Makindo Medical Notes

Hyperlipidaemia, characterized by elevated levels of lipids in the blood, is a significant risk factor for cardiovascular disease (CVD). The management of hyperlipidaemia in the UK is guided by recommendations from the National Institute for Health and Care Excellence (NICE) and aims to reduce the risk of cardiovascular events by lowering lipid levels, particularly low-density lipoprotein cholesterol (LDL-C).

Step 1: Initial Assessment and Risk Stratification

• Lipid Profile: Measure total cholesterol, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides.
• Assess Cardiovascular Risk: Use the QRISK3 tool to estimate the 10-year risk of a cardiovascular event in adults aged 40-84 years.
• Identify Secondary Causes: Evaluate for secondary causes of hyperlipidaemia such as hypothyroidism, diabetes, liver or kidney disease, and lifestyle factors (e.g., diet, alcohol consumption).
• Genetic Testing: Consider testing for familial hypercholesterolaemia (FH) if there is a strong family history of premature cardiovascular disease.

Step 2: Lifestyle Interventions

• Dietary Modifications:
  • Encourage a heart-healthy diet rich in fruits, vegetables, whole grains, and oily fish.
  • Advise reducing saturated fat intake and increasing the consumption of unsaturated fats (e.g., olive oil, nuts).
  • Encourage the use of plant sterols and stanols, which can help lower LDL-C levels.
• Physical Activity: Recommend at least 150 minutes of moderate-intensity aerobic exercise per week.
• Weight Management: Aim for a healthy body weight with a BMI of 20-25 kg/m².
• Smoking Cessation: Advise all patients who smoke to quit and provide support for smoking cessation.
• Alcohol Consumption: Advise limiting alcohol intake to within recommended limits.

Step 3: Pharmacological Therapy

• Statins:
  • First-Line Treatment: Offer atorvastatin 20 mg daily to adults with a 10-year CVD risk ≥ 10% (QRISK3 score), or to those with type 2 diabetes, chronic kidney disease (CKD), or familial hypercholesterolaemia (FH).
  • High-Intensity Statins: For those with a history of cardiovascular events, consider atorvastatin 40-80 mg daily.
  • Monitoring: Check lipid profile and liver function tests (LFTs) at baseline, 3 months, and 12 months after starting statin therapy.
• Ezetimibe: Consider adding ezetimibe to statin therapy if LDL-C targets are not met, or use as monotherapy in patients intolerant to statins.
• PCSK9 Inhibitors: For patients with persistently high LDL-C levels despite maximal tolerated statin and ezetimibe therapy, consider PCSK9 inhibitors such as alirocumab or evolocumab.
• Bempedoic Acid: May be considered in patients who require additional LDL-C lowering and are statin intolerant or cannot achieve targets with existing therapy.
• Fibrates: Primarily used to lower triglycerides, consider in patients with very high triglycerides (>5.6 mmol/L) to reduce the risk of pancreatitis.

Step 4: Ongoing Monitoring and Adjustment

• Lipid Monitoring: Reassess lipid levels annually and adjust therapy as needed to achieve and maintain target lipid levels.
• Assess Adherence: Regularly review medication adherence and lifestyle modifications with the patient.
• Side Effects Management: Monitor for potential side effects of lipid-lowering therapy, such as muscle pain with statins, and adjust therapy accordingly.
• Re-Evaluate Cardiovascular Risk: Periodically reassess cardiovascular risk and consider intensifying therapy in those with high or increasing risk.

Step 5: Consideration of Specialist Referral

• Familial Hypercholesterolaemia (FH): Refer patients with suspected or confirmed FH to a lipid specialist for further evaluation and management.
• Complex Cases: Consider referral for patients with persistent hyperlipidaemia despite optimal therapy, or those with multiple cardiovascular risk factors requiring specialized management.
• Intolerance to Multiple Therapies: Refer patients who are intolerant to multiple lipid-lowering therapies for further evaluation and potential alternative treatments.

Target Levels

Conclusion

The management of hyperlipidaemia in the UK involves a combination of lifestyle interventions and pharmacological therapy, guided by cardiovascular risk assessment. Regular monitoring and patient education are crucial for achieving and maintaining optimal lipid levels and reducing the risk of cardiovascular disease. Referral to a specialist may be necessary for complex cases or those with familial hypercholesterolaemia.