4th Edition of Clinical Practice Guidelines Management of Dyslipidemia 2011 PDF

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II
STATEMENT OF INTENT
This guideline was developed to be a guide for best clinical practice
in the management of dyslipidaemia. It is based on the best
available evidence at the time of development. Adherence to this
guideline does not necessarily lead to the best clinical outcome
in individual patient care. Thus, every health care provider is
responsible for the management of his/her unique patient based
on the clinical presentation and management options available
locally.
REVIEW OF THE GUIDELINE
This guideline was issued in 2011 and will be reviewed in 2016 or
earlier if important new evidence becomes available.
CPG Secretariat
Health Technology Assessment Unit
Medical Development Division
Level 4, Block EI, Parcel E
Government Offices Complex
62590 Putrajaya, Malaysia
Available on the following websites:
http://www.malaysianheart.org
http://www.moh.gov.my
http://www.acadmed.org.my
SUMMARY
Total cholesterol (TC) and High Density Cholesterol (HDL-C)
can be measured in the fasting and non fasting states.
Triglycerides (TG) is best measured in a fasting sample. Low
Density Cholesterol (LDL-C) is calculated using the Friedwalds
equation. When TG > 2.3mmol/l, non HDL-C is a better
indicator of total atherogenic burden.
Dyslipidaemias may be primary or secondary.
Target of therapy:

LDL-C should be the primary target of therapy I,A

Non HDL-C should be an alternative primary target of

therapy in patients with TG > 4.5 mmol/l I,A
Individuals should be risk stratified. I,C (See Table 1, pg 3 and Fig
1A & B, 2A & B, pg 30-31)
Diabetes is a Coronary Heart Disease (CHD) risk equivalent. I,A
Target lipids levels will depend upon the individuals global
risk.
CVD and CHD risk equivalents
LDL-C < 2.6 mmol/L with

(High Risk):

an option of <2.0 mmol/L1,A
Individuals with a 10 year risk score
of 10 20% (Intermediate Risk): LDL-C < 3.4 mmol/L1,A
Individuals with a 10 year risk score
of < 10% (Low Risk):
LDL-C < 4.1 mmol/lL IIa,C
Therapeutic Lifestyle Changes (TLC) should be an integral
component of lipid management in all patients.1,B (Table 3, pg
4)
Individuals with Cardiovascular Disease (CVD) and CHD risk
equivalents should be treated aggressively with drug therapy
from the outset.1,A (Table 1&2, pg 3; Flowcharts I-IV, pg5-8)

Statins are the drug of choice for reducing LDL-C.1,A

Fibrates and nicotinic acid may be considered for increasing

HDL-C and reducing TG after LDL-C treatment goal has been
achieved. IIa, B

Some individuals may require combination therapy to

achieve lipid target goals.
Control of glycaemia alone is inadequate in preventing
cardiovascular (CV) events.1,A Concomitant treatment
of dyslipidaemia, hypertension and other metabolic
abnormalities are also important. 1,A
2
Table 1: Major Risk Factors for CVD (other than LDL Cholesterol)
Positive Risk Factors
Male 45 years of age
Female 55 years of age or premature menopause
without hormonal replacement therapy
Hypertension
Current cigarette smoking
Family history of myocardial infarction or sudden death
prior to age 55 in a male parent or male first degree
relative and prior to age 65 in a female parent or other
female first degree relative
HDL-C < 1.0 mmol/L
Negative Risk Factors
HDL > 1.6 mmol/L
Table 2 : Recommendations for Drug Therapy for Dyslipidaemia
Medications
Statins
Ezetimibe
Grades of
recommendation/
Levels of evidence
I, A
Comments
Reduction of LDL-C. Increase dose

till target levels are achieved or till
tolerated
As an addition to statins if target
LDL-C is not achieved
As monotherapy in statin
intolerant individuals
IIa, B
IIa, C
Fibrates
IIa,B
As monotherapy to increase HDL-C

and/or lower TG in individuals with
mildly raised LDL-C
As part of combination therapy
with statins to increase HDL-C
and lower TG after LDL-C target is
achieved or almost achieved
As monotherapy to increase HDL-C
and/or lower TG in individuals with
mildly raised LDL-C
As part of combination therapy
with statins to increase HDL-C
and lower TG after LDL-C target is
achieved or almost achieved
IIa, B
Nicotinic
Acid
IIa,B
IIa, B
Table 3 : Recommendations for Therapeutic Lifestyle Changes

Grade of
Recommendation
Level of Evidence
Comments
Diet
Saturated Fats and
Trans-fatty acids
I, B
< 7% of calorie intake
Cholesterol
I,B
< 200 mg /day
Monounsaturated
fats
I,B
Up to 10% of calories
Polyunsaturated fats
I,B
Up to 20% of calories
Dietary Fiber
I,B
20-30 gm/day
Plant stanols
IIb, B
2-3 gm /day
Soy protein
IIb, B
25-50 gm/day
Omega 3 fatty acids
IIa, B
A dose of 3-9 gm/day to lower TG

levels
IIb,B
A dose of 0.75-1 gm/day as

secondary prevention to prevent
sudden death
Total fats
I,B
25-35% of calories
Carbohydrates
I,B
50-60% of calories
Proteins
I,B
About 15% of calories
Anti-oxidants
III,A
Avoid
Weight Reduction
Goal:
BMI : 18.5- <23 kg/
m2
Waist circumference
>90 cm in males and
< 80 cm in females
I,C
Assess BMI and waist circumference

at each visit.
Encourage a weight reduction of
0.5-1kg/week in the overweight
and obese. The initial goal should
be to reduce body weight to < 10%
of baseline.
I,B
Exercise
Goal:
30-45 min per session, at least 5 times
a week
I,B
Encourage aerobic exercises such as

brisk walking, jogging, cycling and
swimming
Smoking
Goal:
Complete cessation
I,B
Enquire about smoking status at

each visit and encourage complete
cessation.
Avoid exposure to environmental
tobacco smoke at work and at home
I,C
FLOWCHART I: HIGH RISK INDIVIDUALS

LIPID MANAGEMENT OF PERSONS WITH CVD OR CHD RISK
EQUIVALENTS (Adapted and modified from ATPIII)139
In these high risk individuals the recommended LDL-C goal is <
2.61,A mmol/L with an optional goal < 2.0 mmol/L1,A
CVD + CHD
Risk Equivalents
LDL-C < 2.6mmol/L
LDL-C 2.6mmol/L
TLC + Control Other

Risk Factors *
3 months
LDL-C < 2.6mmol/L
LDL-C 2.6mmol/L
TLC Therapeutic Lifestyle Changes

* Start statins to achieve LDL-C target goal < 2.0 mmol/L1,A
** Consider LDL-C target goal < 2.0 mmol/L in very high risk individuals eg
individuals with ACS, recurrent cardiac events, CHD with T2DM and those
with multiple poorly controlled risk factors1,A
*** Other therapeutic options include increasing the dose of statin, changing to
high intensity statin or combination therapy, intensifying diet therapies, weight
reduction, exercise or adding drugs to lower TG and / or increase HDL-C.
FLOWCHART II: INTERMEDIATE RISK INDIVIDUALS

LIPID MANAGEMENT OF PERSONS WITH
MULTIPLE RISK FACTORS,
10-YEAR RISK 10-20 PERCENT
(Adapted and modified from ATPIII)139
The LDL-C goal is < 3.4 mmol/L. I,A Drugs can be considered after
a trial of TLC if the LDL-C level is 3.4 mmol/L.
LDL-C < 3.4mmol/L
LDL-C 3.4mmol/L
Control other Risk

