Hyperlipidemias and Atherosclerotic Cardiovascular Disease ________________________________________
AHA/ACC RECOMMENDATIONS FOR ASSESSMENT OF BASELINE LEVELS OF LDL AND NON-HDL In adults 20 years of age or older not on lipid-lowering therapy, measurement of either a fasting or a nonfasting plasma a lipid profile is effective in estimating ASCVD risk and documenting baseline LDL (Class I, based on moderate-quality evidence). In adults 20 years of age or older in whom an initial nonfasting lipid profile reveals a triglyceride level of ≥400 mg dL (≥4.5 mmol/L), perform a repeat lipid profile in the fasting state for assessment of fasting triglyceride levels and baseline LDL (Class I, based on moderate-quality evidence). For patients with an LDL level <70 mg/dL (<1.8 mmol/L), measurement of direct LDL or modified LDL estimate is reasonable to improve accuracy over the Friedewald formula (Class IIa, based on limited data). In adults 20 years of age or older without a personal history of ASCVD but with a family history of premature ASCVD or genetic hyperlipidemia, measurement of a fasting plasma lipid profile is reasonable as part of an initial evaluation to aid in the understanding and identification of familial lipid disorders (Class IIa, based on limited data). a Both fasting and nonfasting total cholesterol and HDL levels appear to have similar prognostic value and associations with ASCVD outcomes. Therefore, nonfasting samples can be used for risk assessment in primary prevention and for assessment of baseline LDL levels prior to initiation of a statin. If more precision is necessary, fasting lipids can be measured, but a nonfasting sample is reasonable for most situations. Source: [24] Table 4
Hypertriglyceridemia is associated with an increased risk of ASCVD events and acute pancreatitis, and lowering triglyceride levels in high-risk patients (e.g., those with ASCVD or diabetes) is associated with decreased cardiovascular morbidity and mortality. Management protocols for mixed dyslipidemia are not uniform or clearly defined, so treatment should focus primarily on established lifestyle and pharmacologic means for lowering LDL levels and improving lipid metabolism [105]. Baseline levels are used to estimate risk of ASCVD, guide treatment decisions, and accurately evaluate response to therapy. It is important to note that baseline cholesterol levels may vary by geography and among ethnic minority populations. For example, cholesterol values are about 20% higher in the Western population than in the Asian population [67]. The 2018 AHA/ACC guideline provides recommendations for the accurate measurement of baseline LDL levels ( Table 4 ) [24; 63]. LIFESTYLE MODIFICATION Management of hyperlipidemia is but one component of a general strategy for reducing the risk of ASCVD. It is important that healthcare professionals have a good understanding of other measures required for effective risk reduction, including lifestyle changes that may facilitate lipid management before there is need of pharmacotherapy. The 2019 AHA/ACC Guideline on the Primary Prevention of Cardiovascular Disease presents recommendations related to lifestyle modification (e.g., diet and physical activity), patient comorbidities (e.g., obesity, diabetes, hypertension), and patient-centered approaches (e.g., team-based care, shared decision-making, assessment of social determinants of health) to management [236]. The recommendations for management of hyperlipidemia in the AHA/ACC 2018 Cholesterol Clinical Practice Guidelines have been included in the 2019 AHA/ ACC guideline.
The ACC/AHA recommend a diet emphasizing intake of vegetables, fruits, legumes, nuts, whole grains, and fish decrease ASCVD risk factors. (http://www.onlinejacc. org/content/73/24/e285?_
ga=2.118995977.141815126.1563751668- 1264536891.1558548868. Last accessed July 24, 2025.) Level of Evidence : I (Strong)
Modifiable lifestyle factors for cardiovascular disease risk reduction include diet, weight reduction, physical activity (exercise), and smoking cessation [24; 236]. The 2018 AHA/ ACC guideline on management of blood cholesterol and 2019 guideline on primary prevention of cardiovascular disease concur on the recommendations for good nutrition, diet, and exercise [24; 236]. All adults should consume a healthy diet that [236]: • Emphasizes the intake of fruits, vegetables, nuts, and whole grains • Includes low-fat dairy products, poultry, fish, legumes, and nontropical vegetable oils • Limits the intake of sweets, sugar-sweetened beverages, refined carbohydrates, red meat, and processed meats • Replaces saturated fat (no more than 5% to 6% of calories from saturated fat) with dietary monounsaturated and polyunsaturated fats • Avoids the intake of trans fat
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