Brandon Geer, APRN
Current cholesterol and hyperlipidemia management can have a significant effect on the body. If not properly managed or maintained, high cholesterol or hyperlipidemia can cause an increase of fat deposits in arteries, and can increase the risk of arterial blockages causing conditions such as strokes or cardiac ischemia (American Heart Association, 2020). Lifestyle management and a healthy diet are generally, the best ways to prevent this from happening. This, along with curbing smoking or hypertension can also greatly improve cardiovascular health. In some cases, however, medication may be required to assist in mitigating cardiac risk, and preventing more sinister outcomes.
Screening Guidelines for cholesterol and hyperlipidemia management
The U.S. Preventive Services Task Force (USPSTF) also has several recommendations in regards to screening for lipid disorders:
For children and adolescents under the age of 20
There is insufficient evidence to suggest screening, however there is some short-term data suggesting pharmacotherapy such as statin administration can lead to substantial reduction in cholesterol levels. This is short-term data, however, and long-term risks have not been identified. The overall recommendation by the USPSTF is to use clinical judgment in determining whether screening would be beneficial in persons under the age of 20, and should base their decision on their own knowledge and experience, expert opinion, the patient’s health history, and the values and preference of the patient and their families (USPSTF, 2016).
For patients between the age of 20 years of age and older
The current recommendation is to obtain a non-fasting lipid profile if they are not on lipid-lowering therapy. If this lipid panel reveals a triglyceride level greater than 400 mg/dl, a repeat lipid panel should be ordered, as two elevated readings are generally needed to begin statin therapy (American Family Physician, 2019).
For patients not on statin therapy
The Veterans Affairs Department recommends not screening more frequently than every 10 years (Arnold & Downs, 2021). Neither the ACC nor AHA have any recommendations on this.
For patients on statin therapy
The ACC/AHA recommends re-measuring lipid panels 4-12 weeks after statin initiation, statin dose adjustment, or also significant lifestyle changes. Lipid panel monitoring is then repeated every 3-12 months as needed.
Regardless of the age or general risk factors, every patient should be encouraged to adhere to a heart-healthy diet, and to uphold healthy lifestyle choices to mitigate ASCVD risk.
Risk Assessment
All patients deemed to be at risk of Hyperlipidemia should also have their Atherosclerotic Cardiovascular Disease (ASCVD) risk assessed. Likewise, this is a measure of a patient’s risk of having a first Myocardial Infarction within the next 10 years. This is also categorized by low risk (<5%), borderline risk (5-7.4%), intermediate risk (7.5-19.9%), and high risk (20% or greater).
There are also many online calculators available for this risk scoring. I generally recommend the one by the American College of Cardiology.
Dietary Interventions for cholesterol and hyperlipidemia management
When educating on lifestyle and dietary changes, there are many things to consider. Dietary-wise, the best intervention in lowering cholesterol is the reduction of saturated and also Trans fats. The American Heart Association recommends the limiting of saturated fats to less than 6% of one’s daily caloric intake, as well as an overall minimization of Trans fat (American Heart Association, 2020). In order to do this, red meat and whole milk dairy products should be avoided or at least limited. Whole milk dairy products should also be replaced with skim milk or low-fat/fat-free dairy products.
Cooking should be performed with healthy oils such as vegetable oil, and should limit the inclusion of fried foods. This “heart healthy” diet often emphasizes the usage of foods such as fruits, vegetables, whole grains, poultry, fish, nuts, and non-tropical vegetable oils. This also limits processed foods, or foods and beverages high in sodium or sugar.
There are several diets that fit along these dietary guidelines, including the DASH (Dietary Approaches to Stop Hypertension) Diet, A Mediterranean Diet, The Therapeutic Lifestyle Changes (TLC) Diet, or also the Flexitarian Diet. These are all also helpful for cholesterol and hyperlipidemia management
- DASH DIET: For More Information: https://www.nhlbi.nih.gov/education/dash-eating-plan
- Mediterranean Diet: For More Information: https://www.healthline.com/nutrition/mediterranean-diet-meal-plan
- TLC Diet: For More Information: https://www.nhlbi.nih.gov/files/docs/public/heart/chol_tlc.pdf
- Flexitarian Diet: For More Information: https://www.healthline.com/nutrition/flexitarian-diet-guide
Lifestyle Interventions
Lifestyle changes are critical for cholesterol and hyperlipidemia management. The most obvious lifestyle changes include cessation of smoking, eating healthier as described above, and also burning calories. The first step is knowing how many calories one needs to maintain their weight. Likewise, most food labels and Federal Drug Administration (FDA) recommendations are based on a 2,000 calorie per day diet. Depending on a person’s lifestyle, age, gender, and also activities, this caloric requirement can be higher or lower. Overall, the American Heart Association (2020) recommends burning at least as many calories as taken in. A weight loss of between 5-10% can greatly improve overall cholesterol.