Factors
Healthy lifestyle*
Reevaluate in 1 year
TLC
3 months
LDL-C < 3.4mmol/L
LDL-C 3.4mmol/L

The LDL-C goal is < 3.4 mmol/L. Drugs can be considered after a trial of TLC if the
LDL-C level is 3.4 mmol/L.
*
In patients at intermediate risk of CVD, the presence of high risk features such
as a family history of premature CVD, evidence of subclinical atherosclerosis or
high hs-CRP may warrant statin therapy to lower LDL-C target < 2.6 mmol/L.
FLOWCHART III: LOW RISK INDIVIDUALS

LIPID MANAGEMENT OF PERSONS WITH MULTIPLE (2+) RISK
FACTORS, 10-YEAR RISK < 10 PERCENT
In these individuals the LDL-C goal is < 3.4mmol/L. Drug therapy
can be considered if LDL-C level is 4.1 mmol/L after a trial of
TLC.
LDL-C < 3.4mmol/L
LDL-C 3.4mmol/L
Control other Risk

Factors
Healthy lifestyle*
TLC
3 months
LDL-C < 4.1mmol/L
LDL-C 4.1mmol/L

*
Patients at low risk of CVD with at least 2 other risk factors but with evidence of
subclinical atherosclerosis, high hs-CRP or positive family history of premature
CVD should be considered an LDL-C goal of < 2.6 mmol/L.
FLOWCHART IV: LOW RISK INDIVIDUALS

LIPID MANAGEMENT OF PERSONS WITH 0-1 RISK FACTOR
In these individuals, the LDL-C goal is < 4.1 mmol/L. Drug therapy
can be considered if the LDL-C level is 4.9 mmol/L after a
trial of TLC. If LDL-C is 4.1-4.9 mmol/L, drug therapy is optional
depending on clinical judgment.
0-1 Risk Factors
10-yr risk usually
<10%
LDL-C < 4.1mmol/L
Control other Risk
Factors
Healthy lifestyle*
LDL-C 4.1mmol/L
LDL-C < 4.1

mmol/L
TLC
3 months
LDL-C 4.1-< 4.9mmol/L
LDL-C 4.9mmol/L
Patients at low risk of CVD with 0 to 1 risk factor but with evidence of subclinical
atherosclerosis should be considered for a lower LDL-C target < 2.6 mmol/L.
MESSAGE FROM THE AMERICAN COLLEGE OF CARDIOLOGY

The American College of Cardiology heartily congratulates the
National Heart Association of Malaysia along with the Ministry of
Health of Malaysia and the Academy of Medicine for the creation
of this important Clinical Practice Guideline for the management
of dyslipidemias.
Appreciating that in Malaysia cardiovascular disease is the
leading cause of death in both men and women and that
dyslipidemia is both readily identifiable and treatable offers the
ideal opportunity to translate known cardiovascular science to
the bedside. This CPG focusing on lipid management should
become a cornerstone for practitioners in Malaysia in their
mission to combat cardiovascular disease. Seminal work by Ford
reported in the New England Journal of Medicine points out that
both primary risk factor modifications along with adherence
to secondary prevention measures has markedly decreased
mortality and morbidity of cardiovascular disease.1 Risk factor
modification has a much greater impact on population health than
invasive or interventional cardiac procedures. Evidence based lipid
management is a major component of the worldwide success in
decreasing mortality and morbidity of cardiovascular disease along
with hypertension control, tobacco cessation, diabetic care along
with increasing exercise and successful treatment of obesity.
I again congratulate my Malaysian colleagues and encourage
enthusiastic application of this seminal work to improve the health
of the great people of Malaysia.
Sincerely,
Ralph Brindis, MD, MPH, MACC, FSCAI

Immediate Past President, American College of Cardiology
Reference:
1. Ford ES, Ajani UA, Croft JB et al Explaining the Decrease in U.S. Deaths
from Coronary Disease, 1980-2000. N Engl J Med 2007;356:23882398.
10
Members of the Expert Panel

Chairperson:
Dr Robayaah Zambahari

Secretary :
Dr R. Jeyamalar

Consultant Cardiologist,
Institute Jantung Negara,
Kuala Lumpur
Sime Darby Medical Center,
Subang Jaya, Selangor
Members (in alphabetical order)

Dr Abdul Rashid Rahman
Consultant Physician, Cyberjaya

University College of Medical

Sciences, Cyberjaya, Selangor
Dr Chan Siew Pheng

Consultant Endocrinologist,
Sime Darby Medical Center,
Subang Jaya, Selangor
Dr Khoo Kah Lin

Consultant Cardiologist
Pantai Medical Center
Dr Rosli Mohd Ali

Institute Jantung Negara,
Kuala Lumpur
Dr Sree Raman

Consultant Physician,
Hospital Tuanku Jaafar, Seremban
(HTA trained)

Dr Sim Kui Hian

Sarawak General
Hospital, Kuching
Dr Wan Azman

University Malaya Medical Center
Dr Zanariah Hussein

Consultant Endocrinologist,
Hospital Putrajaya, Putrajaya
11
External Reviewers (in alphabetical order):

Pn Che Zuraini Sulaiman

Pharmacist
Universiti Malaya Medical Centre
Dr Chia Yook Chin

Consultant Primary Care Physician

Universiti Malaya Medical Centre
Dr Ghazali Ahmad Kutty

Consultant Nephrologist
Hospital Kuala Lumpur
Dr Hashim Noh

General Practitioner,
Klinik Young, Newton and Partners
Kuala Lumpur/Petaling Jaya
Dr Lee Chuey Yan
Hospital Sultanah Aminah Johor
Dr Lee Fatt Soon

Consultant Geriatrician
Hospital Kuala Lumpur,
Kuala Lumpur
Dr Santha Kumari

Consultant Physician
Hospital Sultanah Rahimah, Klang
Dr V Paranthaman
Family Medicine Specialist,

Klinik Kesihatan Jelapang,
Ipoh, Perak
Dr Wan Mohamad
Wan Bebakar

Consultant Endocrinologist
Hospital Universiti Sains Malaysia,
Kota Baru, Kelantan
Dr Wong Kai Fatt

General Practitioner,
LW Medical Associates
Kuala Lumpur
Dr Zurkarnai Yusof

Hospital Universiti Sains Malaysia,
Kota Baru, Kelantan
12
RATIONALE AND PROCESS OF GUIDELINE DEVELOPMENT

Rationale:
In Malaysia, cardiovascular disease (CVD) is the leading cause of
death in both men and women1. CVD includes coronary heart
disease (CHD), cerebrovascular disease and peripheral arterial
disease. CHD is a spectrum ranging from stable angina to acute
coronary syndromes (ACS).
Malaysians develop ACS at a younger age when compared to
people in Thailand, mainland China and western countries. Our
local NCVD-ACS Registry, showed that most patients (96.8%) had
at least one established cardiovascular risk factorhypertension
(72.6%), dyslipidaemia (55.9%) and /or diabetes (55%)3.
In preventing CVD, efforts should be aimed at reducing global
risks. The Clinical Practice Guideline (CPG) is on management of
dyslipidaemia. The last CPG (3rd edition) was published in 2004.
Thus the need for an update.
Objectives:
The objective of this CPG is to:
provide guidance on the best treatment strategies for
managing dyslipidemia utilizing and optimizing existing
health resources.
This CPG has been drawn up by a committee appointed by the
National Heart Association of Malaysia, Ministry of Health and the
Academy of Medicine. It comprises cardiologists, endocrinologists
and general physicians from the government and private sectors
as well as from the Universities.
Process:
Evidence was obtained by systematic review of current medical
literature on dyslipidaemia using the usual search engines
PubMed, Medscape and Ovid. The other international guidelines
(American and European) on the subject were also studied. After
much discussion, the draft was then drawn up by the members
of the Expert Panel and submitted to the Technical Advisory
Committee for Clinical Practice Guidelines, Ministry of Health
Malaysia and key health personnel in the major hospitals of the
Ministry Of Health and the Private Sector for review and feedback.
The clinical questions were divided into major subgroups and
members of the Expert Panel were assigned individual topics. The
13
group members met several times throughout the development of

