MOH CLINICAL PRACTICE GUIDELINES 2/2016

1 1 MOH CLINICAL PRACTICE GUIDELINES 2/2016 LIPIDSEXECUTIVE SUMMARYC hapter of Family Medicine PhysiciansAcademy of Medicine, SingaporeCollege of Family Physicians, SingaporeSingapore Cardiac SocietyChapter of EndocrinologistsChapter of General PhysiciansCollege of Physicians, SingaporeEndocrine & Metabolic Society of SingaporeContents PageIntroduction and how to use this document 2 Lipids in coronary artery disease 4 Classification & screening for dyslipidemia 4 Risk assessment of CAD in dyslipidemia 6 Target lipid levels 8 Lifestyle changes 10 Drug therapy 12 Special considerations 16 Quality indicators for lipid management 19 Levels of evidence and grades of recommendation 262 EXECUTIVE SUMMARY OF RECOMMENDATIONS IntroductionThis is the executive summary of the MOH CLINICAL PRACTICE GUIDELINES (CPG) on Lipids.

2 It is intended to be used with reference to the full version of the CPG which is freely available on the MOH website at this link: disease, especially coronary artery disease (CAD) is a very important health problem in Singapore today, and is second only to cancer as a leading cause of mortality in this country. Dyslipidemia is one of the most important modifiable risk factors for CAD. Target audienceThese GUIDELINES are developed for all healthcare professionals, in particular, primary care physicians, as an evidence-based resource to provide up-to date information and guidance on the diagnosis, and management of dyslipidemia. How to use this documentAll recommendations made in the CPG are summarised in this document.

3 Please note the following:a. The page numbers of the full CPG document where each recommendation is explained are provided. b. Each recommendation has a corresponding Grade of Recommendation and Level of Evidence (refer to back cover page for details). Key recommendations are highlighted in light Commonly used abbreviationsThe following is a list of abbreviations commonly used in this set of GUIDELINES (arranged in alphabetical order), and a description of what they represent: ALT Alanine transaminase ApoA1 Apolipoprotein A1 ApoB Apolipoprotein B AST Aspartate transaminase BNP B-type natriuretic peptide CAD Coronary artery disease DHA Docosahexaenoic acid eGFR Estimated glomerular filtration route EPA Eicosapentaenoic acide HDL High density lipoprotein HMG-CoA 3-hydroxy-3-methyl-glutaryl-CoA IDL Intermediate density lipoprotein LDL Low density lipoprotein Lp(a) Lipoprotein(a) NT-proBNP N-terminal prohormone of brain natriuretic peptide TC Total cholesterol TG Triglyceride VLDL Very low density lipoprotein FH Familial Hypercholesterolemia4 Lipids in coronary artery diseaseBlood lipid levels are important risk factors for CAD.

4 The relationship between CAD and total cholesterol levels is continuous and curvilinear. In these GUIDELINES , total cholesterol (TC), LDL cholesterol, HDL cholesterol and TG are used for risk stratification (Chapter 5) and for making decisions on treatment (Chapter 7). Classification & screening for dyslipidemia The screening for dyslipidemia should be carried out in accordance with MOH CPG 1/2011 Screening for cardiovascular disease and risk factors , where risk factors for CAD include:a. Diabetes mellitus;b. Multiple CAD risk factors ( tobacco use, hypertension, impaired fasting glycaemia or impaired glucose tolerance);c. A family history of cardiovascular disease before age 50 years in male relatives or before age 60 years in female relatives;d.

5 A family history suggestive of familial hyperlipidemia. Dyslipidemia can be classified as hypercholesterolemia, mixed (combined) dyslipidemia, hypertriglyceridemia, and severe hypertriglyceridemia (Table 1).Table 1 Classification of dyslipidemia (CPG pg. 22)* LDL cholesterol (mmol/L) = TC - (HDL cholesterol + )Secondary dyslipidemia may occur in the various conditions and should be excluded in any patient presenting with dyslipidemia (Table 2). Types of DyslipidemiaIncreased ConcentrationLipoproteinSerum LipidHypercholesterolemia LDL TC & LDL cholesterol*Mixed (Combined)Dyslipidemia LDL & VLDL TC, LDL cholesterol* & TG ( [150-99mg/dL])Hypertriglyceridemia VLDLTG ( [150-99mg/dL])SevereHypertriglyceridemia ChylomicronsTG ( [400mg/dL])5 Table 2 Common causes of secondary dyslipidemia (CPG pg.)

