1. Bays HE, Jones PH, Orringer CE, et al. National Lipid Association Annual Summary of Clinical Lipidology 2016. J Clin Lipidol. 2016;10(1 Suppl):S1-S43.
2. Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: part 1—full report. J Clin Lipidol. 2015;9(2):129-69.
3. Jacobson TA, Maki KC, Orringer CE, et al. National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2. J Clin Lipidol. 2015;9(6 Suppl):S1-S122.e1
Table 1
Dyslipidemia in Children and Adolescents (<21 years)
Screening
Targeted screening recommended for children ≥2 years when
One/both parents have hypercholesterolemia or are receiving lipid-lowering medications
Family history of premature ASCVD
Family history unknown
Universal screening beginning at 10 years
Repeat every 5 years
Repeat more frequently in the event of change in ASCVD risk factors
Management
Implement early intervention
Focus on lifestyle changes plus weight management when relevant
Consider lipid-altering pharmacotherapy when risk is moderate to high
Prioritize lipid-altering pharamchotherapy in those with severe genetic dyslipidemias
Statin therapy
Drug of choice for LDL-C lowering in those >10 years
Generally not recommended in those <10 years in absence of risk factors
Based on clinical judgment
Consider after 6-month trial of lifestyle/diet management
All marketed statins except pitavastatin approved by FDA for children with FH and LDL-C >190mg/dL or >160mg/dL plus ≥1 risk factor
Pravastatin indicated to treat hypercholesterolemia in those >8 years, other statins in those >10 years
Additional follow-up/management with non-HDL cholesterol ≥145mg/dL
In children with FH, treatment goal is LDL <130mg/dL or at least 50% reduction in LDL-C
Non-statin therapy
Evaluate cigarette smoking, nutrition, physical activity, family history of ASCVD, medication history, BMI, BP, lipid levels, general blood chemistry, creatinine kinase in those with muscle symptoms
Ezetimibe and colesevelam are FDA-approved to lower LDL-C in youth ≥10 years with FH
Genetic mutations likely present in children <2 years with severely elevated triglycerides
Very high triglyceride levels are risk factor for pancreatitis
Omega-3 fatty acids, fibrates and niacin may be considered when triglyceride levels are ≥500 mg/dL
ASCVD=atherosclerotic cardiovascular disease; HDL-C=high density lipoprotein cholesterol; LDL-C=low density lipoprotein cholesterol; FH=familial hypercholesterolemia
Upper age limits for ASCVD risk scores typically ≤65 years, 75 years, or 80 years depending upon calculator
Total cholesterol and LDL-C levels after 65 years not as strongly associated with predicted ASCVD risk, but may have greater absolute ASCVD risk reduction with statin therapy
Total cholesterol and LDL-C levels poorly correlated to ASCVD after 80 years, with potential inverse relationship to all-cause mortality
Considerations in initiation of statin therapy in patients ≥75 years
Patient-provider discussion of risks vs benefits
Potential drug-drug interactions/polypharmacy
Overall health of patient as applies to life expectancy/QOL
Cost
Patient preference
ASCVD=atherosclerotic cardiovascular disease; HDL-C=high density lipoprotein cholesterol; LDL-C=low density lipoprotein cholesterol; FH=familial hypercholesterolemia
Table 3
Dyslipidemia in Select Populations
Established ASCVD risk factors generally apply to all races/ethnicities
Predictive strength of ASCVD risk factors may differ among racial/ethnic groups
Asians
Increased risk of atherosclerotic coronary disease, compared to Caucasians
Other increased risks include metabolic syndrome, insulin resistance, adiposopathic mixed dyslipidemia, elevated triglycerides, reduced HDL-C levels
Compared with treatment of Caucasians at same statin dose, Asians typically have increased statin levels
African Americans
More favorable lipid profile, compared to Caucasians (ie, higher HDL-C, lower triglycerides)
Highest ASCVD event rates of any US ethnic/racial group
Excess prevalence of hypertension, left ventricular hypertrophy, obesity (women) and type 2 diabetes mellitus
Lp(a) levels may be higher
Hispanics
Increased prevalence of elevated triglyceride/reduced HDL-C, > risk for insulin resistance
Disproportionate increase in triglyceride levels ≥500 mg/dL
“Hispanic Mortality Paradox”
Compared with European Americans, Mexican Americans have lower coronary heart disease mortality
American Indians and Alaskan Natives
American Indians appear to have increased incidence of ASCVD, possibly related to high prevalence of diabetes mellitus, obesity, metabolic syndrome, cigarette smoking, sedentary lifestyle, and low socioeconomic status
Early nutritional/physical activity interventions especially important
Aggressive management of multiple ASCVD risk factors warranted
ASCVD risk tools are not validated for these populations and may underestimate risk
ASCVD=atherosclerotic cardiovascular disease; HDL-C=high density lipoprotein cholesterol; LDL-C=low density lipoprotein cholesterol; Lp(a)=lipoprotein a