Dyslipidaemia

Also known as High cholesterol · Hyperlipidaemia · Lipid disorder

GP-fellowship guide to dyslipidaemia: the lipid profile and what to measure including ApoB, non-HDL-C and once-only Lp(a), absolute risk frameworks from the Australian calculator to ESC SCORE2, LDL targets by risk tier with the CTT meta-analysis numbers behind every 1 mmol/L reduction, the statin-intolerance pathway through dechallenge/rechallenge, ezetimibe, bempedoic acid (CLEAR Outcomes) and PCSK9 inhibitors (FOURIER, ODYSSEY OUTCOMES), severe hypertriglyceridaemia above 10 mmol/L and pancreatitis risk, familial hypercholesterolaemia suspicion with Dutch Lipid Clinic Network criteria, quantified lifestyle effects, and monitoring cadence.

high11 referencesUpdated 21 Aug 20266 min readVerification in progress

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Key points

Every 1 mmol/L reduction in LDL cholesterol cuts major vascular events by about 22% (RR 0.78) — and the proportional benefit is at least as large in the lowest-risk people as in the highest, which is why absolute risk, not LDL alone, drives the decision to treat.^[1]^[2]
Statins are the foundation; ezetimibe adds ~18-20% LDL reduction with proven outcome benefit (IMPROVE-IT); bempedoic acid adds ~21% for statin-intolerant patients with proven outcomes (CLEAR Outcomes); PCSK9 inhibitors add ~59% LDL reduction with outcome benefit (FOURIER, ODYSSEY OUTCOMES).^[10]^[5]^[3]^[4]
Familial hypercholesterolaemia: suspect it when LDL is very high or there is premature ASCVD family history — the DLCN score structures the assessment, and cascade screening finds relatives who have not yet had their first event.^[9]
Triglycerides above 10 mmol/L threaten pancreatitis; above 20 mmol/L is often monogenic and frequently causes it — correct secondary causes first, then fibrate/omega-3, and statins remain the ASCVD-prevention cornerstone.^[11]

Overview

Dyslipidaemia is not a disease; it is a risk state. The consultation's job is to translate a lipid panel into a probability, the probability into a treatment threshold, and the treatment into numbers a patient can act on. The CTT meta-analyses supply the arithmetic that makes every conversation concrete: per 1 mmol/L of LDL reduction, major vascular events fall by about a fifth, and this benefit scales down to the lowest-risk people studied.^[1]^[2]

References11Show

[1]Cholesterol Treatment Trialists’ (CTT) Collaboration, Baigent C, Blackwell L, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials Lancet, 2010.PMID 21067804
[2]Cholesterol Treatment Trialists' (CTT) Collaborators, Mihaylova B, Emberson J, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials Lancet, 2012.PMID 22607822
[3]Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease N Engl J Med, 2017.PMID 28304224
[4]Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome N Engl J Med, 2018.PMID 30403574
[5]Nissen SE, Lincoff AM, Brennan D, et al. Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients N Engl J Med, 2023.PMID 36876740
[6]Sever PS, Dahlöf B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial Lancet, 2003.PMID 12686036
[7]Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group N Engl J Med, 1995.PMID 7566020
[8]SCORE2 working group and ESC Cardiovascular risk collaboration SCORE2 risk prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in Europe Eur Heart J, 2021.PMID 34120177
[9]Casula M, Olmastroni E, Pirillo A, et al. Evaluation of the performance of Dutch Lipid Clinic Network score in an Italian FH population: The LIPIGEN study Atherosclerosis, 2018.PMID 30270079
[10]Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes N Engl J Med, 2015.PMID 26039521
[11]Watts GF, Ooi EM, Chan DC Demystifying the management of hypertriglyceridaemia Nat Rev Cardiol, 2013.PMID 24060958