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Clinical guidelines

Guidelines for preventive activities in general practice 8th edition

8.3 Cholesterol and other lipids

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80

Aboriginal and Torres Strait Islander peoples

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80

Adults should have their fasting blood lipids assessed starting at age 45 years, every 5 years (A for males, C for females). Lipid levels should be interpreted in the context of an absolute cardiovascular risk assessment after age 45 years (35 years for Aboriginal and Torres Strait Islander peoples) (B). Aboriginal and Torres Strait Islander adults should have fasting lipid tests performed every 5 years from age 35 years (B).

Table 8.3.1 Cholesterol and lipids: identifying risk
Who is at risk?What should be done?How often?
Low risk
  • Absolute CVD risk <10%
Provide lifestyle advice (I,A). Repeat fasting lipids every
5 years*424
Moderate risk
  • Absolute CVD risk 10–15%
Provide intensive lifestyle advice (II,B).
Consider pharmacotherapy if not reaching target after 6 months (I,A) or if family history of premature CVD, or Aboriginal or Torres Strait Islander, South Asian, Middle Eastern, Maori or Pacific Islander descent (II,C).
Repeat fasting lipids every
2 years310,424,426,427
High risk
  • Absolute cardiovascular risk >15%
  • Patient with the following clinically determined high-risk factors:
  • diabetes and age >60 years
  • diabetes with microalbuminuria (>20 µg/min or UACR >2.5 mg/mmol for males, >3.5 mg/mmol for females)
  • CKD (persistent microalbuminuria or Stage 4 renal failure eGFR <30 mL/min/1.73 m2) or Stage 3a renal failure eGFR <45 mL/min/1.73 m2)
  • previous diagnosis of FH
  • SBP ≥180 mmHg or DBP ≥110 mmHg
  • serum total cholesterol >7.5 mmol/L
  • Aboriginal and Torres Strait Islander peoples aged over 74 years
See Section 8.2: BP
Provide intensive lifestyle advice (II,C).
Commence cholesterol lowering therapy (simultaneously with ntihypertensive unless contraindicated) (II,C-III,D).†
Every 12 months (III,C)424
High risk
  • Existing CVD (previous event, symptomatic CVD)
Lifestyle risk factor counselling
Pharmacotherapy to lower risk (I,A)
Every 12 months (III,C)434

* Lipid blood test results within 5 years can be used to calculate absolute CVD risk every 2 years. Patients with diabetes,
cardiac disease, stroke, hypertension or kidney disease should have their lipids tested every 12 months (III,C).
† D recommendation for clinically determined high risk.

Table 8.3.2 Cholesterol and lipids: preventive interventions
InterventionTechnique
Fasting blood lipids Fasting total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides (TG).435 If lipid levels are abnormal, a second confirmatory sample should be taken on a separate occasion (as levels may vary between tests) before a definitive diagnosis is made.436,437
Screening tests using capillary blood samples produce total cholesterol results that are slightly lower than on venous blood. These may be used, providing they are confirmed with full laboratory testing of venous blood for patients with elevated levels and there is good follow-up.
In adults at low absolute risk of CVD, blood test results within 5 years may be used for review of absolute cardiovascular risk unless there are reasons to the contrary.
Lifestyle modification Lifestyle risk factors should be managed at all risk levels.424,429
All people, regardless of their absolute risk level, should be given dietary advice
Those at low to moderate absolute risk of CVD should be given dietary and other lifestyle advice (see Section 7: Prevention of chronic disease).
Advise to aim for healthy targets:
  • at least 30 minutes of moderate-intensity physical activity on most, if not all, days
  • smoking cessation
  • waist measurement <94 cm for men and <80 cm for women, BMI <25 kg/m2
  • dietary salt restriction ≤4 g/day (65 mmol/day sodium)
  • limit alcohol intake to ≤2 standard drinks per day for men and ≤1 standard drink per day for women.
Pharmacotherapy Lipid lowering therapy for primary prevention should (while balancing risks and benefits) aim towards:424
  • Total cholesterol <4.0 mmol/L
  • HDL-C ≥1.0 mmol/L
  • LDL-C <2.0 mmol/L
  • Non-HDL-C <2.5 mmol/L
  • TG <2.0 mmol/L
Treatment should commence with a statin. If LDL-C levels are not sufficiently reduced on maximally tolerated dose of a statin, add one of ezetimibe, bile acid binding resin or nicotinic acid. These agents may be used as monotherapy if statins cannot be tolerated at all. If TG levels remain elevated, consider use of one of fenofibrate, nicotinic acid or fish oil.

References

  1. Welborn TA, Dhaliwal SS, Bennett SA. Waist–hip ratio is the dominant risk factor predicting cardiovascular death in Australia. Med J Aust 2003;179(11/12):580–5
  2. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. Heart Foundation, 2012
  3. van Dis I, Kromhout D, Geleijnse JM, Boer JM, Verschuren WM. Body mass index and waist circumference predict both 10-year nonfatal and fatal cardiovascular disease risk: study conducted in 20,000 Dutch men and women aged 20–65 years. Eur J Cardiovasc Prev Rehabil 2009;16(6):729–34
  4. Levy PJ, Jackson SA, McCoy TP, Ferrario CM. Clinical characteristics of patients with premature lower extremity atherosclerosis associated with familial early cardiovascular disease and/or cancer. Int Angiol 2006;25(3):304–9
  5. National Heart Foundation of Australia (National Blood Pressure and Vascular Disease Advisory Committee).Guide to management of hypertension 2008. Updated December 2010. Heart Foundation, 2010
  6. National Stroke Foundation. Clinical guidelines for stroke management. Melbourne: NSF, 2010
  7. National Heart Foundation of Australia, The Cardiac Society of Australia and New Zealand. Position statement on lipid management 2005. Heart Lung Circ 2005;14(4):275–91
  8. Bachorik PS, Cloey TA, Finney CA, Lowry DR, Becker DM. Lipoprotein-cholesterol analysis during screening: accuracy and reliability. Ann Intern Med 1991;114(9):741–7
  9. Bradford RH, Bachorik PS, Roberts K, Williams OD, Gotto AM Jr. Blood cholesterol screening in several environments using a portable, dry-chemistry analyzer and fingerstick blood samples. Lipid Research Clinics Cholesterol Screening Study Group. Am J Cardiol 1990;65(1):6–13
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