6 23)DisorderLipid abnormalitiesDiabetes mellitus TG and HDL cholesterolChronic kidney disease TGNephrotic syndrome TCHypothyroidism TCAlcohol abuse TGCholestasis TCPregnancy TGDrugs diuretics, beta-blockers, oral contraceptives, corticosteroids, retinoids, anabolic steroids, progestins related to testosterone TG and / or TC, HDL cholesterolWho should be screened for lipids disorders?B Clinicians should routinely screen men and women aged 40 years and older for lipid disorders. (Grade B, Level 2++, CPG pg. 19)GPP Clinicians can routinely screen younger adults (men and women aged 18 and older) for lipid disorders if they have other risk factors for CAD. (CPG pg. 19)GPP For individuals with screening results within the LDL cholesterol targetlevels (see Table 3 pg.

7 8) and have low TG levels, screening should be repeated at 3 yearly intervals unless they are at very high or high risk of CAD, in which case screening should be repeated annually. (CPG pg. 20)What should a lipid profile include?D A lipid profile should include TC, TG, LDL cholesterol and HDL cholesterol. These should be obtained after 10 to 12 hours of fasting, which is required for the measurement of TG. (Grade D, Level 4, CPG pg. 21)D Routine ApoB and ApoA1 determination is not recommended. (Grade D, Level 4, CPG pg. 17) 6C Lp(a) determination is not recommended for routine cardiovascular disease screening. However, further to a global cardiovascular risk assessment, Lp(a) measurements may be useful in individuals with strong family history of premature cardiovascular disease.

8 (Grade C, Level 2+, CPG pg. 18)Recent illnesses may affect lipid levels and lipid tests may need to be deferred or repeated in these circumstances GPP Physicians and patients may wish to defer lipid tests for at least 2 weeksafter a febrile illness as blood lipids may be abnormal after an acute illness such as an infection. (CPG pg. 20)D Patients who suffer myocardial infarction may have depressed cholesterol levelsthat do not require treatment. These patients should have their blood lipids repeated 3 months after a myocardial infarction. (Grade D, Level 3, CPG pg. 20) Risk assessment of CAD in dyslipidemiaA basic principle in the prevention of CAD is that the intensity of risk reduction therapy should be adjusted to a person s risk of developing future coronary events.

9 The steps taken for risk stratification are illustrated in Figure 1. First, very high risk and high risk patients can be identified based on whether they have existing CAD, atherosclerotic cerebrovascular disease, aortic aneurysm, peripheral arterial disease, diabetes, chronic kidney disease, or familial hypercholesterolemia. If the patient is not in the very high risk or high risk strata, his/her 10-year CAD risk can be estimated using Tables A-1 to A-4, pg. 1 Risk stratification (CPG pg. 28)8 Target lipid levelsWhile it was noted that randomised controlled trials used fixed doses of statins, physicians in Singapore involved in treating patients at risk of CAD with lipid lowering therapy were of the view that there was sufficient evidence for a causal link between LDL cholesterol and the risk of CAD, such that a strategy to treat patients to achieve target lipid levels ( treat to target strategy) remains relevant today.

10 Table 3 shows the recommended LDL cholesterol target levels in the four risk group 3 LDL cholesterol target levels in the four risk categories(Grade B, Level 1++, CPG pg. 34 36)B The recommended LDL cholesterol target level for the intermediate riskgroup is < (130mg/dL), with an LDL cholesterol level of < (100mg/dL) being an option if the physician feels that the benefits of more intensive therapy outweigh the risks. (Grade B, Level 1++, CPG pg. 35)B The recommended LDL cholesterol target level for the low risk group is< (160mg/dL), with an LDL cholesterol level of < (130mg/dL) being an option if the physician feels that the benefits of more intensive therapy outweigh the risks.