How can I effectively assess and manage dyslipidaemia in patients with established atherosclerosis?

To effectively assess and manage dyslipidaemia in patients with established atherosclerosis, a structured approach involving initial assessment, lifestyle modifications, pharmacological treatment, and ongoing monitoring is recommended.

• Initial Lipid Measurement: Measure both total blood cholesterol and high-density lipoprotein (HDL) cholesterol to get the best estimate of cardiovascular disease (CVD) risk ¹. A full lipid profile, which includes total cholesterol, HDL cholesterol, and triglyceride levels, is used to calculate non-HDL cholesterol and LDL cholesterol; a fasting sample is not mandated ¹.

• Exclude Secondary Causes: Before considering specialist review, exclude common secondary causes of dyslipidaemia such as excessive alcohol intake, uncontrolled diabetes, hypothyroidism, liver disease, and nephrotic syndrome ¹.

• Assess for Familial Lipid Disorders: Use clinical findings, a full lipid profile, and family history to judge the likelihood of a familial lipid disorder, rather than relying solely on strict lipid cut-off values ¹. Refer to NICE's guideline on familial hypercholesterolaemia to determine if familial hypercholesterolaemia should be suspected and how to treat it ¹.

• Specialist Referral Criteria: Arrange for specialist assessment if a patient has a total blood cholesterol level over 9.0 mmol per litre or a non-HDL cholesterol level over 7.5 mmol per litre, even without a first-degree family history of premature coronary heart disease ¹. Refer for urgent specialist review if a triglyceride level is over 20 mmol per litre and is not due to excess alcohol intake or poor glycaemic control ¹. For triglyceride levels between 10 mmol and 20 mmol per litre, repeat the measurement with a fasting test within 2 weeks, review for secondary causes, and seek specialist advice if the level remains above 10 mmol per litre ¹.

• Lifestyle Modifications: Encourage and discuss dietary and lifestyle changes ¹. Advise and support all patients who smoke to stop ¹. Offer appropriate interventions for patients who are overweight or obese ¹. Provide advice on physical activity and alcohol consumption ¹. Do not advise patients being treated for secondary prevention to take plant stanols or sterols to prevent CVD ¹.

• Statin Therapy: For patients stable on a low-intensity or medium-intensity statin, discuss the benefits and risks of changing to a high-intensity statin during medication reviews and agree on any necessary changes ¹. High-intensity statins include atorvastatin 20 mg to 80 mg and rosuvastatin 10 mg to 40 mg ². Do not stop statins due to an increase in blood glucose level or HbA1c ¹. Remind patients to restart statins if they stopped due to drug interactions or intercurrent illnesses ¹.

• Other Lipid-Lowering Treatments: If lipid levels are not at target, consider alternative or additional lipid-lowering treatments such as alirocumab, bempedoic acid, evolocumab, and inclisiran ¹.

• Treatments Not Routinely Offered: Do not routinely offer fibrates, nicotinic acid (niacin), or bile acid sequestrants to prevent CVD ¹. Do not offer coenzyme Q10 or vitamin D to increase statin adherence ¹. Omega 3 fatty acid compounds should not be offered to prevent CVD, with the exception of icosapent ethyl when used as described in NICE guidance for patients with raised triglycerides ¹. Do not offer combination treatment of a statin with a bile acid sequestrant, fibrate, nicotinic acid, or omega 3 fatty acid compound (except icosapent ethyl) ¹.

• Blood Tests: Measure liver transaminase and a full lipid profile 2 to 3 months after starting or changing lipid-lowering treatment ¹. Measure liver transaminase at 12 months, and then only if clinically indicated ¹.

• Muscle Symptoms: Advise patients on statins to seek medical advice for unexplained muscle symptoms (pain, tenderness, or weakness) ¹. If this occurs, measure creatine kinase ¹. If creatine kinase is less than 5 times the upper limit of normal, reassure the patient that symptoms are unlikely due to the statin and explore other causes ¹. Do not measure creatine kinase in asymptomatic patients on statins ¹.

• Annual Medication Review: Provide annual medication reviews for patients on lipid-lowering treatment ¹. Offer an annual full lipid profile to inform discussions about secondary prevention of CVD ¹. During the review, discuss and encourage medication adherence, dietary and lifestyle changes, and address other CVD risk factors ¹.