Cardiovascular

Hyperlipidaemia

Hyperlipidaemia is raised atherogenic lipoprotein cholesterol or triglycerides; it is usually silent, so treatment is based on overall cardiovascular risk, established disease, familial lipid disorders and pancreatitis risk rather than on a cholesterol number in isolation.

In a nutshell

Hyperlipidaemia is usually silent but causes cumulative atherosclerotic risk. Use a full lipid profile and QRISK3 only for eligible primary prevention; do not use QRISK3 as the treatment gate in established CVD or familial hypercholesterolaemia. NICE uses a greater-than-40% non-HDL reduction for primary prevention and current LDL or non-HDL thresholds for secondary prevention. Severe triglycerides need a separate pancreatitis-risk pathway.

Classic presentation

An asymptomatic adult is found to have raised non-HDL cholesterol during cardiovascular risk assessment, or a patient with premature coronary disease has tendon xanthomata and a family history suggesting familial hypercholesterolaemia.

Key points

Measure total cholesterol, HDL cholesterol, triglycerides and non-HDL cholesterol; interpret LDL in context.
Use QRISK3 for eligible primary prevention, but treat established CVD and familial hypercholesterolaemia through their dedicated pathways.
Offer a guideline-recommended statin for primary prevention when QRISK3 is 10% or more after informed discussion; lower scores do not automatically exclude treatment.
Offer high-intensity statin treatment for secondary prevention regardless of baseline cholesterol, unless a lower intensity is clinically or personally appropriate.
For primary prevention aim for a greater-than-40% non-HDL reduction; for secondary prevention use the current LDL or non-HDL threshold.
Total cholesterol above 9.0 mmol/L or non-HDL above 7.5 mmol/L needs specialist assessment; triglycerides above 20 mmol/L need urgent specialist review.
Tendon xanthomata or premature coronary disease suggest familial hypercholesterolaemia: confirm, treat lifelong and cascade-test relatives.
Statins are contraindicated in pregnancy and should not be restarted until breastfeeding has finished.

First-line investigation

Full lipid profile, cardiovascular risk assessment where appropriate, examination and family history, plus secondary-cause and baseline safety tests.

Management

Identify high-risk and pancreatitis pathways

Separate established CVD, suspected familial hypercholesterolaemia and severe triglyceride elevation from ordinary QRISK3 primary prevention; urgently assess abdominal symptoms suggesting pancreatitis.^1,3

Measure risk and secondary causes

Obtain a full lipid profile, family and personal history, clinical examination and baseline safety tests; use QRISK3 only when the person is eligible for primary-prevention risk estimation.^1,3,4

Start shared-decision prevention

Address diet, activity, weight, smoking, alcohol, blood pressure and diabetes, then offer guideline-based statin treatment after discussing benefits, harms, interactions, comorbidity, frailty, life expectancy and preference.^1,4

Intensify or refer

Check lipids and transaminases 2 to 3 months after starting or changing therapy; address adherence and secondary causes, then consider NICE-listed additional agents or specialist lipid referral when the target is not met.^1,2,4

Maintain lifelong risk reduction

Review lipid treatment at least annually, support adherence and lifestyle change, continue lifelong specialist treatment and cascade testing in familial hypercholesterolaemia, and revisit pregnancy or breastfeeding plans before prescribing.^1,3,4

Exam traps

Do not use QRISK3 to decide treatment in established CVD or familial hypercholesterolaemia.
A greater-than-40% non-HDL reduction is a primary-prevention target; do not substitute it for the current secondary-prevention threshold.
Do not treat xanthelasma as diagnostic of familial hypercholesterolaemia without lipid and family assessment.
Very high triglycerides carry pancreatitis risk and require secondary-cause review and specialist escalation.
Do not stop a statin permanently after muscle symptoms without assessing CK, interactions, rechallenge and alternatives.

Illustrations

Bilateral xanthelasmaA clinical photograph showing soft yellow plaques at the medial upper eyelids, with a caption noting that xanthelasma is not diagnostic of familial hypercholesterolaemia without the lipid and family-history context.Klaus D. Peter, Wiehl, Germany, Wikimedia Commons · CC-BY-3.0-DE

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.