2011 CPG Management of Dyslipidemia

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II

STATEMENT OF INTENT
This guideline was developed to be a guide for best clinical practice
in the management of dyslipidaemia. It is based on the best
available evidence at the time of development. Adherence to this
guideline does not necessarily lead to the best clinical outcome
in individual patient care. Thus, every health care provider is
responsible for the management of his/her unique patient based
on the clinical presentation and management options available
locally.
REVIEW OF THE GUIDELINE
This guideline was issued in 2011 and will be reviewed in 2016 or
earlier if important new evidence becomes available.
CPG Secretariat
Health Technology Assessment Unit
Medical Development Division
Level 4, Block EI, Parcel E
Government Offices Complex
62590 Putrajaya, Malaysia
Available on the following websites:
http://www.malaysianheart.org
http://www.moh.gov.my
http://www.acadmed.org.my
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SUMMARY
* Total cholesterol (TC) and High Density Cholesterol (HDL-C)
can be measured in the fasting and non fasting states.
Triglycerides (TG) is best measured in a fasting sample. Low
Density Cholesterol (LDL-C) is calculated using the Friedwald's
equation. When TG > 2.3mmol/l, non HDL-C is a better
indicator of total atherogenic burden.
* Dyslipidaemias may be primary or secondary.
* Target of therapy:

*
LDL-C should be the primary target of therapy I,A

*
Non HDL-C should be an alternative primary target of


therapy in patients with TG > 4.5 mmol/l I,A
* Individuals should be risk stratified. I,C (See Table 1, pg 3 and Fig
1A & B, 2A & B, pg 30-31)
* Diabetes is a Coronary Heart Disease (CHD) risk equivalent. I,A
* Target lipids levels will depend upon the individual's global
risk.

- CVD and CHD risk equivalents
LDL-C < 2.6 mmol/L with

(High Risk):
an option of <2.0 mmol/L1,A

- Individuals with a 10 year risk score

of 10 - 20% (Intermediate Risk): LDL-C < 3.4 mmol/L1,A

- Individuals with a 10 year risk score

of < 10% (Low Risk):
LDL-C < 4.1 mmol/lL IIa,C
* Therapeutic Lifestyle Changes (TLC) should be an integral
component of lipid management in all patients.1,B (Table 3, pg
4)
* Individuals with Cardiovascular Disease (CVD) and CHD risk
equivalents should be treated aggressively with drug therapy
from the outset.1,A (Table 1&2, pg 3; Flowcharts I-IV, pg5-8)

*
Statins are the drug of choice for reducing LDL-C.1,A

*
Fibrates and nicotinic acid may be considered for increasing


HDL-C and reducing TG after LDL-C treatment goal has been
achieved.
IIa, B

*
Some individuals may require combination therapy to


achieve lipid target goals.
* Control of glycaemia alone is inadequate in preventing
cardiovascular (CV) events.1,A Concomitant treatment
of dyslipidaemia, hypertension and other metabolic
abnormalities are also important. 1,A
2

Table 1: Major Risk Factors for CVD (other than LDL Cholesterol)
Positive Risk Factors
* Male 45 years of age
* Female 55 years of age or premature menopause
without hormonal replacement therapy
* Hypertension
* Current cigarette smoking
* Family history of myocardial infarction or sudden death
prior to age 55 in a male parent or male first degree
relative and prior to age 65 in a female parent or other
female first degree relative
* HDL-C < 1.0 mmol/L
Negative Risk Factors
* HDL > 1.6 mmol/L
Table 2 : Recommendations for Drug Therapy for Dyslipidaemia
Medications
Grades of
Comments
recommendation/
Levels of evidence
Statins
I, A
Reduction of LDL-C. Increase dose
till target levels are achieved or till
tolerated
Ezetimibe
IIa, B
As an addition to statins if target
LDL-C is not achieved
IIa, C
As monotherapy in statin
intolerant individuals
Fibrates
IIa,B
As monotherapy to increase HDL-C
and/or lower TG in individuals with
mildly raised LDL-C
IIa, B
As part of combination therapy
with statins to increase HDL-C
and lower TG after LDL-C target is
achieved or almost achieved
Nicotinic
IIa,B
As monotherapy to increase HDL-C
Acid
and/or lower TG in individuals with
mildly raised LDL-C
IIa, B
As part of combination therapy
with statins to increase HDL-C
and lower TG after LDL-C target is
achieved or almost achieved
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Table 3 : Recommendations for Therapeutic Lifestyle Changes
Grade of
Comments
Recommendation
Level of Evidence
Diet

