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Introduction

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The landmark Scandinavian Simvastatin Survival Study (4S) published in 1994, may well be remembered as the study that finally put to rest many of the apprehensions and misconceptions regarding lipid-lowering therapy.

Duffy and Meredith 19961

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Dyslipidaemia is the presence of an abnormal lipid/lipoprotein profile in the serum and can be classified as:

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  • predominant hypertriglyceridaemia

  • predominant hypercholesterolaemia

  • mixed pattern with elevation of both cholesterol and triglyceride (TG)

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Modern epidemiological studies have established the facts that elevated plasma cholesterol causes pathological changes in the arterial wall leading to CAD, and that lipid-lowering therapy results in reduction of coronary and cerebrovascular events with improved survival.

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These studies, which can be summarised by their acronyms—4S,2 PLACI,3 PLACII,4 ACAPS,5 KAPS6 and REGRESS7—all reinforce the benefits of lipid-lowering therapy for dyslipidaemia and the primary prevention of coronary heart disease (CDH).

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One systematic review showed that statins and n-3 fatty acids are the most favourable lipid-lowering interventions, with reduced risks of overall and cardiac mortality.8

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The main focus of treatment will be on primary dyslipidaemia but secondary causes (see Table 87.1) also need to be addressed. LDL-C is the lipid with the highest correlation with CHD.

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Table Graphic Jump Location
Table 87.1

Common causes of secondary dyslipidaemia

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Established facts9,10,11

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  • Major risk factors for CAD include:

    • increased LDL cholesterol + reduced HDL cholesterol

    • ratio LDL-C:HDL-C >4

  • Risk increases with increasing cholesterol levels (90% if >7.8 mmol/L)

  • TG levels >10 mmol/L increases risk of pancreatitis

  • Management should be correlated with risk factors

  • 10% reduction of total cholesterol gives 20% reduction in CAD after 3 years

  • LDL-C reduction with statin therapy reduces heart attacks, stroke, the need for revascularisation and death

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Investigations10

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The following fasting tests are recommended in all adult patients 18 years and over:

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  • serum triglyceride level

  • serum cholesterol level and HDL-C and LDL-C levels if cholesterol ≥5.5 mmol/L

  • TFTs if overweight elderly female

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Confirm an initial high result with a second test at 6–8 weeks. Patients requiring treatment are summarised in Table 87.2. Testing should occur at least every 5 years.

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Table Graphic Jump Location
Table 87.2

Patients requiring treatment (National Heart Foundation and PBS guidelines)9

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