose, alternate-day dosing, or different statin)

- Consider coenzyme Q10 supplementation (though evidence is limited)

- Progress to non-statin therapies if statin intolerance persists

 Step 10: Special Considerations

- Elderly: Individualize therapy based on comorbidities and life expectancy

- Pregnancy: Discontinue statins before and during pregnancy

- Chronic Kidney Disease: Adjust medication doses as needed

- HIV Patients: Consider drug interactions with antiretroviral therapy

 References

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2. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111-188.

3. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(11):e596-e646.

4. Virani SS, Morris PB, Agarwala A, et al. 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia. J Am Coll Cardiol. 2021;78(9):960-993.

5. Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk. J Am Coll Cardiol. 2022;80(14):1366-1418.

6. Rosenson RS, Baker SK, Jacobson TA, et al. An assessment by the Statin Muscle Safety Task Force: 2014 update. J Clin Lipidol. 2014;8(3 Suppl):S58-S71.