Dyslipidemia: current diagnosis and management

1. Diagnosis and assessment

• Total cholesterol, LDL-C, HDL-C, triglycerides (TG), and non-HDL-C.
• A nonfasting sample is often acceptable for routine assessment. Obtain a fasting profile if TG are markedly high, familial disease is suspected, or results are unclear.

• Ask about established ASCVD: previous myocardial infarction, angina/revascularization, ischemic stroke/TIA, peripheral arterial disease.
• Assess age, blood pressure, diabetes, smoking, chronic kidney disease, HIV, obesity, family history of premature ASCVD, diet, alcohol, and physical activity.
• For adults without ASCVD, risk assessment should guide primary-prevention treatment. The 2026 guideline uses PREVENT-ASCVD risk assessment and supports coronary artery calcium (CAC) scoring where treatment decisions remain uncertain. ACC review of the guideline

• Measure Lp(a) at least once in adulthood. High Lp(a) is inherited and supports earlier, more intensive risk-factor control; consider family screening when elevated.
• Consider apoB in diabetes, obesity/metabolic syndrome, high TG, or when LDL-C may underestimate atherogenic particle burden.
• Check for secondary causes, especially when LDL-C is ≥160 mg/dL or TG ≥500 mg/dL: diabetes or poor glycemic control, hypothyroidism, obesity, alcohol excess, chronic kidney/liver disease, nephrotic syndrome, pregnancy, and medicines such as corticosteroids, retinoids, estrogen, antipsychotics, and some beta-blockers. Goldman-Cecil Medicine, section “Secondary Causes of Hyperlipidemia.”

• LDL-C ≥190 mg/dL suggests possible familial hypercholesterolemia, particularly with tendon xanthomas or a family history of early coronary disease. Screen first-degree relatives. Washington Manual of Medical Therapeutics, section “LDL-C ≥190 mg/dL.”

2. Treatment for everyone

• Mediterranean-style or DASH-style eating pattern.
• Replace saturated fats with unsaturated fats; avoid trans fats.
• Increase vegetables, fruits, legumes, whole grains, nuts, and soluble fiber.
• Reduce refined carbohydrates, sugar-sweetened drinks, and alcohol, especially if TG are high.
• Aim for weight loss if overweight or obese.
• At least 150 minutes/week of moderate aerobic activity plus resistance exercise.
• Stop smoking and control blood pressure and diabetes.

3. LDL-C lowering: medication approach

1. Clinical ASCVD: use high-intensity or maximally tolerated statin therapy.
2. LDL-C ≥190 mg/dL: initiate intensive LDL-C lowering without waiting for risk-calculator results.
3. Diabetes, CKD, or HIV: treatment is often indicated based on guideline risk category and age.
4. Primary prevention: treat according to calculated risk, risk-enhancing factors, and shared decision-making. CAC imaging can help when the decision is uncertain.

• Clinical or subclinical ASCVD: LDL-C <70 mg/dL and non-HDL-C <100 mg/dL.
• Very-high-risk ASCVD: LDL-C <55 mg/dL and non-HDL-C <85 mg/dL.
• Most high-risk patients should also achieve at least a 50% LDL-C reduction from baseline. ACC guideline application summary

• Ezetimibe
• PCSK9 monoclonal antibody: evolocumab or alirocumab
• Bempedoic acid
• Inclisiran in selected patients needing sustained LDL lowering with infrequent injections

4. Hypertriglyceridemia

5. Follow-up and safety

• Repeat lipid profile 4-12 weeks after starting or changing treatment, then every 3-12 months based on adherence and clinical need. Swanson’s Family Medicine Review, section “Monitoring Response to Therapy.”
• Check adherence, lifestyle, adverse effects, and drug interactions at every review.
• Check liver enzymes before statin therapy if clinically appropriate. Check creatine kinase only for significant unexplained muscle symptoms or high-risk situations.
• Do not stop a statin automatically for muscle symptoms. Assess timing, interacting medicines, hypothyroidism, vitamin D deficiency if relevant, and consider dose adjustment, a different statin, or nonstatin therapy.

Practical summary

1. Confirm the lipid abnormality and assess total cardiovascular risk.
2. Check secondary causes and measure Lp(a) once.
3. Start lifestyle treatment for all.
4. Use a statin first when ASCVD risk or LDL-C level warrants it.
5. Add ezetimibe, PCSK9 therapy, bempedoic acid, or inclisiran if LDL-C remains above the risk-based goal.
6. Treat TG ≥500 mg/dL urgently to prevent pancreatitis, particularly when ≥1,000 mg/dL.