Elsevier

Journal of Clinical Lipidology

Volume 9, Issue 2, March–April 2015, Pages 129-169
Journal of Clinical Lipidology

National Lipid Association Recommendations - Part 1
National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 1—Full Report

https://doi.org/10.1016/j.jacl.2015.02.003Get rights and content

Abstract

The leadership of the National Lipid Association convened an Expert Panel to develop a consensus set of recommendations for patient-centered management of dyslipidemia in clinical medicine. An Executive Summary of those recommendations was previously published. This document provides support for the recommendations outlined in the Executive Summary. The major conclusions include (1) an elevated level of cholesterol carried by circulating apolipoprotein B-containing lipoproteins (non–high-density lipoprotein cholesterol and low-density lipoprotein cholesterol [LDL-C], termed atherogenic cholesterol) is a root cause of atherosclerosis, the key underlying process contributing to most clinical atherosclerotic cardiovascular disease (ASCVD) events; (2) reducing elevated levels of atherogenic cholesterol will lower ASCVD risk in proportion to the extent that atherogenic cholesterol is reduced. This benefit is presumed to result from atherogenic cholesterol lowering through multiple modalities, including lifestyle and drug therapies; (3) the intensity of risk-reduction therapy should generally be adjusted to the patient's absolute risk for an ASCVD event; (4) atherosclerosis is a process that often begins early in life and progresses for decades before resulting a clinical ASCVD event. Therefore, both intermediate-term and long-term or lifetime risk should be considered when assessing the potential benefits and hazards of risk-reduction therapies; (5) for patients in whom lipid-lowering drug therapy is indicated, statin treatment is the primary modality for reducing ASCVD risk; (6) nonlipid ASCVD risk factors should also be managed appropriately, particularly high blood pressure, cigarette smoking, and diabetes mellitus; and (7) the measurement and monitoring of atherogenic cholesterol levels remain an important part of a comprehensive ASCVD prevention strategy.

Section snippets

Background and conceptual framework for formulation of the NLA Expert Panel recommendations

Clinical decisions often need to be made in the absence of ideal or complete evidence, and well-informed experts will not always evaluate or interpret the evidence base in the same way. Clinical recommendations aim to assist clinicians in making decisions about the best strategies for management of a condition, taking into account potential benefits and risks of the available options. The NLA Expert Panel recommendations are intended to inform, not replace, clinical judgment. A patient-centered

Screening and classification of initial lipoprotein lipid levels

In all adults (≥20 years of age), a fasting or nonfasting lipoprotein profile should be obtained at least every 5 years. At a minimum, this should include total cholesterol and HDL-C, which allows calculation of non-HDL-C (total-C – HDL-C). If fasting (generally 9–12 hours), the LDL-C level may be calculated, provided that the triglyceride concentration is <400 mg/dL.29, 145

Classifications for lipoprotein lipid levels are shown in Table 1. Lipoprotein lipid levels should be considered in

Non–HDL-C and LDL-C

When intervention beyond public health recommendations for long-term ASCVD risk reduction is used, levels of atherogenic cholesterol (non–HDL-C and LDL-C) should be the primary targets for therapies. LDL is the major atherogenic lipoprotein carrying cholesterol in a majority of patients, and LDL-C comprises ∼75% of the cholesterol in circulation carried by lipoprotein particles other than HDL, although this percentage may be lower in those with hypertriglyceridemia. Although LDL-C has

ASCVD risk assessment and treatment goals based on risk category

In addition to lipoprotein lipid levels, ASCVD risk assessment includes evaluation of other major ASCVD risk factors (Table 7) and other conditions known to be associated with high or very high risk for an ASCVD event (Table 9). For high- and very high–risk patient groups (see the following for definitions), quantitative risk scoring (described in detail in the High risk section) will often underestimate ASCVD event risk so is generally not recommended unless a validated equation for that

Lifestyle therapies

Figure 12 shows a model of the steps in application of lifestyle therapies. For patients at low or moderate risk, lifestyle therapies should be given an adequate trial (at least 3 months) before the use of drug therapy is considered. In patients at very high risk, drug therapy may be started concurrently with lifestyle therapies. This may also be the case for selected patients in the high risk category if the clinician feels it is unlikely that lifestyle therapies alone will be sufficient to

Updates to this document

Because the evidence in clinical medicine related to lipid management is always evolving, these recommendations will undergo annual review with revision as necessary to reflect important changes to the evidence base.

Acknowledgments

The National Lipid Association (NLA) Expert Panel wishes to express its gratitude to the following individuals, whose assistance was invaluable in preparation of these recommendations: Mary R. Dicklin, PhD (Midwest Center for Metabolic & Cardiovascular Research), Ryan J. Essegian, Esq. (NLA), Lindsay Hart (NLA), and Christopher R. Seymour, MBA (NLA).

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    T.A.J. and M.K.I. are the joint first authors.

    Industry Support Statement: The National Lipid Association received no industry support for the development of this Expert Panel report.

    NLA Support Statement: The NLA has nothing to disclose.

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