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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.


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 through lifestyle factors or drug therapy results in reduction of coronary and cerebrovascular events with improved survival.

A Cochrane systematic review2 of 18 large RCTs found high-quality evidence that statins reduce all-cause mortality and major vascular events. The number needed to treat (NNT) with statins varies markedly depending on the risk category the person falls into (see TABLE 78.1).

Table 78.1Number needed to treat (NNT) with a statin for 1 year to prevent 1 death2

As with other cardiovascular risk factors, focussing on any one measure (in this case, lipid profile) is only part of the whole-person approach to reducing risk.

The main focus of treatment will be on primary dyslipidaemia but secondary causes (see TABLE 78.2) also need to be addressed. LDL-C is the lipid with the highest correlation with CHD and its level remains the primary target of lipid-modifying therapy. The statins are the first-line therapy for a raised level. Like total cholesterol measurement, LDL-C should not be used in isolation.

Table 78.2Common causes of secondary dyslipidaemia


  • 4,5,6Major risk factors for CAD include:

    • – increased LDL cholesterol + reduced HDL cholesterol

    • – ratio LDL-C:HDL-C >4

  • Risk increases with increasing cholesterol levels

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

  • Management depends on other cardiovascular 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

  • Screening is recommended 5 yearly from age 45 years (Aboriginal and Torres Strait Islander people from 35 years)


5The following fasting tests are recommended in patients every 5 years, ...

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