the guideline. All retrieved literature were appraised by individual
members and subsequently presented for discussion during group
meetings. All statements and recommendations formulated were
agreed collectively by members of the Expert Panel. Where the
evidence was insufficient the recommendations were derived by
consensus of the Panel. The draft was then sent to local external
reviewers for comments. It was also sent to the American College
of Cardiology and the European Society of Cardiology for feedback.
The level of recommendation and the grading of evidence used in
this guideline was adapted from the American Heart Association
and the European Society of Cardiology (ACC/ESC) and outlined
on page 15. In the text, this is written in black on the left hand
margin. In the Summary and Key Recommendations, it is written
as a superscript immediately after the therapeutic agent or at the
end of the statement as applicable.
Clinical Questions Addressed:
What is the current evidence on the management of patients
with dyslipidaemia?
Which management and recommendations are most
applicable to our local setting?
Target Group:
This guideline is directed at healthcare providers including general
practitioners, medical officers, pharmacists, general and family
physicians, cardiologists and endocrinologists.
Target Population: All individuals.
Period of Validity of the Guidelines:
This guideline needs to be revised at least every 5 years to keep
abreast with recent developments and knowledge.
Applicability of the Guidelines:
This guideline was developed taking into account our local health
resources. Blood chemistry for lipid profiles, liver and renal
function tests can be done in all government health facilities. The
medications recommended are approved for use in Malaysia.
This guideline aims to educate health care professional on
strategies to optimize existing resources in the management of
dyslipidemia.
14
Implementation of the Guidelines:

The implementation of the recommendations of a CPG is part of
good clinical governance. To ensure successful implementation of
this CPG we suggest:

increasing public awareness of CVD and its prevention

continuing medical education and training of healthcare
providers.
monitoring lipid levels in the population through National
health surveys which will now be conducted every 5 years
and through the NCVD ACS/PCI registry.
clinical audit at hospital level- documentation of target LDL-C
levels.
GRADES OF RECOMMENDATIONS AND LEVELS OF EVIDENCE

GRADES OF RECOMMENDATION
Conditions for which there is evidence and/or general agreeI
ment that a given procedure/therapy is beneficial, useful and/
or effective.
Conditions for which there is conflicting evidence and/or diverII
gence of opinion about the usefulness/efficacy of a procedure/
therapy.
II-a
Weight of evidence/opinion is in favor of its usefulness/efficacy.
II-b
Usefulness/efficacy is less well established by evidence/opinion
III
Conditions for which there is evidence and/or general agreement that a procedure/therapy is not useful/effective and in
some cases may be harmful.
LEVELS OF EVIDENCE
Data derived from multiple randomized clinical trials or meta
A
analyses
Data derived from a single randomized clinical trial or large
B
non randomized studies
Only consensus of opinions of experts, case studies or standard
C
of care
Adapted from the American Heart Association/American College of
Cardiology (AHA/ACC) and the European Society of Cardiology (ESC)
15
TABLE OF CONTENTS
Statement of Intent
1
Summary 2
Flowcharts I,II,III and IV
5-8
Message from Director General of Health
9
Members of the Expert Panel
11
External Reviewers
12
Rationale and Process of Guideline Development
13-15
Grades of Recommendation and Levels of Evidence
15
1.
2.
3.
4.
5.
6.

7.
8.

9.

10.

11.
12.
13.
14.
15.
16.
Introduction
Measurement of Lipids and Apoproteins
Classification of Dyslipidaemias
Dyslipidaemia as a Risk factor for CVD
Other Risk Factors for CVD
Global Cardiovascular Risk Assessment
6.1 Risk Stratification
6.2 Diabetes mellitus and Dysglycaemia as CHD
risk equivalents
6.3 Targets of therapy
Prevention of CVD
Management of Dyslipidaemia
8.1 Therapeutic Lifestyle Changes
8.2 Lipid lowering Drug Therapy
8.3 LDL Apheresis
Management in Specific Conditions
9.1 Specific Lipid Disorders
9.2 Diabetes Mellitus
9.3 Coronary Heart Disease
9.4 Hypertension
9.5 Stroke
9.6 Renal Disease
Management in Specific Groups
10.1 Women
10.2 Children and Adolescents
10.3 Elderly
Adherence, Compliance and Quality Assurance
References
Appendixes
Acknowledgement
Disclosure Statements
Source of Funding
16
17
17-19
19-22
22-24
24-27
27-34
27-32
32-34
34
35
36-47
36-39
40-47
47
47-60
47-52
52-54
54-56
56-57
57
58-60
61-63
61
61-62
62-63
63-64
65-79
80-84
85
85
85
1. INTRODUCTION
In 2009, cardiovascular disease (CVD) was the leading cause of
death in both men and women1. CVD includes coronary heart
disease (CHD), cerebrovascular disease and peripheral arterial
disease. CHD is a spectrum ranging from stable angina to acute
coronary syndromes (ACS).
The peak incidence of ACS in Malaysia was in the 51-60 year age
group and the male to female ratio was 3:12. The mean age in the
local NCVD-ACS Registry 2006 was 58.1 years.3 This is younger
than that noted in neighbouring countries such as Thailand (65
years) 4, China (63 years) 5 and in the western population (GRACE
Registry- 66 years6, Canada- 68 years7).
In the NCVD-ACS Registry, most patients (96.8%) had at least one
established cardiovascular risk factor hypertension (72.6%),
dyslipidaemia (55.9%) and/or diabetes (55%)3.
In the prevention of CVD, efforts should be aimed at reducing
global risks. This guideline emphasizes:
a multifactorial approach that addresses all risk factors.
This is because the benefits of modifying several risk factors
simultaneously are synergistic.
that preventing CVD should be directed at global CVD burden
rather than CHD alone.
In the management of dyslipidaemia the following changes have
been made:
identification of those at high risk this includes individuals
with established CVD, diabetes, multiple risk factors and
established renal disease.
emphasizes the importance of a family history of premature
CVD and familial dyslipidaemia
treatment targets.
The objectives of this CPG is to:
provide guidance on the best treatment strategies for
managing dyslipidemia utilizing and optimizing existing
health resources.
17
2. MEASUREMENT OF LIPIDS AND APOLIPOPROTEINS

