Makindo Medical Notes.com

NICE recommend the use of non-high-density lipoprotein (non-HDL) cholesterol rather than low-density lipoprotein (LDL) cholesterol. Non-HDL cholesterol is total cholesterol minus HDL cholesterol. LDL cholesterol is not directly measured but requires a calculation using a fasting sample and for triglyceride levels to be less than 4.5 mmol/litre, whereas the measurement of non-HDL cholesterol does not.

About

• LDL often seen as bad cholesterol and is associated with cardiovascular risk
• HDL seen as good cholesterol
• Tests are usually done after an overnight fast

Summary of recent NICE guidance

• Before starting lipid modification therapy for the primary prevention of CVD, take at least 1 lipid sample to measure a full lipid profile. This should include measurement of total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol, and triglyceride concentrations. A fasting sample is not needed. [NICE 2014]
• Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool.link [NICE 2014]
• Start statin treatment in people with CVD with atorvastatin 80mg. Use a lower dose of atorvastatin if any of the following apply: potential drug interactions high risk of adverse effects, patient preference. [NICE 2014]
• Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment at 3 months of treatment and aim for a greater than 40% reduction in non-HDL cholesterol. If a greater than 40% reduction in non-HDL cholesterol is not achieved: discuss adherence and timing of dose optimise adherence to diet and lifestyle measures consider increasing dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement. [new 2014]
• Exclude possible common secondary causes of dyslipidaemia (such as excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome) before referring for specialist review [NICE 2014]

Familial hypercholesterolaemia

• Consider the possibility of familial hypercholesterolaemia and investigate as described in Familial hypercholesterolaemia if they have: A total cholesterol concentration more than 7.5 mmol/litre and a family history of premature coronary heart disease. [NICE 2014]
• Arrange for specialist assessment of people with a total cholesterol concentration of more than 9.0 mmol/litre or a non-HDL cholesterol concentration of more than 7.5 mmol/litre even in the absence of a first-degree family history of premature coronary heart disease. [NICE 2014]
• Refer for urgent specialist review if a person has a triglyceride concentration of more than 20 mmol/litre that is not a result of excess alcohol or poor glycaemic control. [NICE 2014]

Hypertriglycerideaemia[NICE 2014]

• Those with a triglyceride concentration between 10 and 20 mmol/litre: repeat the triglyceride measurement with a fasting test (after an interval of 5 days, but within 2 weeks) and review for potential secondary causes of hyperlipidaemia and seek specialist advice if the triglyceride concentration remains above 10 mmol/litre. [new 2014]
• In people with a triglyceride concentration between 4.5 and 9.9 mmol/litre: be aware that the CVD risk may be underestimated by risk assessment tools and optimise the management of other CVD risk factors present and seek specialist advice if non-HDL cholesterol concentration is more than 7.5 mmol/litre.

Starting Statins for the prevention of cardiovascular events

• The decision whether to start statin therapy should be made after an informed discussion between the clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle modifications, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy
• Before starting statin treatment perform baseline blood tests and clinical assessment, and treat comorbidities and secondary causes of dyslipidaemia. Include all of the following in the assessment: smoking status, alcohol consumption, blood pressure (see Hypertension, body mass index or other measure of obesity, total cholesterol, non-HDL cholesterol, HDL cholesterol and triglycerides, HbA1c renal function and eGFR, transaminase level (alanine aminotransferase or aspartate aminotransferase), thyroid-stimulating hormone.