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Introduction

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

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

  • predominant hypertriglyceridaemia

  • predominant hypercholesterolaemia

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

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.

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).

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

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.

Table 87.1

Common causes of secondary dyslipidaemia

Established facts9,10,11

  • 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

Investigations10

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

  • serum triglyceride level

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

  • TFTs if overweight elderly female

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.

Table 87.2

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

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