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Practice Practice Pointer

Managing dyslipidaemia for the primary prevention of cardiovascular disease

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k946 (Published 23 March 2018) Cite this as: BMJ 2018;360:k946

Rapid Response:

Managing dyslipidaemia

I read with interest the articles by Ryan et al on dyslipidaemia and cardiovascular risk in this weeks BMJ [1, 2]. Importantly, the increased cardiovascular risk in individuals with chronic inflammatory diseases such as rheumatoid arthritis is highlighted. This group also includes psoriasis, axial spondyloarthropathies, gout and SLE. There is a significantly increased risk of myocardial infarction in SLE in particular, when compared to the general population [3]. Recent guidelines recommend screening for modifiable risk factors for cardiovascular disease, including dyslipidaemia, in individuals with SLE [4] and in those with gout [5].

With regard to the evaluation of lipid profiles in at risk individuals, some laboratories, including our own, also report cholesterol: HDL ratio (normal ratio <5.0, desirable <3.5). To this end, it can prove very useful to discuss lipid profile results with at risk individuals using this ratio, sometimes using such terms ‘happy’ (HDL) cholesterol, in addition to total serum cholesterol levels.

There was no mention in these articles on the role for fibric acid derivatives, such as fenofibrate and bezafibrate. Although usually reserved for use as secondary prevention in a minority of individuals with dyslipidaemia, fibrates should be considered in certain groups, such as those with type II diabetes or gout, who may have predominantly raised serum triglycerides [6], and in those intolerant of both statins and ezetimibe.

References:

1. Ryan A et al. Managing dyslipidaemia for the primary prevention of cardiovascular disease. BMJ 2018; 360: k946
2. Ryan A et al. Dyslipidaemia and cardiovascular risk. BMJ 2018; 360: k835
3. Lin CY et al. Increased risk of acute myocardial infarction and mortality in patients with systemic lupus erythematosus: two nationwide retrospective cohort studies. Int J Cardiol 2014; 176 (3):847-51
4. Gordon C et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults: Rheumatology 2018; 57 (1): e1-e45
5. Hui M et al. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology 2017; 56 (7): e1–e20
6. Feher MD et al. Atherogenic phenotype in type 2 diabetes: reversal with micronised fenofibrate. Diabetes Metabolism Res Rev 1999; 15: 395-399

Competing interests: No competing interests

24 March 2018
Alastair L Hepburn
Consultant Physician
Western Sussex Hospitals NHS Foundation Trust
Worthing Hospital