Approach to the Patient with Dyslipidemia.

Abstract

In evaluating a patient with dyslipidemia the initial step is to decide which particular lipid/lipoprotein abnormalities need to be evaluated and whether they need treatment. These disorders can be divided into elevations of LDL-C, triglycerides, non-HDL-C, and Lp(a) and decreases in plasma HDL-C. Frequently a patient can have multiple lipid/lipoprotein abnormalities. The next step is to rule out secondary causes that could account for the abnormal lipid/lipoprotein levels. These secondary causes can be due to diet, various disease states, or drug therapy. One should be suspicious of a secondary cause if a patient suddenly develops a lipid/lipoprotein abnormality or the lipid/lipoprotein profile suddenly worsens. Next one should consider the possibility of a genetic disorder and therefore ask whether relatives have either premature cardiovascular disease, lipid disorders, or are receiving lipid lowering medications. If the triglyceride levels are markedly elevated one should inquire about a family history of pancreatitis. When the lipid/lipoprotein abnormality is markedly abnormal or begins at a young age, the likelihood of a genetic disorder is increased and the family history assumes even greater importance. In most circumstances a routine lipid panel consisting of plasma triglycerides, total cholesterol, HDL-C, and calculated LDL-C and non-HDL-C provides sufficient information to appropriately decide on who to treat and the best treatment approach. However, it should be recognized that there are certain situations where more sophisticated and detailed laboratory studies can be helpful. The purpose of treating lipid disorders is to prevent the development of other diseases, particularly cardiovascular disease. Thus, the decision to treat should be based on the risk of the hyperlipidemia leading to those medical problems. Several guidelines have been published that discuss in detail cardiovascular risk assessment and provide recommendations on treatment strategies. Additionally, calculators are available on-line to determine an individual patient’s risk of developing cardiovascular disease in the next 10 years or their lifetime risk. In the prevention of cardiovascular disease, the main priority is to lower the LDL-C levels. Reductions in other apolipoprotein B containing lipoproteins may be instituted if LDL-C levels are at goal. Depending on the specific guideline the percent reduction in LDL-C and/or the goal LDL-C will vary depending upon the patient profile. When LDL-C levels are at goal but triglyceride and non-HDL-C levels are still elevated a recent study suggests further treatment with icosapent ethyl may be beneficial. Whether decreasing Lp(a) is beneficial in preventing cardiovascular disease is uncertain and further studies are in progress. Lifestyle changes are the initial treatment but in most patients’ drug therapy will be necessary. For complete coverage of all related areas of Endocrinology, please visit our on-line FREE web-text, WWW.ENDOTEXT.ORG.