Serum lipid levels are affected by several factors:
acute stress or illness, eg fever, surgery, acute myocardial
infarction.
drugs eg beta-blockers, thiazides, steroids.
2.1 Lipids TC, HDL-C, LDL-C and TG
Total cholesterol (TC) and high density lipoprotein cholesterol
(HDL-C) can be measured both in the fasting and in the non fasting
states. Triglycerides (TG) however should be measured after 1012 hours of fasting. TG levels are influenced by alcohol intake in
the preceding 24 hours and by smoking during the fasting state.
Low density lipoprotein cholesterol (LDL-C) is calculated using the
Friedewald equation:
LDL-C (mmol/l) = TC HDL-C - TG / 2.2
If TG > 4.5mmol/L, this formula is not valid.
LDL-C may also be measured directly although these methods are
not well standardized and not routinely performed.
2.2 Lipids non HDL-C
More recent data suggest that when TG > 2.3mmol/l, LDL-C
calculation using the above formula may not be accurate.
Cholesterol rich remnant lipoproteins - small Very Low Density
Lipoprotein (VLDL) and Intermediate Density Lipoproteins
(IDL) - are also significantly elevated.8,9 In this situation, LDLC
measurement alone does not reflect the entire atherogenic
lipoprotein fraction and Non-HDL-C is more representative of
the atherogenic burden.10 This can be calculated by the following
formula:
Non-HDL-C(mmol/l) = TC HDL-C
Non HDL-C levels can be calculated from a non-fasting serum. It is
a target of therapy in patients with TG > 4.5mmol/l.
18
Measurements made from whole blood differs slightly from that

obtained from plasma or serum. TC, TG and HDL-C measured using
desktop machines are acceptable when performed according to
specifications.
Lipid levels especially TG show biological variability. Because of
this and laboratory variability more than one measurement is
required in borderline cases.
2.3 Apolipoproteins (Appendix I, pg 80)
Apoproteins are proteins attached to lipid particles to form
lipoproteins. There are several apolipoproteins. Apo B is a
better indicator of CVD risk than LDL-C alone.11-14 It is found in
chylomicrons, VLDL, IDL, LDL and Lp(a) particles. Since each of these
particles contains a single Apo B molecule, measurement of Apo B
represents the total atherogenic burden. Apo B measurement has
been standardized, automated and can be done in the non-fasting
state. It is not routinely measured.
Key messages:
TC and HDL-C can be measured in the fasting and non
fasting states. TG is best measured in a fasting sample.
LDL-C is calculated using the Friedwalds equation.
When TG > 2.3mmol/l, non HDL-C is a better indicator
of total atherogenic burden.I,A
3. CLASSIFICATION OF DYSLIPIDAEMIAS
Dyslipidaemia is defined as lipid values outside the norm. Based
on therapeutic considerations, dyslipidaemias may be classified as
follows (Table 4):
Table 4: Classification of Dyslipidaemias
Hypercholesterolemia
Mixed Hyperlipidemia
Lipoprotein
LDL
LDL + VLDL
Hypertriglyceridemia
VLDL
Low HDL Cholesterol
HDL
19
Serum Lipid
T C
TC and TG
TG and
or HDL-C
TC and
or TG
Table 5: Primary Dyslipidaemia

Risk
of
CHD
Risk of
Pancreatitis
Plasma
Cholesterol
Plasma
Triglyceride
Serum Physical
signs
(if present)
Common
(polygenic)
Corneal Arcus
Xanthelasma
Familial
Combined
Hyperlipidemia
or
or
Corneal Arcus
Xanthelasma
Tendon
xanthomata,
(finger extensor,
Achilles tendons)
Corneal Arcus,
Xanthelasma,
Aortic stenosis
Tuberous
xanthomata,
(elbows), striae
xanthomata,
(palm creases)
tendon
xanthomata
Eruptive
xanthomata,
(buttocks, elbows)
retinal lipemia,
hepatosplenomegaly
Eruptive
xanthomata,
(buttocks, elbows)
retinal lipemia,
hepatosplenomegaly
Familial
Remnant
Chylomicronemia
Syndrome
or
Familial
Hypertriglyceridemia
High HDL-C
Low HDL-C
or
20
Dyslipidaemias may be primary or secondary in etiology. (Tables

5 & 6).
In the following situations, secondary causes of dyslipidaemia
should be considered:

When TC exceeds 7.0 mmol/l, exclude conditions such as

primary hypothyroidism, nephrosis, obstructive liver disease.
Cushings syndrome (including subclinical disease) can
lead to lipid abnormalities in 40-70% of patients.15 Patients
on exogenous steroids may also develop secondary
dyslipidemias. Hypothyroidism is another important cause.16
It is more prevalent in the elderly in whom a high index of
suspicion may be necessary for diagnosis.17
When TG exceeds 4.5 mmol/l, exclude secondary causes such
as alcoholism.
When there is high TG with low HDL-C, insulin resistance
states such as type 2 Diabetes (T2DM) and metabolic
syndrome have to be considered
Failure to respond to anti-lipid therapy.
In patients with a family history of T2DM or a past history of
thyroid disease.
Table 6: Causes of Secondary Dyslipidaemias
DISORDER
CHOLESTEROL
TRIGLYCERIDES
HDLCHOLESTEROL
Metabolic / Endocrine
Hypothyroidism
T2DM
Metabolic Syndrome
Cushings Syndrome
Renal
End stage renal disease
Nephrotic syndrome
or
Hepatic
Obstructive liver
disease
Primary biliary cirrhosis
Drugs
Alcohol
Thiazide diuretics
Beta blockers
21
Key messages:
Dyslipidaemias may be primary or secondary to
nephrotic syndrome, obstructive liver disease,
hypothyroidism,
Cushings
syndrome,
drugs,
alcoholism and insulin resistance states such as T2DM
and metabolic syndrome.
4. DYSLIPIDAEMIA AS A RISK FACTOR FOR CVD
Dyslipidaemia has been identified as one of the main risk factors
for CVD. Our local NCVD ACS Registry showed that dyslipidaemia
was present in 55% of our patients3. Specific lipid abnormalities
implicated are:
4.1. Elevated LDL-C levels
LDL-C has been shown to be atherogenic in epidemiological
studies. There is a direct relationship between levels of LDL-C
(or TC) and the rate of new onset CHD in men and women who
were initially free from CHD.18-21 In people with established CHD,
elevated LDL-C correlates with recurrent cardiac events.22,23 There
is a near absence of clinical CHD in populations with very low
levels of serum cholesterol throughout their life (TC<3.9mmol/L
or LDL-C< 2.6 mmol/L).24,25 The risk for CHD appears to increase
progressively above these levels. At levels of LDL-C above 3.4
mmol/L, atherogenesis proceeds at a significant rate particularly
in the presence of other major risk factors.26
Randomized controlled trials have repeatedly shown that lowering
of LDL-C reduces CVD events in both primary and secondary
prevention.27-34 Studies have also shown that LDL-C particle
concentration and size are important predictors of CVD.34,35,36
However measurement of these are not widely available and are
not standardized.
Thus LDL-C should be the primary target for cholesterol therapy.
Meta- analysis have shown that reducing LDL-C by 1% reduces
CHD risk by 1%.37
22
4.2. Low HDL-C levels

There is substantial data linking a low HDL-C level (< 1.0 mmol/L)
with increased risk of CHD.18,38,39,40 A 1% decrease in HDL-C, in
epidemiological studies, has been associated with 2-3% increase
in CHD risk.40 Clinical trials using pharmacotherapy to increase
HDL-C levels have, however, showed mixed results. 41,42,43
4.3. Elevated TG levels
Data suggest that a raised TG level indicates a modest but highly
significant association with CHD.44,45,46 This suggests that some
TG-rich lipoproteins are atherogenic. Weight reduction and drug
therapies (fibrates, nicotinic acid and statins) reduce remnant
lipoproteins and are accompanied by a reduced risk for CHD.43,47,48
4.4. Elevated Non-HDL-C levels
Non HDL-C reflects the concentration of cholesterol within all lipoprotein particles considered atherogenic. Many studies have
demonstrated that non HDL-C is a better predictor of CV risk than
is LDL-C and may be especially true in statin-treated patients.49,50,51
4.5. Atherogenic Dyslipidaemia
This consists of low HDL-C, raised TG and small dense LDL
particles.52,53 The LDL-C levels are usually normal but there is a
higher proportion of small dense LDL particles which are more
atherogenic.
Although epidemiological data indicates that the ratio of TC/
HDL-C is a CVD risk marker, there have been no outcome studies
to support using this as a target of therapy.
4.6 Lipoprotein Lp(a)
Elevated levels of Lp(a) have been shown to be related to
cardiovascular risk in some but not all studies.54,55
23
Key messages:
LDL-C should be the primary target of therapy I,A
Non HDL-C should be an alternative primary target of
therapy in patients with TG > 4.5 mol/L I,A
5. OTHER RISK FACTORS FOR CVD
More than 90% of CVD can be explained by 9 to 10 modifiable
risk factors dyslipidaemia, hypertension, smoking, diabetes,
abdominal obesity, psychosocial stress, low intake of fruits and
vegetables, alcohol intake and physical inactivity.56,57(Appendix II,
pg 80)
5.1. Age
The incidence of CVD increases with age.18 This is due to the
combined effects of age related changes in the vascular system as
well the duration of exposure to adverse risk factors.
5.2. Gender
The incidence of CVD is about 3-4 times higher in men than
women in the middle decades of life and approximately twice as
high in the elderly.18
5.3. Hypertension
Both elevated systolic and diastolic blood pressures are linked
with increased CVD risk.58,59,60 From epidemiological data, elevated
systolic blood pressure appears to be more important when
compared to diastolic blood pressure as a risk factor especially
in middle aged and elderly individuals.61-64 The presence of left
ventricular hypertrophy is associated with increased CV risk.
5.4. Smoking
This is an important CV risk factor and cause of mortality in both
men and women.65,66,67 The incidence and mortality of CVD is 2-3
times as high in cigarette smokers compared to non smokers.68,69
24
The risk of developing CVD is directly related to the number of

