AKT · Endocrine/Lipids, metabolic & inherited

Hyperlipidaemia / dyslipidaemia

Raised LDL/cholesterol/triglycerides → atherosclerotic risk

Overview

Raised plasma lipids (LDL cholesterol and/or triglycerides), a major modifiable driver of atherosclerotic cardiovascular disease. Managed by cardiovascular risk assessment (QRISK), lifestyle, and statins for primary (QRISK ≥10%) and secondary prevention, with ezetimibe/PCSK9 inhibitors/inclisiran as add-ons. Severe elevations suggest a familial disorder.

Recognise

Asymptomatic — detected on screening / CVD risk assessment
Signs of severe/familial disease: tendon xanthomata, xanthelasma, corneal arcus (premature), eruptive xanthomata (very high triglycerides)
Very high triglycerides → acute pancreatitis risk

Red flags

Total cholesterol >9.0 or non-HDL >7.5 (without obvious cause) → suspect familial hypercholesterolaemia, refer
Severe hypertriglyceridaemia → pancreatitis risk

Differentials & how to tell them apart

Familial hypercholesterolaemiavery high LDL, tendon xanthomata, premature CVD/family history — genetic, needs high-intensity statin ± PCSK9

Secondary dyslipidaemiahypothyroidism, poorly controlled diabetes, nephrotic syndrome, alcohol — treat the cause

Familial hypertriglyceridaemia / chylomicronaemiavery high triglycerides, eruptive xanthomata, pancreatitis risk

Investigations

Full lipid profile (non-fasting acceptable). QRISK cardiovascular risk score. Exclude secondary causes (hypothyroidism, diabetes, nephrotic, alcohol, drugs). Family history.

Management

Lifestyle + atorvastatin (20 mg primary / 80 mg secondary prevention)

1Assess CVD risk (QRISK) and exclude secondary causes. Lifestyle for all. Offer atorvastatin 20 mg for primary prevention if QRISK ≥10% (or CKD/T1DM/FH); 80 mg for secondary prevention (established CVD). Aim for >40% reduction in non-HDL cholesterol.Gate: Statins are CONTRAINDICATED in pregnancy (stop 3 months pre-conception); check LFTs and ask about muscle symptoms (rare rhabdomyolysis); a total cholesterol >9 / non-HDL >7.5 suggests FAMILIAL hypercholesterolaemia → specialist referral, not just a standard statin
2Not at target → add ezetimibe, then PCSK9 inhibitor/inclisiran; fibrates/omega-3 for severe hypertriglyceridaemia.

Atorvastatin (HMG-CoA reductase inhibitor) — 20 mg primary prevention (QRISK ≥10%), 80 mg secondary prevention; myalgia, rare rhabdomyolysis, deranged LFTs; CONTRAINDICATED in pregnancy

Ezetimibe — add if statin insufficient/not tolerated (blocks cholesterol absorption)

PCSK9 inhibitor / inclisiran — for FH or high-risk patients not at target on statin + ezetimibe

Fibrate / omega-3 — for severe hypertriglyceridaemia (pancreatitis prevention)

Key points

Statin first (20 primary / 80 secondary), titrate by non-HDL reduction. Pregnancy is the absolute contraindication. Tendon xanthomata + very high LDL + family history = FH (refer). Eruptive xanthomata + very high triglycerides = pancreatitis risk.

Monitor & prognosis

Lipids (non-HDL response), LFTs, muscle symptoms.

Modifiable CVD risk.

Source: NICE NG238 (lipid modification); CKS