Hyperlipidaemia
🩸 Hyperlipidaemia = abnormal elevation of lipids in the blood (cholesterol and/or triglycerides).
⚠️ It is a major modifiable risk factor for cardiovascular disease (CVD), including MI and stroke.
🎯 NICE guidelines (UK) focus on LDL-C reduction to cut cardiovascular risk, especially in high-risk groups (e.g., diabetes, CKD, familial hypercholesterolaemia).
🔍 Step 1: Initial Assessment & Risk Stratification
- 🧪 Lipid Profile: Total cholesterol, LDL-C, HDL-C, triglycerides.
- 📊 QRISK3 tool: Estimate 10-yr CVD risk in adults 40–84 yrs.
- 🧠 Secondary Causes: Hypothyroidism, diabetes, nephrotic syndrome, liver disease, alcohol excess, obesity.
- 🧬 Familial Hypercholesterolaemia: Suspect if TC > 7.5 mmol/L or FHx of premature CVD → consider Simon Broome criteria / genetic testing.
🥦 Step 2: Lifestyle Interventions (First-line for All)
- 🥗 Diet: ↑ fruit/veg/wholegrains/oily fish. ↓ saturated fat. Use plant sterols/stanols.
- 🏃 Exercise: ≥150 min/week moderate intensity.
- ⚖️ Weight: Aim BMI 20–25 kg/m².
- 🚭 Smoking: Cessation reduces CVD risk more than any drug.
- 🍷 Alcohol: Keep within UK safe limits (≤14 units/week).
💊 Step 3: Pharmacological Therapy
- 🌟 Statins = First-line
- Offer atorvastatin 20 mg OD if QRISK3 ≥10%, T2DM, CKD, or FH.
- Use high-intensity statins (atorvastatin 40–80 mg) if established CVD.
- 🧪 Monitor: Lipids + LFTs baseline, 3m, 12m.
- ➕ Ezetimibe: Add if LDL target not reached, or use alone if statin-intolerant.
- 💉 PCSK9 inhibitors (alirocumab, evolocumab): Severe/refractory hyperlipidaemia despite max therapy.
- 🟢 Bempedoic acid: Alternative for statin-intolerant patients.
- 🧪 Fibrates: Mainly for triglycerides >5.6 mmol/L (prevent pancreatitis).
📈 Step 4: Monitoring & Adjustment
- 📉 Annual lipids to check control and adherence.
- 🔎 Ask about side effects (myalgia with statins, LFT derangements).
- 📊 Reassess CVD risk periodically → consider intensifying therapy if risk rises.
👩⚕️ Step 5: Referral
- 🏠 Familial Hypercholesterolaemia: Refer to lipid clinic.
- ❗ Complex cases: Refractory hyperlipidaemia or statin intolerance → specialist input.
🎯 Target LDL-C Levels (UK context)
| Patient Group | Target LDL-C (mmol/L) | Target LDL-C (mg/dL) | Notes |
|---|
| 🧍 General population | <3.0 | <115 | No major risk factors |
| ⚠️ High risk (QRISK3 ≥10%, DM) | <2.0 | <77 | Start atorvastatin 20 mg |
| ❤️ Very high risk (CVD) | <1.8 | <70 | Secondary prevention |
| 🧬 Familial hypercholesterolaemia | <1.8 | <70 | Genetic or strong family history |
| 🩺 CKD | <2.0 | <77 | eGFR <60 |
| 🍬 Diabetes | <2.0 | <77 | Offer statin regardless of QRISK |
📚 Exam Pearls & Teaching Commentary
💡 Remember: In UK exams, always mention QRISK3 + statin therapy when asked about hyperlipidaemia.
🔑 Familial hypercholesterolaemia = tendon xanthomata + FHx of early MI → refer to lipid clinic.
🧠 Statin side effect buzzwords: “muscle pain”, “LFT derangement”, “new onset diabetes risk (small)”.
⚠️ For OSCEs: show awareness of lifestyle + drug + monitoring, not just prescribing statins.
✅ Conclusion
Management of hyperlipidaemia requires a combined lifestyle + pharmacological approach, guided by cardiovascular risk.
Regular monitoring, patient education, and early referral in suspected familial cases are essential.
In clinical practice, lowering LDL-C translates directly into fewer heart attacks and strokes - making this a cornerstone of preventive medicine. ❤️