cigarettes smoked.70,71 The relative risk of CV events is greater
in younger than in older patients although the absolute excess
mortality related to smoking increases with age.68,70
Smoking interacts in a multiplicative manner with other risk
factors ie the risk is higher than that would have resulted from
simply adding together the independent risks.72,73
In individuals who discontinue smoking, the risk decreases within
a year or two of stopping and the curve flattens out within 4 years
although the relative risk remains slightly higher compared to
never-smokers.74,75
5.5. Family History of Premature CVD
Familial and genetic factors may play an important role in the
determination of some major risk factors, especially hypertension,
lipid abnormalities and glucose intolerance. In addition there
appears to be a familial predisposition to CVD.76,77,78 The presence
of premature CVD in first degree male relatives below the age of 55
years or female relatives below the age of 65 years is a recognized
independent risk factor for CVD.79 This risk is greater when more
family members are affected and the younger their age of onset
of CVD.
5.6 Others
Other risk factors include:
5.6.1 Lifestyle Risk Factors
- Abdominal obesity:
Risk for CVD is increased although a recent analysis seems
to indicate that abdominal obesity just helps to identify
high risk individuals with metabolic abnormalities. In
Asians, a waist circumference of > 90 cm in men and >
80 cm in women has been found to be associated with
increased CV risk.80-84 (Appendix III, pg 81)
25
- Physical Inactivity:
Numerous studies have shown that physical inactivity is
associated with increased mortality and CVD.85,86,87
- Intake of fruits and vegetables:
Low intake (less than 5 servings a day) increases CV
risk.88
5.6.2.: Risk Markers
The following risk markers maybe helpful in intermediate risk
patients to determine the intensity of therapeutic targets.
- Inflammatory markers (hs-CRP)
Pathological studies strongly support a role for
inflammation in the pathogenesis of the early stages
of atherosclerosis, plaque progression and rupture.
One such acute phase reactant is high sensitivity
C-reactive protein (hs-CRP). Data show that an elevated
level of hs-CRP identifies healthy individuals who are
at an increased risk of an initial and recurrent cardiac
events.89-93 Results of a recent trial indicated that healthy
persons with LDL-C levels in the normal range but with
elevated hs-CRP benefited from statins.94
- Hemostatic markers
An elevated level of fibrinogen has been associated with
an increased risk for coronary events.95,96
- Subclinical atherosclerosis Individuals with subclinical atherosclerotic disease are
at increased risk for major coronary events.97 Subclinical
atherosclerosis may be identified by the:
presence of abnormalities in the resting and / or
stress ECG
measurement of the ankle / brachial blood pressure
(ABI) (a level of less than 0.9 is significant)
measurement of carotid intima-medial thickness
(IMT) by ultrasound (more than 75th percentile for
age and sex)
measurement of coronary calcium score by computed
tomography (CT)
non invasive imaging of the coronary arteries by CT
angiography.
26
These tests may be used for risk stratification in individuals at intermediate risk. Patients with subclinical atherosclerotic disease may warrant a more aggressive preventive treatment strategy.
Key messages:
Increasing age, male gender, hypertension, smoking
and a family history of premature CVD are major
independent risk factors for CVD.
Diabetes is a CHD risk equivalent I,A
6. GLOBAL CARDIOVASCULAR RISK ASSESSMENT
Based on the Malaysian National Health and Morbidity Survey
2006, the prevalence of dyslipidaemia in Malaysians above the age
of 40 years was 28%98. All adults above the age of 40 years should
have a complete fasting lipid profile (TC, LDL-C, HDL-C, TG). If the
levels are normal, then screening should be done annually.
Individuals who already have evidence of atherosclerosis or are at
high risk of developing CVD, should have a complete lipoprotein
profile earlier in life. This includes individuals with a family history
of premature CVD, genetic dyslipidaemias, metabolic syndrome,
T2DM and abdominal obesity.
6. 1 Risk Stratification
Individuals with CVD and CHD risk equivalents belong to the
highest risk category.
The CHD risk equivalents are:
Other clinical forms of atherosclerotic disease (atherosclerosis
in any vascular bed - aorta including abdominal aortic
aneurysm, carotid, cerebral and peripheral vessels)
T2DM
Multiple risk factors that confer a 10 year risk for CVD > 20%
These individuals are at high risk of developing CVD . They should be
screened for the traditional risk factors and treated appropriately.
27
Table 7: Major Risk Factors for CVD (Other than LDL

Cholesterol)
Positive Risk Factors
Male 45 years of age
Female 55 years of age or premature menopause
without hormonal replacement therapy
Hypertension
Current cigarette smoking
Family history of myocardial infarction or sudden death
prior to age 55 in a male parent or male first degree
relative and prior to age 65 in a female parent or other
female first degree relative
HDL-C < 1.0 mmol/L
Negative Risk Factors
HDL > 1.6 mmol/L
In all other patients, their global CVD risk should be determined.
There are several risk equations that may be used.99 (Appendix IV,
pg 82). All have some limitations and difficulty to extrapolate to
our local population.
Until local data are available we recommend adopting the latest
(2008) Framingham CV risk score.100 This estimates CVD risk while
the earlier version (2002) provides a risk estimate of hard CHD
events ie cardiac death and nonfatal myocardial infarction.
The intensity of risk reduction therapy is dependent on an
individuals global risk of developing CVD. In determining CV risk
the following steps are taken:
Count the number of major risk factors for CVD (Table 7,pg
28).
In individuals with more than 2 risk factors, calculate the 10year CVD risk using the Framingham score sheets (Figures 1A
& B, 2A & B, pg 30-31).
The vascular age can also be determined (Figure 1C and 2C,
pg 32)
In individuals with 0 1 risk factors, the CV risk score need
not be calculated since the 10-year CVD risk is <10%.
28
Other risk factors not included in the general risk profile that
should be taken into account in evaluating risk include:
Clinical features of insulin resistance such as abdominal
obesity, elevated triglycerides, and dysglycaemia (See Section
6.2)
ECG evidence of left ventricular hypertrophy
hs-CRP levels
Evidence of subclinical atherosclerosis
Chronic kidney disease (GFR<60ml/min)
Chronic autoimmune inflammatory disorders such as
systemic lupus erythematosis and rheumatoid arthritis
Chronic HIV infection
These individuals are at high risk of developing CVD. They
should be screened for the traditional risk factors and treated
appropriately.
Individuals with 0-1 risk factor almost always have a 10 year CVD
risk <10%.
Individuals with 2 or more risk factors can fall into one of the
following risk categories for developing CVD over 10 years:
> 20%
10-20 %
< 10%
Those individuals with a 10-year risk of developing CVD of > 20%
have a very high risk and are therefore considered as CHD risk
equivalents. (see 6.1)
Determining an individuals global CVD risk will guide LDL-C target
goal and management strategies. (Table 8, pg 34)
The 10 year risk calculation is to be performed at the outset to help
guide the intensity of cholesterol lowering therapy. It cannot be
used to track changes in risk over time as risk factors are modified.
In calculating the risk scores (Figures 1A & B, 2A & B, pg 30-31), the
TC and HDL-C should be the average of at least 2 measurements.
The average baseline blood pressure (BP) must be obtained from
an average of several readings. A smoker means any cigarette
smoking in the past month.
29
Figure 1A: Estimation of 10 year CVD Points for MEN

