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KEY CONCEPTS
Lipid abnormalities increase the risk for coronary heart disease (CHD) and cerebrovascular morbidity and mortality.
Low-density-lipoprotein cholesterol (LDL-C) is the primary target for lipid-lowering therapy.
Genetic abnormalities and environmental factors are involved in the development of dyslipidemia.
Therapeutic lifestyle change is first-line therapy for any lipoprotein disorder.
If therapeutic lifestyle changes are insufficient, lipid-lowering agents should be chosen based on which lipid is at an undesirable level and the degree to which it is expected to increase the risk of atherosclerotic cardiovascular disase (ASCVD).
Statins are the drugs of choice for dyslipidemia because of potency and cost-effectiveness.
If statin monotherapy is insufficient, patients may be treated with evidence-based combination therapy but should be monitored closely for drug–drug interactions.
Reducing total cholesterol and LDL-C reduces CHD and total mortality.
Lipid-lowering therapies that reduce ASCVD event rates are cost-effective.
Several novel medications including antisense oligonucleotide inhibitors of apoB, microsomal triglyceride transport protein inhibitors, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are now available to treat familial hypercholesterolemia. These medications can be used as an adjunct therapy or in lieu of statin therapy.
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Patient Care Process for the Management of Dyslipidemias
Collect
Patient characteristics (eg, age, race, gender, pregnant)
Patients history: Past medical (eg, HTN), family (eg, early-onset coronary heart disease), social
Current medications (including over-the-counter [OTC]) and prior lipid-lowering medication use
Socioeconomic factors that may affect access to treatment or other aspects of care
Lifestyle assessment: smoking status, exercise, diet, and alcohol intake
Symptoms indicative of ischemic injury (eg, chest pain)
Objective data
Height, weight, BMI, and blood pressure
Lipoprotein concentrations (eg, Total Cholesterol/LDL-C/HDL-C/Triglycerides)
Labs (eg, AST/ALT, UA, TSH, glucose, Serum Creatinine, and BUN at baseline)
Assess
Potential secondary causes (eg, diabetes mellitus, alcohol abuse, renal dysfunction, liver disease, drug-induced, thyroid disorder)
Special needs of specific patient populations such as children/adolescents, pregnant or menopausal women, older adults, ethnic/racial groups, or high-risk conditions/residual risks (eg, patients with rheumatoid arthritis or residual risk despite statin and lifestyle therapy)
Presence of high-risk comorbid conditions: diabetes mellitus, peripheral arterial disease, coronary artery disease, chronic kidney disease, carotid artery stenosis, abdominal aortic aneurysm
Dyslipidemia-related complications (eg, heart disease, stroke)
Ten-year atherosclerotic cardiovascular disease (ASCVD)-risk assessment (only if primary prevention)
Current medications that may contribute to dyslipidemia
LDL-C reduction based on statin benefit group, if applicable (see Table 31-4)
Appropriateness and effectiveness of current lipid-lowering therapy (if any)
Plan*
Tailored therapeutic lifestyle changes (eg, diet and nutrition)
Drug therapy regimen including specific lipid-lowering medication, dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Table 31-4)
Monitoring parameters including efficacy (eg, lipid panel, cardiovascular events), safety (medication-specific adverse effects), and time frame (3-month initial follow-up intervals, followed by 6-12 month intervals once at goal)
Patient education (eg, purpose of treatment, dietary and lifestyle modification, drug therapy)
Self-monitoring of weight, exercise, diet, drug adherence/adverse effects
Referrals to other providers when ...