Exercise, or at least increased physical activity is highly recommended. This should of course start with gradually increasing the amount and intensity of physical activity, and not suddenly trying to run a marathon. The general recommendations are to aim for at least 150 minutes of moderate physical activity, or 75 minutes of vigorous activity each week. This can also include a combination of these (American Heart Association, 2020). It’s not always easy to schedule this activity in today’s busy lifestyle, but adding short bursts of activity into the daily routine can help. This can include such changes as parking further away from destinations, taking stairs instead of the elevator, or taking walking breaks throughout the day instead of sitting at a desk or on the couch.
Pharmacological Interventions for hyperlipiemia
The ACC/AHA 2019 updates recommend the following:
For patients between 20 to 75 years of age, an LDL level greater than 190mg/dL should trigger the initiation of maximally tolerated statin therapy. The goal is to reduce LDL levels by 50% or greater.
- If noted to have high ASCVD risk, and who have LDL levels of >70mg/dL it is also reasonable to add ezetimibe therapy.
- If high-intensity statin therapy is not tolerated, reduce to moderate-intensity therapy, and also attempt to reduce LDL levels by 30-49%.
For patients between 20 to 75 years of age, an LDL level of 70 to 189mg/dL with intermediate ASCVD risk, moderate-intensity statin therapy should also be initiated. The goal in this group is to minimize LDL levels by at least 30%.
For patients between 40-75 years of age with Diabetes, moderate-intensity statin therapy should be initiated, regardless of measured ASCVD risk score.
-If these individuals are measured to be high risk on ASCVD scoring, it is reasonable to add ezetimibe (Zetia) to their moderate-intensity statin therapy, in order to increase LDL lowering properties.
For patients in Intermediate-Risk that do not tolerate high-intensity statins, it is reasonable to consider adding ezetimibe (Zetia) to their moderate-intensity statin therapy, in order to increase LDL lowering properties.
For patients between 40-75 years of age, who have a baseline LDL of greater than 220mg/dL, and who achieve an initial LDL reduction to greater than 130mg/dL with maximally tolerate statin and ezetimibe therapy, it is reasonable to consider adding
Statin Options for hyperlipidemia
| High Intensity | Moderate Intensity | Low Intensity |
| Atorvastatin 40-80mg | Atorvastatin 10-20mg | Fluvastatin 20-40mg |
| Rosuvastatin 20-40mg | Fluvastatin 80mg | Lovasatin 20mg |
| Lovastatin 40-80mg | Pravastatin 10mg | |
| Pitavastatin 1-4mg | Simvastatin | |
| Pravastatin 40-80mg | ||
| Rosuvastatin 5-10mg | ||
| Simvastatin 20-40mg |
References
American College of Cardiology. ASCVD Risk Estimator Plus. Retrieved February 25, 2022 from https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
American Family Physician. (2009). Cholesterol management: ACC/AHA updates guideline. American Family Physician, 99(9). 589-591. https://www.aafp.org/afp/2019/0501/p589.html
Arnett, D. K., Blumenthal, R. S., Albert, M. A., Buroker, A. B., Goldberger, Z. D., Hahn, E. J., Himmelfarb, C. D., Khera, A., Lloyd-Jones, D., McEvoy, J. W., Michos, E. D., Miedema, M. D., Muñoz, D., Smith, S. C., Virani, S. S., Williams, K. A., Yeboah, J., Ziaeian, B. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: Executive summary. Circulation, 140, 563-595. https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000677
Arnold, M. J., & Downs, J. R. (2021). Key recommendations on managing dyslipidemia for cardiovascular risk reduction: Stopping where the evidence does. American Family Physician, 103(8), 455-458. https://www.aafp.org/afp/2021/0415/p455.html
American Heart Association. (2020). Prevention and treatment of high cholesterol (Hyperlipidemia). American Heart Association. Retrieved from: https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia
Reiter-Brennan ,C., Osei, A. D., Uddin, S. M. I., Orimoloye, O. A., Obisesan, O. H., Mirbolouk, M., Blaha, M. J., & Dzaye, O. (2020). ACC/AHA lipid guidelines: Personalized care to prevent cardiovascular disease. Cleveland Clinic Journal of Medicine, 87(4), 231-239. DOI: https://doi.org/10.3949/ccjm.87a.19078
U.S. Preventive Services Task Force. (2016). Lipid screening disorders in children and adolescents. JAMA. Retrieved from: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lipid-disorders-in-children-screening
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