(Framingham Point Scores) 100
Points
Age,y
HDL-C
-2
1.6+
-1
1.3-1.6
30-34
1
2
35-39
TC
SBP
(not
treated)
SBP
(treated)
Smoker
Diabetes
<120
No
No
<120
1.2-<1.3
<4.2
120-129
0.9-<1.2
4.2-<5.2
130-139
<0.9
5.2-<6.3
140-159
120-129
6.3-<7.4
160+
130-139
>7.4
40-44
45-49
140-159
Yes
Yes
160+
7
8
50-54
9
10
55-59
11
60-64
12
65-69
13
14
70-74
15
75+
Points
allotted
Grand Total :_____________points
Figure 1B: CVD Risk for Men100

Total Points
<-3or less
-2
-1
0
1
2
3
4
5
6
7
10 year Risk %
<1
1.1
1.4
1.6
1.9
2.3
2.8
3.3
3.9
4.7
5.6
30
Total Points
8
9
10
11
12
13
14
15
16
17
18+
10 year Risk %
6.7
7.9
9.4
11.2
13.2
15.6
18.4
21.6
25.3
29.4
>30
Figure 2A: Estimation of 10 year CVD Points for WOMEN

(Framingham Point Scores) 100
Points
Age,y
HDL-C
TC
-3
Smoker Diabetes
<120
-2
1.6+
-1
1.3-1.6
30-34 1.2-<1.3
0.9-<1.2
SBP (not
SBP
treated) (treated)
35-39
<120
<4.2
120-129
4.2-<5.2
130-139
<0.9
140-149
5.2-<6.3
No
120-129
130-139
40-44
6.3-<7.4
150-159
45-49
>7.4
160+
No
Yes
Yes
140-149
150-159
50-54
55-59
60-64
10
65-69
11
70-74
12
75+
160+
Points
allotted
Grand Total :_____________points
Figure 2B: CVD Risk For Women100

Total Points
<-2
-1
0
1
2
3
4
5
6
7
8
9
10 year Risk %
<1
1.0
1.2
1.5
1.7
2.0
2.4
2.8
3.3
3.9
4.5
5.3
Total Points
10
11
12
13
14
15
16
17
18
19
20
21+
31
10 year Risk %
6.3
7.3
8.6
10.0
11.7
13.7
15.9
18.5
21.5
24.8
28.5
>30
Figure 1C : Heart Age/ Vascular Age for Men100

Points
Heart age, y
<0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
>17
<30
30
32
34
36
38
40
42
45
48
51
54
57
60
64
68
72
76
>80
Figure 2C : Heart Age/ Vascular Age for Women100

Points
Heart age, y
<1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
<30
31
34
36
39
42
45
48
51
55
59
64
68
73
79
>80
32
6.2. Diabetes mellitus and Dysglycaemia as CHD risk equivalents

Patients with type 2 diabetes mellitus (T2DM) and impaired
glucose tolerance
(IGT) have an increased risk of cardiovascular events.101,102 These
patients have higher mortality and a higher incidence of recurrent
cardiac events.103
The two main types of DM (type 1 and type 2) have different
patterns of dyslipidaemia. Type 2 diabetes (T2DM) may be
associated with insulin resistance, as in some individuals with the
metabolic syndrome.
The current definition of metabolic syndrome (2009) includes any
3 or more of the following (including those on treatment)*:
Elevated Waist circumference (Asian cut-off) :
- females >80cm
- males >90cm
Elevated TG > 1.7 mmol/L
Reduced HDL-C < 1.3 mmol/L (female) or

< 1.0 mmol/L (male)
Elevated blood pressure (BP):

- Systolic BP > 130 and / or diastolic BP > 85 mmHg
Disorders of glycaemia:
- T2DM, or
- impaired glucose tolerance (IGT)

[Fasting plasma sugar < 7.0 mmol/L and

2 hours after 75 gm glucose load: 7.8 11.1 mmol/L], or
- impaired fasting glucose (IFG)
[Fasting plasma sugar: 6.1 7.0 mmol/L]
*Adapted from Joint Interim Statement (Joint Interim Statement of International
Diabetes Federation Task Force on Epidemiology and Prevention, National Heart Lung
Blood Institute (NHLBI), American Heart Association (AHA), World Heart Federation
(WHF), International Atherosclerotic Society (IAS and International Association for
Study of Obesity (IASO) Circulation 2009:120:1640-1645
Proatherogenic risk markers like elevated Lp(a), prothrombotic

risk markers eg. raised PAI-1, increased fibrinogen and endothelial
dysfunction are found in insulin resistance states and contribute
to the increased CV risk. These associated abnormalities of insulin
resistance can be present for up to 10 years before detection of
the glycaemic disorder.
33
I,A
Individuals with type 1 diabetes are more likely to have elevated

TC, with rise in LDL-C and increased TG. These lipid abnormalities
can be fully corrected with good glycaemic control with insulin.
Individuals with T2DM have the atherogenic dyslipidaemia. Improvement of glycaemic control may not fully correct this dyslipidaemia.104 Some studies show better correlation of non HDL-C
than LDL-C to coronary mortality.10 (see 4.4. & 4.5)
6.3. Target Lipid Levels
I,A
LDL-C is the primary target for therapy.
I,A
The target LDL-C level will depend on the individuals global risk.
(see Table 8)
Table 8: Target LDL-C levels
Global Risk
0-1 risk factor a
2 or more risk
factors b
CVD and CVD risk
Equivalents
LDL-C levels to
initiate Drug therapy
Target LDLC
levels (mmol/l)
4.9 c
3.4 c
2.6
2.0 to < 2.6
< 4.1
3.4d
< 2.6e
< 2.0f
a Almost all individuals with 0-1 risk factor have a 10 year risk < 10%, thus 10 year risk
assessment in individuals with 0-1 risk factor is not necessary.
b These include individuals with multiple risk factors but a 10 year risk of CVD of < 20%.
c After 8-12 weeks of TLC.
d An optional target of <2.6mmol/L in certain high risk individuals. See flowchart II & III,
pg 4
e The lower the LDL-C achieved, the greater the CV benefits seen.
f Consider LDL-C target goal < 2.0 mmol/LI,A in very high risk individuals eg individuals
with ACS, recurrent cardiac events, CHD with T2DM and those with multiple poorly
controlled risk factors
See Flowcharts I-IV, pg 5-8.
Key messages:
Individuals should be risk categorized I,C (Table 7, pg 28,
Fig 1A & B, 2A & B, pg 30-31).
Target lipids levels will depend upon the individuals
global risk.
Individuals with CVD and CHD risk equivalents should be
treated aggressively with drug therapy I,A (Table 8, pg 34;
Flowcharts I-IV, pg 5-8).
34
7. PREVENTION OF CVD
Prevention can be divided into:

