Dyslipidemia: Clinical sciences

Dyslipidemia, or high lipid levels in the blood, is a condition associated with an increased risk of atherosclerotic cardiovascular disease, or ASCVD for short, which includes myocardial infarction, stroke, and peripheral arterial disease. Because of this, the management of individuals with dyslipidemia is usually more aggressive if your patient has a history of ASCVD.

Dyslipidemia is usually asymptomatic, but can be found on labs like a lipid panel. Next, consider whether they have severe dyslipidemia or diabetes. If they do not have any of these conditions, management is based on their 10 year risk of developing ASCVD.

The first step when evaluating a patient for dyslipidemia is performing a focused history and physical, and sending labs for a lipid panel. The history will help identify risk factors for ASCVD, like smoking, diabetes, or hypertension. ASCVD is also more common as you get older, and there’s an increased risk in biological males and people with previously diagnosed ASCVD.

Now, the physical exam is usually unremarkable in patients with dyslipidemia. They may have elevated blood pressure, and if the cholesterol level is very high, you might see xanthomas, which are cholesterol deposits in the skin, classically around the eyes.

Next, let’s discuss the lipid panel, which is the best screening test for dyslipidemia. It includes the total cholesterol, or TC for short, high-density lipoprotein cholesterol, or HDL, low-density lipoprotein cholesterol, or LDL-C, and triglycerides, or TG. The LDL-C value is important for determining which patients need medications for dyslipidemia. You’ll also use TC and HDL values to help predict the 10-year ASCVD risk, which impacts treatment decisions for dyslipidemia.

Alright, now that you have the history and lipid panel results, let’s move on to management. Treatment for dyslipidemia varies based on whether the patient has ASCVD. Patients with ASCVD and dyslipidemia should be started on a high-intensity statin, which inhibits HMG-CoA reductase in the liver and slows down cholesterol production, and aids in plaque stabilization, which helps keep previously formed cholesterol plaques from breaking off and causing arterial occlusion.

After 4 to 12 weeks on a high-intensity statin, you should recheck the patient’s lipid panel. If their LDL-C level is under 70 mg/dL, they should continue the current statin medication. However, if their LDL-C level is equal to or above 70 mg/dL, you should examine their adherence to the treatment plan. Find out when they are taking their medication or if they missed doses due to forgetting or having adverse effects.

If they are taking their medications, but the LDL-C level is not dropping, you might want to adjust their medications. You have two options here: either maximize the dose of the statin that they are already on, or change them to a different statin. After this, the lipid panel should be rechecked in another 4 to 12 weeks.

If the LDL-C is less than 70 mg/dL, they can continue on their current treatment regimen. However, if the LDL-C still remains 70 mg/dL or greater, you can add a cholesterol absorption inhibitor, like ezetimibe. Once again, after 4 to 12 weeks, recheck the LDL-C. If it remains 70 mg/dL or higher, you can add a PCSK-9 inhibitor like alirocumab or evolocumab. These medications work by inhibiting the enzyme PCSK-9 which indirectly increases uptake of LDL in the liver. Finally, you should discuss lifestyle modifications, like sticking to a healthy diet, smoking cessation, and increasing aerobic exercise.