References

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

Table 2

Dyslipidemia in Older Individuals

  • Many sentinel ASCVD outcomes trials excluded older patients (eg, >75 years)
  • 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

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