Dyslipidemia & Statin use

Dyslipidemia & Statin use

Dyslipidemia Management Protocol

Key principles

  • The primary therapeutic target is LDL-cholesterol (LDL-C).
  • Treatment decisions are based on overall CVD risk, not LDL level alone.
  • Statins are first-line therapy for most patients requiring pharmacologic treatment.
  • Treatment goals are defined according to risk category.

Lipid profile reference values

Parameter

Optimal

Borderline

High

LDL-C

<2.6 mmol/L (<100 mg/dL)

2.6–4.1 (100–159)

≥4.1 (≥160)

Total cholesterol

<5.2 mmol/L (<200 mg/dL)

5.2–6.2 (200–239)

≥6.2 (≥240)

HDL-C

>1.0 mmol/L (>40 mg/dL men)
>1.3 mmol/L (>50 mg/dL women)

Low if below these values

Cardiovascular risk categories and LDL targets

Risk category

Examples

LDL target

Low risk

No major risk factors

<3.0 mmol/L (<116 mg/dL)

Moderate risk

Multiple risk factors

<2.6 mmol/L (<100 mg/dL)

High risk

Diabetes, CKD, markedly elevated risk score

<1.8 mmol/L (<70 mg/dL)

Very high risk

Established ASCVD (MI, stroke, PAD)

<1.4 mmol/L (<55 mg/dL)

Indications for statin therapy

1) Secondary prevention (established ASCVD)

Management:

  • Initiate high-intensity statin.
  • Target:
    • LDL-C <1.4 mmol/L (<55 mg/dL)

2) LDL-C ≥4.9 mmol/L (≥190 mg/dL)

  • Suggestive of familial hypercholesterolemia.

Management:

  • Start high-intensity statin
  • Regardless of age or calculated risk

3) Diabetes mellitus (age ≥40 years)

Management:

  • At least moderate-intensity statin

If any of the following is present, Use high-intensity statin:

  • Diabetes ≥10 years
  • Age ≥50
  • Albuminuria
  • eGFR <60 (CKD)
  • Hypertension
  • Smoking
  • Family history of premature ASCVD

Target:

  • LDL-C <1.8 mmol/L (<70 mg/dL)

4) Primary prevention (age 40–75 years)

LDL-C: 1.8–4.9 mmol/L (70–189 mg/dL)

Step 1: Calculate 10-year ASCVD risk

ASCVD risk

Decision

<5%

Lifestyle only

5–7.4%

Consider moderate-intensity statin if risk enhancers present

7.5–19.9%

Start moderate-intensity statin

≥20%

Start high-intensity statin

Risk enhancers (used when ASCVD risk 5–7.4%)

  • Family history of premature ASCVD
  • LDL ≥4.1 mmol/L (≥160 mg/dL)
  • Metabolic syndrome
  • CKD
  • Chronic inflammatory disease
  • South Asian ancestry
  • Persistent elevated lipids

Statin intensity classification

Intensity

Medication

Expected LDL reduction

High intensity

Atorvastatin 40–80 mg
Rosuvastatin 20–40 mg

≥50%

Moderate intensity

Atorvastatin 10–20 mg
Rosuvastatin 5–10 mg
Simvastatin 20–40 mg

30–49%

Low intensity

Simvastatin 10 mg
Pravastatin 10–20 mg

<30%

Stepwise treatment approach

Step 1: Initiate statin

  • According to indication and risk category.

Step 2: Reassess lipid profile

  • After 4–12 weeks.

Step 3: If LDL target not achieved

  • Add: Ezetimibe 10 mg once daily.

Step 4: If still above target (very high risk)

  • Refer to specialist as appropriate.

Follow-up and safety monitoring

Baseline tests (before statin)

Mandatory:

  • Lipid profile
  • ALT

Creatine Kinase (CK):

  • Not routine
  • Check only if:
    • History of muscle disease
    • Previous statin intolerance
    • Unexplained muscle symptoms
    • Hypothyroidism
    • CKD
    • High-risk or frail patients

Routine follow-up

Test

Timing

Lipid profile

4–12 weeks after starting or dose change

Lipid profile (stable)

Every 6–12 months

ALT or CK

Only if symptoms develop

Routine CK or LFT monitoring is not required in asymptomatic patients.

Muscle symptoms (statin myalgia)

Mild pain, CK normal or  <3× ULN

  • Continue statin.
  • Reassure.
  • Reassess in 2–4 weeks.

Persistent symptoms or CK 3–10× ULN

  • Hold statin temporarily (for 2-4 weeks or until symptoms resolve).
  • Check CK, TSH, renal function.
  • Restart:
    • Lower dose, or
    • Different statin once symptoms resolve.

Severe symptoms or CK >10× ULN

  • Stop statin immediately.
  • Evaluate for rhabdomyolysis.
  • Refer if indicated.

Liver enzyme elevation

ALT <3× ULN

  • Continue statin.
  • Repeat test in 4–6 weeks.

ALT ≥3× ULN (confirmed)

  • Stop statin.
  • Investigate possible causes.
  • Restart lower dose or different statin after normalization.

Stop statin immediately if

  • CK >10× ULN
  • ALT ≥3× ULN with symptoms
  • Suspected rhabdomyolysis
  • Severe unexplained muscle pain


Author: Dr. Fahad Saad Almutairi