• The Review Course in Family Medicine

2021 Guidelines for Management of Dyslipidemia – What You Need To Know


The updated 2021 Guidelines for Management of Dyslipidemia have kept some recommendations the same as those presented in 2016, such as diet and lifestyle recommendations, the use of the Framingham risk score to assess who to treat, and statins as first-line treatment in preventing atherosclerotic cardiovascular disease (ASCVD).


In addition to these familiar guidelines, The Canadian Cardiovascular Society has also highlighted new areas of focus and recommendations. Read below for a summary of the highlights:


Intensifying lipid-lowering therapy with non-statin agents, featuring PCSK9 inhibitors

Ezetimibe lowers LDL-C by roughly 20% in addition to a statin regimen or 15% as monotherapy, whereas recently available monoclonal antibodies, PCSK9 inhibitors, have been shown to lower LDL-C by between 50% and 70% when used with OR without statins.

SUMMARY OF RECOMMENDATIONS:

  • PCSK9 inhibitors and/or ezetimibe recommended in addition to maximal statin therapy if LDL-C remains ≥ 1.8mmol/L, if non-HDL-C remains ≥ 2.4mmol/L, or if ApoB is ≥ 0.7g/L

  • PCSK9 inhibitors recommended to lower LDL-C levels in patients with heterozygous Familial Hypertriglyceridemia, with or without clinical ASCVD

Lipoprotein A (LpA) as a once-in-a-lifetime screening parameter

LpA is an LDL-like particle that is not influenced by age, race, sex, inflammation, or lifestyle, but one that is largely heritable and undoubtedly associated with CVD.

SUMMARY OF RECOMMENDATIONS:

  •  LpA levels should be measured once in a persons’ lifetime as part of initial lipid screening

  •  Earlier and more drastic lifestyle modifications recommended for persons with Lp(a) levels of ≥ 50mg/dL or ≥ 100mmol/L

Non-HDL-C or ApoB preferred over LDL-C for screening when triglycerides are elevated


Non-HDL-C and ApoB may provide a more accurate assessment of the total concentration of atherogenic particles and thus overall CV risk versus LDL-C in the setting of hypertriglyceridemia.

SUMMARY OF RECOMMENDATIONS:

  •  Recommended that HDL-C or ApoB be used as preferred lipid screening parameters for those with triglyceride levels ≥ 1.5mmol/L

Coronary artery calcium (CAC) scoring proposed as a clinical decision-making tool

A CAC score greater than 0 confirms the presence of an atherosclerotic plaque, highlighting its role as a helpful parameter in deciding whether or not initiate statin therapy.

SUMMARY OF RECOMMENDATIONS:

  •  CAC screening might be considered suitable for asymptomatic persons ≥ 40 years at an intermediate risk (FRS 10-20%) or those at a low risk with a positive family history, where treatment course is uncertain

Preventative care for women with hypertensive disorders of pregnancy


Pregnancy complications (gestational diabetes, pre-eclampsia, hypertension, preterm delivery, low birth weight) put women at higher risk for developing CV risk factors and overt ASCVD for up to 10-15 years post-partum.


SUMMARY OF RECOMMENDATIONS:

  •  Counselling to emphasize the importance of healthy behaviours and post-partum lipid metabolic screening for women who experienced complications during their pregnancy

  •  When deciding on lipid-lowering pharmacotherapy for pregnant women, prioritize CV age over 10-year risk, and select hydrophilic compounds over hydrophobic compounds

CV benefit associated NOT associated with diet and supplementary sources of Omega-3s


Research has shown that high doses of diet and supplementary Omega-3s reduce triglyceride levels, but DO NOT improve CV health. However, the same is not true for newly derived Icosapent ethyl (IPE), a purified compound of Omega-3 fatty acid, ethyl EPA.


SUMMARY OF RECOMMENDATIONS:

  •  Diet sources and other omega-3 supplements NOT recommended to reduced CVD risk

  •  IPE recommended to decrease CV events in patients with ASCVD or those with diabetes and ≥ 1 CVD risk factor with elevated triglyceride levels (1.5-5.6mmol/L) despite maximum statin therapy




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