When should I consider referring a patient with hyperlipidaemia to a specialist?

Consider referring a patient with hyperlipidaemia to a specialist in the following situations:

• If the total blood cholesterol level is more than 9.0 mmol/L or the non-high-density lipoprotein (non-HDL) cholesterol level is more than 7.5 mmol/L, even without a first-degree family history of premature coronary heart disease, arrange for specialist assessment.
• If the triglyceride concentration is more than 20 mmol/L and this is not due to excess alcohol intake or poor glycaemic control, refer for urgent specialist review.
• If the triglyceride concentration is between 10 and 20 mmol/L, repeat the triglyceride measurement with a fasting test (after 5 days but within 2 weeks), review for secondary causes of hyperlipidaemia, and seek specialist advice if the triglyceride concentration remains above 10 mmol/L.
• If the triglyceride concentration is between 4.5 and 9.9 mmol/L and the non-HDL cholesterol concentration is more than 7.5 mmol/L, seek specialist advice.
• If familial hypercholesterolaemia (FH) is suspected based on clinical findings, family history, or lipid profile (e.g., total cholesterol >7.5 mmol/L with premature coronary heart disease in family), refer to an FH specialist service for further assessment and possible DNA testing.
• Refer people with FH who are at very high risk of coronary events (e.g., established coronary heart disease, family history of premature coronary heart disease, or two or more other cardiovascular risk factors) to a specialist with expertise in FH.
• Offer urgent referral to a cardiology specialist for people with FH who have symptoms or signs of possible coronary heart disease that are not immediately life-threatening.
• Refer all adults and children with homozygous FH to a specialist centre for evaluation.

Before referral, exclude secondary causes of hyperlipidaemia such as excess alcohol intake, uncontrolled diabetes, hypothyroidism, liver disease, and nephrotic syndrome.

These recommendations are based on UK NICE guidelines and Clinical Knowledge Summaries (CKS) on lipid modification, familial hypercholesterolaemia, and cardiovascular disease prevention ¹,²,³,⁴,⁵.