Lipids

Secondary prevention

If the person already has evidence of underlying CVD eg previous MI, CVA or has angina or diabetes then that person is at high risk of a CVD event and the hyperlipidaemia should be treated. Do not use the primary prevention charts.

1. Check non fasting lipid profile

If the total cholesterol result is > 7.5 mmol/L then Familial Hypercholesterolaemia (FH) should be considered. Ask about a family history of CVD, get lipid results from other family members if possible, check for physical signs of FH (in particular tendon xanthomata as well as xanthelasmata).

2. Exclude possible secondary causes of hypercholesterolaemia by checking U+E, glucose, LFT, TFT, CK, FBC. The CK is important as it serves as a baseline value to check against prior to statin treatment.

3. If elevated triglycerides repeat the lipid profile in the fasting state. If the triglycerides remain elevated in the fasting sample then treatment of the triglycerides in secondary prevention is recommended (in particular if the HDL cholesterol is < 1 mmol/L). The elevated triglycerides may indicate an underlying pathology eg diabetes or impaired fasting glycaemia, obesity, excessive alcohol intake, Familial Combined Hyperlipideamia (FCH). Consider combination treatment with a statin and fibrate (eg fenofibrate)

4. Treatment should aim to get the cholesterol below 4 mmol/L. Consider the use of a more potent statin eg atorvastatin and possible use of combination therapy (eg statin/ezetimibe or statin/fibrate) to achieve this.

NB Always warn about possible risk of muscle aching with statins and ask patient to stop the drug if this occurs and see a doctor.


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Treat with a statin eg Simvastatin 40mg od

Aim for cholesterol
< 4 mmol/L

?FH

?Secondary Cause