Primary prevention is the prevention of occurrence of CVD

events in people without CVD.
Secondary prevention is the prevention of progression of CVD
and its complications in people with established CVD or CVD
risk equivalents.
Strategy of primary prevention

The strategy is based on a:

Population based strategy
This strategy is aimed at educating the public concerning CVD,
its presentation and complications, cardiac risk factors, and the
importance of maintaining a healthy lifestyle, which is a healthy
diet, weight control, increased physical activity and the avoidance
or cessation of smoking. These measures should be started early
in life. Mass screening for dyslipidaemia is not advocated as it is
not cost effective and there may be inadequate follow-up and
counseling.
Individual based strategy
The aim is to identify individuals at risk of developing CVD and
modifying their risk factors. This would include all individuals
above the age of 40 years. (See Section 6).
Strategy of secondary prevention
This is aimed at individuals with established CVD or with CVD risk
equivalents. In these high-risk persons, drug therapy should be
initiated together with therapeutic lifestyle changes (TLC).
35
8. MANAGEMENT OF DYSLIPIDAEMIA
8.1. THERAPEUTIC LIFESTYLE CHANGES
Introduction
Therapeutic lifestyle changes (TLC) refer to dietary modification,
weight reduction, regular physical activity, cessation of smoking
and alcohol restriction. TLC is an integral component of the
treatment of dyslipidaemia. It should precede or be initiated
together with drug therapy and is directed especially at individuals
who are obese, who smoke and who seldom exercise. For patients
without CVD or CVD risk equivalents, emphasis should be placed
on TLC.
8.1.1. Dietary Modification
I,B
This is aimed at optimizing lipid levels while maintaining a

balanced diet. It is encouraged to refer an individual to a dietician
for medical nutrition therapy. Dietary therapy can lower TC by
10-15% and occasionally >20%.105 Dietary therapy is continued
indefinitely. (Appendix V, pg 83)
I,B
The intake of food high in cholesterol content must be reduced.106-109

A high intake of saturated fatty acids (SFA) and trans fatty acids
(TFA) raise LDL-C levels while a high intake of monounsaturated
fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) lower
LDL-C and reduce CV risk.106,110,111 Thus both PUFA and MUFA
should be encouraged in place of SFA and TFA. SFA should not be
replaced with carbohydrates.
I,B
A high intake of carbohydrate (> 60% of total caloric intake) results

in a reduction of HDL-C and a rise in TG levels.112,113 In individuals with the metabolic syndrome a lower carbohydrate intake is
important.
IIa,B
The use of viscous (soluble) forms of dietary fibre (oats, pectin,

guar and psyllium) of at least 510 gm per day is encouraged as
they have been shown to reduce LDL-C levels.114,115,116
36
IIb,B
Plant stanol/sterol esters (23 gm/day) also have a LDL-C lowering

effect117 which is dose related but there is inter-individual variation in their response. Plant sterols and stanols are not routinely
recommended for the prevention of CVD since there are no CV
outcome data.
IIb,B
High intake of soy protein (25-50 gm/day) can cause small reductions in LDL-C.106
8.1.2. Weight Reduction
I,B
I,B
This is important in overweight and obese individuals particularly

those with the metabolic syndrome. Weight reduction helps to
lower TG and increase HDL-C levels, in addition to enhancing the
cholesterol (TC and LDL-C) lowering effects of dietary modification.118
A weight reduction of 0.5-1.0 kg per week is recommended. According to the Asia Pacific Western Pacific Regional World Health
Organization, the recommended BMI in Asians is 18.5 - < 23 kg/
m2 and a waist circumference < 90 cm for males and < 80 cm for
females.81
8.1.3. Physical Activity
I,B
I,A
Physical activity and weight reduction enhance the lipid-lowering

effects of dietary therapy. They also improve cardiovascular fitness, lower BP, increase insulin sensitivity, increase HDL-C levels
and decrease TG levels.119,120 Such activities include aerobic exercises such as brisk walking, jogging, cycling, swimming. Exercise
needs to be regular and adequate (30-45 minutes per session at
least 5 times a week).
8.1.4. Cigarette Smoking
Smoking is one of the major risk factors for CVD and must be
stopped. Even passive smokers are at high risk of developing CVD.
The decline in CVD risk begins within a year or two after smoking
cessation.74,75
37
I,B
I,A
8.1.5. Alcohol
Restriction of alcohol is advised in patients with dyslipidaemia as it
increases plasma TG levels.121,122
Moderate alcohol consumption (not more than 14 units for males
and 7 units for female per week) increases HDL-C and apo A-I and
is associated with a reduction in all cause mortality.123-127
Over-consumption is however associated with a higher mortality
rate. High intake of alcohol elevates BP and can precipitate acute
pancreatitis in individuals with high TG levels. Nondrinkers should
therefore not be encouraged to start alcohol consumption to
improve their dyslipidaemia.
(1 unit of alcohol is equivalent to 250 ml of beer, 100 ml of wine
and 30 ml of whisky)
IIa,B
IIb,B
8.1.6. Miscellaneous
Omega3 polyunsaturated fatty acids are useful in individuals with
high TG and can be considered in addition to fibrates or nicotinic
acid. For lowering TG, a dose of 3-9 gm/day of omega-3 fatty acids
is required
In patients with CVD, omega-3 fatty acids (dose of 0.75 gm-1
gm/day) has been shown to reduce sudden cardiac death, CHD
mortality and total mortality although a recent trial showed no
benefit.128,129,130
It is recommended to increase intake of omega-3-fatty acids
by eating more fish, walnuts, flaxseed oil and green, leafy
vegetables.128,131
III,B
The importance of the following in treating dyslipidaemia remains

uncertain : - trans-fatty acids, essential fatty acids (linoleic acid,
linolenic acid), and lecithin.
III,A
The use of antioxidants (such as vitamin C, E, beta carotene,

bioflavonoids) selenium and Coenzyme Q-10 has not been shown
to be effective in preventing or treating CVD. Foods, vitamins and
minerals which act as antioxidants include Co-enzyme Q10, ginkgo,
green tea, Vitamin A (Beta-carotene), Vitamin C, Vitamin E.132,133
38
III,B
None of the formulations of garlic have been shown to produce a

statistically significant effect on the cholesterol level.134 Guggulipid
has not been found to be effective in lowering LDL-C levels and
may cause a hypersensitivity rash in some individuals.135
8.1.7. Assessing response to TLC
The lipid profile should be measured 6-12 weeks after initiating
TLC. Generally, TLC may reduce lipid levels (at best) up to 20%.
For individuals who attain target lipid levels, they should continue
these lifestyle changes life-long to maintain these effects. They can
be assessed every 6 months with a full lipoprotein analysis.
On the other hand, if these levels are not achieved, patient
compliance should be re-assessed and TLC intensified. They
are then reassessed after 6-12 weeks. There is a genetically
determined inter-individual variability in the response to diet.
Thus poor response to TLC is not always due to non-compliance.
For individuals at low risk, failure to achieve a defined target
value for LDL-C does not necessarily mean that dietary therapy
be replaced by drug therapy. Whatever reduction that is achieved
will help lower the risk of CVD especially with the concomitant
adoption of a healthy lifestyle.
When a decision has been made to start drug therapy, TLC must
still be continued indefinitely because it provides substantial
additive LDL-C lowering effects.136
Key messages:
A multifactorial lifestyle approach is recommended to
reduce the risk of CVD. I,B
In patients without CVD or CHD risk equivalents, a
period of at least 6-12 weeks is given to assess the
effectiveness of TLC before considering drug therapy. I,C
39
8.2. DRUG THERAPY