Saturated Fats and
I, B
< 7% of calorie intake
Trans-fatty acids
Cholesterol
I,B
< 200 mg /day
Monounsaturated
I,B
Up to 10% of calories
fats
Polyunsaturated fats
I,B
Up to 20% of calories
Dietary Fiber
I,B
20-30 gm/day
Plant stanols
IIb, B
2-3 gm /day
Soy protein
IIb, B
25-50 gm/day
Omega 3 fatty acids
IIa, B
A dose of 3-9 gm/day to lower TG
levels
IIb,B
A dose of 0.75-1 gm/day as
secondary prevention to prevent
sudden death
Total fats
I,B
25-35% of calories
Carbohydrates
I,B
50-60% of calories
Proteins
I,B
About 15% of calories
Anti-oxidants
III,A
Avoid
Weight Reduction
I,C
Assess BMI and waist circumference
Goal:
at each visit.
BMI : 18.5- <23 kg/
I,B
Encourage a weight reduction of
m2
0.5-1kg/week in the overweight
Waist circumference
and obese. The initial goal should
>90 cm in males and
be to reduce body weight to < 10%
< 80 cm in females
of baseline.
Exercise
I,B
Encourage aerobic exercises such as
Goal:
brisk walking, jogging, cycling and
30-45 min per ses-
swimming
sion, at least 5 times
a week
Smoking
I,B
Enquire about smoking status at
Goal:
each visit and encourage complete
Complete cessation
I,C
cessation.
Avoid exposure to environmental
tobacco smoke at work and at home
4

FLOWCHART I: HIGH RISK INDIVIDUALS
LIPID MANAGEMENT OF PERSONS WITH CVD OR CHD RISK
EQUIVALENTS (Adapted and modified from ATPIII)139
In these high risk individuals the recommended LDL-C goal is <
2.61,A mmol/L with an optional goal < 2.0 mmol/L1,A
CVD + CHD
Risk Equivalents
LDL-C < 2.6mmol/L
LDL-C 2.6mmol/L
TLC + Control Other
Risk Factors *
3 months
LDL-C < 2.6mmol/L
LDL-C 2.6mmol/L
TLC - Therapeutic Lifestyle Changes
* Start statins to achieve LDL-C target goal < 2.0 mmol/L1,A
** Consider LDL-C target goal < 2.0 mmol/L in very high risk individuals eg
individuals with ACS, recurrent cardiac events, CHD with T2DM and those
with multiple poorly controlled risk factors1,A
*** Other therapeutic options include increasing the dose of statin, changing to
high intensity statin or combination therapy, intensifying diet therapies, weight
reduction, exercise or adding drugs to lower TG and / or increase HDL-C.
5

FLOWCHART II: INTERMEDIATE RISK INDIVIDUALS
LIPID MANAGEMENT OF PERSONS WITH
MULTIPLE RISK FACTORS,
10-YEAR RISK 10-20 PERCENT
(Adapted and modified from ATPIII)139
The LDL-C goal is < 3.4 mmol/L. I,A Drugs can be considered after
a trial of TLC if the LDL-C level is 3.4 mmol/L.
LDL-C < 3.4mmol/L
LDL-C 3.4mmol/L
Control other Risk
TLC
Factors
Healthy lifestyle*
Reevaluate in 1 year
3 months
LDL-C < 3.4mmol/L
LDL-C 3.4mmol/L
TLC - Therapeutic Lifestyle Changes
The LDL-C goal is < 3.4 mmol/L. Drugs can be considered after a trial of TLC if the
LDL-C level is 3.4 mmol/L.
*
In patients at intermediate risk of CVD, the presence of high risk features such
as a family history of premature CVD, evidence of subclinical atherosclerosis or
high hs-CRP may warrant statin therapy to lower LDL-C target < 2.6 mmol/L.
6

FLOWCHART III: LOW RISK INDIVIDUALS
LIPID MANAGEMENT OF PERSONS WITH MULTIPLE (2+) RISK
FACTORS, 10-YEAR RISK < 10 PERCENT
(Adapted and modified from ATPIII)139
In these individuals the LDL-C goal is < 3.4mmol/L. Drug therapy
can be considered if LDL-C level is 4.1 mmol/L after a trial of
TLC.
LDL-C < 3.4mmol/L
LDL-C 3.4mmol/L
Control other Risk
TLC
Factors
Healthy lifestyle*
Reevaluate in 1 year
3 months
LDL-C < 4.1mmol/L
LDL-C 4.1mmol/L
TLC - Therapeutic Lifestyle Changes
*
Patients at low risk of CVD with at least 2 other risk factors but with evidence of
subclinical atherosclerosis, high hs-CRP or positive family history of premature
CVD should be considered an LDL-C goal of < 2.6 mmol/L.
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FLOWCHART IV: LOW RISK INDIVIDUALS
LIPID MANAGEMENT OF PERSONS WITH 0-1 RISK FACTOR
(Adapted and modified from ATPIII)139
In these individuals, the LDL-C goal is < 4.1 mmol/L. Drug therapy
can be considered if the LDL-C level is 4.9 mmol/L after a
trial of TLC. If LDL-C is 4.1-4.9 mmol/L, drug therapy is optional
depending on clinical judgment.
0-1 Risk Factors
10-yr risk usually
<10%
LDL-C < 4.1mmol/L
LDL-C 4.1mmol/L
Control other Risk
LDL-C < 4.1
TLC
Factors
Healthy lifestyle*
mmol/L
Reevaluate in 1 year
3 months
LDL-C 4.1-< 4.9mmol/L
LDL-C 4.9mmol/L
*
Patients at low risk of CVD with 0 to 1 risk factor but with evidence of subclinical
atherosclerosis should be considered for a lower LDL-C target < 2.6 mmol/L.
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