MANAGEMENT OF DYSLIPIDEMIA AND THE PREVENTION

OF CARDIOVASCULAR DISEASE
Summary of the “Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: 2003 update.”

ASSESSING RISK AND SCREENING

• A patient’s 10-year risk of coronary artery disease can be estimated using the model provided in the 2003 guidelines
(and also found at http://www.topalbertadoctors.org/guidelines/guidelinespdf.aspx). The three categories of risk and
corresponding target lipid levels are outlined in Table 1.

• Routinely screen men over age 40 and women who are postmenopausal or over age 50.
Note: Although there are no evidence-based recommendations regarding the optimal frequency for
screening, it is reasonable to suggest asymptomatic patients with previously normal lipids be screened
every 5 years after age 40 (men) or 50 (women).

• Screen those with diabetes mellitus; risk factors such as hypertension, smoking or abdominal obesity; a strong
family history of premature cardiovascular disease; manifestations of hyperlipidemia; or evidence of symptomatic
or asymptomatic atherosclerosis.

• Patients of any age may be screened at the discretion of the physician, particularly when lifestyle changes are
indicated.

Table 1 Table 2
Risk Categories and Target Lipid Levels Clinical Identification of the
Metabolic Syndrome*
RISK CATEGORY TARGET LEVEL
LDL-C level Total cholesterol • The clustering of cardiovascular risk factors is recognized as
mmol/L HDL-C ratio being an important health issue.
High <2.5 and <4.0 • The metabolic syndrome is defined in qualitative terms and
(10 year risk of coronary encompasses abdominal obesity, insulin resistance, elevated
artery disease ≥ 20%, or plasma triglyceride levels, low HDL-C levels and high blood
history of diabetes mellitus; pressure.
any atherosclerotic disease Risk factor Defining level
including CAD, PAD, CVD;
Abdominal obesity
chronic kidney disease or
Men Waist circumference > 102cm (40in)
those undergoing long term
dialysis) Women Waist circumference > 88cm (35in)

Moderate <3.5 and <5.0

(10 year risk 11% - 19%) Triglyceride level ≥ 1.7 mmol/L

Low* HDL-C level

<4.5 and <6.0 Men < 1.0 mmol/L
(10 year risk ≤ 10%) Women < 1.3 mmol/L
* In the very low risk stratum, treatment may be deferred if the
10-year estimate of cardiovascular disease is <5% and the LDL-C is Blood pressure ≥ 130/85 mm Hg
<5.0 mmol/L.
Apolipoprotein B can be used as an alternative measurement, Fasting glucose level 6.2 - 7.0 mmol/L
particularly for follow-up of patients treated with statins. An * Criteria: 3 or more of the risk factors. If metabolic syndrome is
optimal level of Apo-B in a patient at high risk is <0.9 g/L, diagnosed, consider increasing calculated risk by one category
moderate risk <1.05 g/L and low risk <1.2 g/L.

Alberta
Drug
For complete guideline: http://www.cmaj.ca/cgi/reprint/169/9/921
Utilization
Program
References available upon request.
www.topalbertadoctors.org
TREATMENT
• Diet: An important focus should be on decreasing energy consumption, in particular by reducing intake of refined
carbohydratesand sugar to achieve and maintain a body mass index of less than 25 kg/m2.

• Exercise: Recommend at least 30 minutes of physical activity (such as walking) per day, most days of the week.

• Medication:
- In people at high risk of coronary artery disease, treatment should be started immediately, concomitant with
diet and therapeutic lifestyle changes.
- For patients at low and moderate risk, pharmacological treatment should be initiated if target lipid levels
(Table 1) are not met after 3 and 6 months respectively, of lifestyle therapy.
Lipid Lowering Medications:
Relative Lipid Lowering Effects Drugs of Choice for Management
Drug LDL-C HDL-C Triglycerides Lipid Profile 1st Choice 2nd Choice

Statins ↓18-55% ↑5-15% ↓7-30% ↑↑ LDL Statin Resin or ezetimibe

Resins ↓15-30% ↑3-5% No change or increase ↑↑ LDL, ↑ TG Statin Fibrate or niacin
Ezetimibe ↓17% ↑1.3% ↓ 6% ↑ LDL, ↓ HDL Fibrate or statin Combination therapy
Fibrates ↓5-20% ↑10-35% ↓20-50% ↑ LDL, ↑↑ TG Fibrate or niacin Combination therapy
Niacin ↓5-25% ↑15-35% ↓20-50% ↓ HDL, ↑ TG Fibrate or niacin Combination therapy

Approximate Equivalent Doses Based on LDL-C Lowering Effect

Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin

5 mg 40 mg 20 mg 20 mg 2.5 mg 10 mg

MONITORING
• Lipid Levels
- It is generally recommended that lipid levels be rechecked 4 - 6 weeks after the commencement of therapy.
- Treatment goal reached: recheck lipid profile every 6 - 12 months depending on the risk profile of the patient.
- Treatment goal not reached: recheck lipid profile 4 - 6 weeks after each dosage change.

• CK and ALT
- Baseline CK and ALT levels (prior to initiating drug therapy) should be obtained.
- It is generally recommended that CK and ALT levels be rechecked 4 to 6 weeks after the commencement
of therapy.
- After 6 weeks, routine monitoring of CK and ALT may not be required in patients receiving statin therapy.
- Patients with unexplained symptoms of weakness, muscle aches, and soreness should have statin therapy
stopped and prompt laboratory investigation of CK and ALT.
- With a CK level between 5 - 10 times the upper limit of normal (ULN), clinical judgement should dictate
whether to continue therapy or not. If CK is elevated greater than 10 times ULN in a symptomatic patient
then the drug should be discontinued.
- For patients receiving a statin with an interacting medication it may be prudent to monitor CK every 6 months
due to the increased risk of myopathy.
- Inform patients of possible side-effects of medications (e.g., myalgia with statins) and when to contact
prescribing doctor.