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Lipid modification - primary and secondary CVD prevention - Management
When should I refer?

  • Refer people with suspected familial hypercholesterolaemia (FH) or other monogenic familial disorders for specialist management.
    • Consider the possibility of FH in adults with elevated cholesterol (total cholesterol typically greater than 7.5 mmol/L), especially when there is a personal or family history of premature coronary heart disease.
      • A diagnosis of FH should be made using the Simon Broome criteria.
      • Confirm the diagnosis by referral to a specialist.
    • Consider a clinical diagnosis of homozygous FH in adults with a low-density lipoprotein cholesterol concentration greater than 13 mmol/L.
    • Note: a CKS topic on familial hypercholesterolaemia is currently under development.
  • Consider seeking specialist advice in managing people with:
    • Severe hyperlipidaemia.
    • Mixed hyperlipidaemia.
    • Serum triglyceride level greater than 10 mmol/L.
    • Resistant hyperlipidaemic states.
    • Secondary hyperlipidaemia (see Clarification for further information).
    • Abnormal pretreatment liver enzymes or creatine kinase activity.
    • Multiple drug intolerance (to lipid-modifying drugs).
    • Lipodystrophy syndromes.
    • Dyslipidaemia related to HIV.
    • People taking complex combinations of drugs with high risk of serious drug interaction with lipid modification therapy.
Clarification / Additional information
  • Secondary hyperlipidaemia
    • Causes of secondary hyperlipidaemia include [Bhatnagar et al, 2008]:
      • Nephrotic syndrome
      • Obstructive jaundice
      • Hypothyroidism
      • Cushing's syndrome
      • Anorexia nervosa
      • Thiazide diuretics
      • Ciclosporin
    • Consider seeking specialist advice regarding management where appropriate.
Basis for recommendation
  • People with severe hyperlipidaemia, suspected familial hypercholesterolaemia (FH) or other monogenic familial disorders:
    • The recommendation to refer these people are based on the expert opinion of the National Institute for Health and Clinical Excellence (NICE) Guidance Development Group. NICE found no good evidence to guide which individuals, with which lipid disorders, should be referred for specialist assessment and management [National Collaborating Centre for Primary Care, 2008a].
    • The criteria for diagnosing suspected familial hypercholesterolaemia are based on those issued by NICE (which include the use of Simon Broome diagnostic criteria) [NICE, 2008b].
  • People with triglyceridaemia greater than 10 mmol/L:
  • Other groups:
    • The recommendation to seek specialist advice for the other patient groups is based on expert opinion [Bhatnagar et al, 2008].

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