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Content Update

February 1, 2019

New Cholesterol Management Guidelines Emphasize Practicality and Clinical Judgment: The 2018 AHA/ACC Guideline on the Management of Blood Cholesterol reinforces the need to encourage lifestyle modification to prevent atherosclerotic cardiovascular disease (ASCVD) and to use high-potency statins in patients at high risk of major adverse cardiovascular (CV) events. LDL-C targets have been re-introduced into the guidelines. Combination therapy using a statin plus either ezetimibe or a PCSK-9 inhibitor should be considered in very high-risk patients who do not reach their LDL-C target. Clinicians and patients can now consider a wider array of risk-enhancing factors when making treatment decisions. Most patients no longer need to fast before obtaining a lipid profile.

PATIENT CARE PROCESS

Patient Care Process for the Management of Dyslipidemias

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Collect

  • Patient characteristics (e.g., age, race, gender, pregnant)

  • Patients history: Past medical (e.g., HTN), family (e.g., early-onset CHD), social

  • Current medications (including 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 and diet, alcohol intake

  • Symptoms indicative of ischemic injury (e.g., chest pain)

  • Objective data

    • Height, weight, BMI, and blood pressure

    • Lipoprotein concentrations (e.g., total cholesterol/LDL-C/HDL-C/triglycerides)

    • Labs (e.g., AST/ALT, UA, TSH, glucose, serum creatinine, and BUN at baseline)

Assess

  • Rule out secondary causes (e.g., diabetes mellitus, alcohol abuse, renal dysfunction, liver disease, drug-induced, thyroid disorder)

  • Assess groups with special considerations such as children/adolescents, pregnant or menopausal women, older adults, ethnic/racial groups, or high-risk conditions/residual risks (e.g., patients with rheumatoid arthritis or residual risk despite statin and lifestyle therapy).

  • Presence of high-risk, co-morbid conditions: Diabetes mellitus, peripheral arterial disease, coronary artery disease, chronic kidney disease, carotid artery stenosis, abdominal aortic aneurysm

  • Dyslipidemia-related complications (e.g., heart disease, stroke)

  • 10-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 to patient (see Table 21-7)

  • Appropriateness and effectiveness of current lipid-lowering therapy (if any)

Plan*

  • Tailored therapeutic lifestyle changes (e.g., diet and nutrition; see Table 21-10)

  • Drug therapy regimen including specific lipid-lowering medication, dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Table 21-13)

  • Monitoring parameters including efficacy (e.g., lipid panel, cardiovascular events), safety (medication-specific adverse effects), and timeframe (3-month initial follow-up intervals, followed by 6-12 month intervals once at goal

  • Patient education (e.g., purpose of treatment, dietary and lifestyle modification, drug therapy)

  • Self-monitoring of weight, exercise, diet, drug adherence/adverse effects

  • Referrals to other providers when appropriate for coordination of care (e.g., physician, dietician)

Implement*

  • Provide patient education regarding all elements of treatment plan, including self-management training

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up and timeframe to achieve goals of therapy

Follow-up: Monitor and Evaluate

  • Determine response to lipid-lowering therapy and weight-loss goals

  • Presence of medication-induced adverse effects (e.g., elevated transaminases or myalgia on statins)

  • Occurrence of CV events

  • Patient adherence ...

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