I,A
Therapeutic Lifestyle Change forms an integral component in the

management of dyslipidaemia. In secondary dyslipidaemia, efforts
should be made to correct the underlying cause.
8.2.1 Lipid Lowering Drugs
In those with established CVD / CHD risk equivalents, drug
treatment will need to be initiated in conjunction with TLC (Table
8, pg 33). There are 5 major groups of anti-lipid drugs. (Table 9,
pg 41)
8.2.1.1 HMG CoA Reductase Inhibitors (Statins)
I,A
Statins are inhibitors of HMG CoA reductase , the rate limiting enzyme in hepatic cholesterol synthesis. They are the most effective
drug class and the treatment of choice in reducing LDL-C. They
are suitable first-line agents in familial hypercholesterolemia, for
primary prevention of CVD, secondary prevention of CVD and CHD
equivalents.
They have moderate effect in lowering TG and in elevating HDL-C.
Treatment is initiated at the recommended starting dose with the
evening meal or at bed time except for long-acting statins that
can be taken at any time. The dose is then adjusted accordingly to
achieve target levels. Serum lipids and alanine aminotransferase
should be measured at 6-8 weeks after starting treatment and
thereafter as necessary especially when doses are increased.
III,C
Statin therapy is contraindicated in pregnancy and lactation. It

should not be prescribed to women of child bearing potential unless adequate contraception is taken.
40
Table 9: Major Anti Lipid Drug Classes (Adapted from ATPIII)139

Drug Class
Lipid Effects
Side Effects
Contraindications
HMG-CoA
Reductase
Inhibitors
(statins)
LDL-C 18-55%
HDL-C 5-15%
TG
7-30%
-Myopathy
-Increased liver
Enzymes
Absolute:
-Active or chronic liver
disease
Relative:
-Concomitant use of
certain
drugs*
Fibric-Acid
Derivatives
(Fibrates)
LDL-C 5-20%
HDL-C 10-35%
TG
20-50%
-Dyspepsia
-Gallstones
-Myopathy
Absolute:
-Severe hepatic
disease
-Severe renal disease
Relative:
-Concomitant use of
certain drugs**
Bile-Acid
Sequestrants
(Resins)
LDL-C 15-30%
HDL-C 3-5%
TG
/
-GIT distress
-Constipation
-***Decreased
absorption of
certain drugs
Absolute:
-Dysbetalipoproteinemia
-Tg > 4.5 mmol/l
Relative:
-Tg > 2.3 mmol/l
Nicotinic Acid
(Niacin)
LDL-C 5-25%
HDL-C 15-35%
TG
20-50%
-Flushing
-Hyperglycemia
-Hyperuricemia
(or gout)
-Upper-GIT
distress
-Hepatotoxicity
Absolute:
-Chronic-liver disease
-Severe Gout
Relative:
-Diabetes (high doses
only)
-Hyperuricemia
-Peptic-Ulcer Disease
Cholesterol
Absorption
Inhibitors****
LDL-C 18-25%
HDL-C 3-5%
TG
8-14%
-Headache
-Abdominal pain
-Diarrhea
cyclosporin, macrolide antibiotics, various anti fungal agents and cytochrome P-450
inhibitors (fibrates and nicotinic acid should be used with appropriate caution)
**
gemfibrozil and repaglinide140
*** Paracetamol, NSAIDs, anticoagulant, valproate, digitalis, thiazides, thyroxine,
raloxifene, propranolol and tricyclic antidepressants.
**** usually used in combination with statins.
These data are derived from short-term clinical trials meant for
drug registration. In real life long term use, the amount of lipid
change achieved may be less than this.
41
Recent concern about statin and new onset diabetes has not been
substantiated. In fact statins have been proven to prevent CV
events in diabetics with no overt CVD.137,138 There is no evidence
that patients on statins have increased risk of cancer, poor memory
and renal toxicity.
The routine use of Co enzyme Q 10 to prevent muscle toxicity is
unproven and therefore not recommended.
Recommended Dosages for Statins*
Drug
Recommended
initiating dose
Usual dose range
Lovastatin
20 mg
10-80 mg/day in single

or divided doses
Pravastatin
20 mg
10-40 mg daily
Simvastatin
20 mg
5-80 mg once daily
Fluvastatin
20 mg
20-80 mg/day single

or divided doses
Atorvastatin
10 mg
10-80 mg once daily
Rosuvastatin
10 mg
10-20 mg once daily
* As stated in MIMS,Malaysia
8.2.1.2. Fibric Acid Derivatives (Fibrates)

Fibrates are Peroxisome Proliferator Activated Receptor (PPAR)
agonist which in turn stimulates synthesis of fatty acid oxidation.
Fibrates are particularly useful in individuals with combined
(mixed) dyslipidaemia and hypertriglyceridaemia as they reduce
serum TG levels and increase HDL-C effectively. Fibrates are
alternative treatment in individuals with mild to moderate
hypercholesterolemia who are statin intolerant.
IIa,B
In men with established CHD with low LDL-C and HDL-C, fibrates
have been shown to improve CV outcome. In individuals with
T2DM, fibrates reduced the composite endpoint of CV death, CV
events and the need for coronary and carotid revascularization.43,47
42
IIa,B
Doses of fibrates need to be adjusted in the presence of CKD.

Serum alanine aminotransferase should be monitored when
starting therapy or when doses are increased.
Recommended Dosages for Fibrates*
Drug
Recommended Dosage
Bezafibrate
200 mg daily increasing to a maximum dose of 200 mg

tds (regular) or 400 mg daily (sustained release)
Fenofibrate
300 mg daily or in divided doses (regular) or 200 mg

daily (micronised) or 160 mg daily (supra)
Gemfibrozil
600-1500 mg daily in divided doses (regular) or 900

mg daily (sustained release)
Ciprofibrate
100 mg daily
* As stated in MIMS,Malaysia
8.2.1.3. Bile Acid Sequestrants (Resins)

IIa,B
Bile acid sequestrants bind to bile acids to promote their secretion

into the intestines. They are effective in lowering LDL-C. Resins may
increase TG and HDL-C slightly. Monotherapy has a modest effect
on CHD in primary prevention. Resins are therefore not suitable as
monotherapy in combined hyperlipidaemia. Combination with a
statin may be necessary in severe hypercholesterolaemia.
Other medications should be taken 1 hour before and / or 4 hours
after resins.
This class of drug is currently not available in the Malaysian market.
8.2.1.4. Nicotinic Acid (Niacin) and its derivatives
IIa,B
Nicotinic acid decrease mobilization of free fatty acids from adipose tissues. It is very effective in increasing HDL-C and also effectively lowers both TC and TG levels. It is also the first to show
mortality reduction in individuals with CHD.48
43
However its side effects (particularly flushing and gastrointestinal

side effects) tend to limit compliance. Acipimox is a derivative
of nicotinic acid which produces fewer side effects (especially
less cutaneous flushing) and does not worsen glucose tolerance.
Tredaptive is a combination of modified release nicotinic acid
and laropiprant (a prostaglandin inhibitor) which will reduce the
flushing caused by nicotinic acid.
Recommended Dosages:
Nicotinic acid (Niacin) is available as capsules of 100 mg or 500mg,
and sustained release form:
- starting dose: 150-300 mg daily in divided doses, titration of dose
up to 2g/day (Usual dose) It should be taken with meals to reduce
gastrointestinal side effects.
Acipimox is currently not available in the Malaysian market.
8.2.1.5 Cholesterol Absorption Inhibitors
Cholesterol absorption inhibitors selectively block intestinal
absorption of both dietary and biliary cholesterols and other
phytosterols. This leads to a reduction in hepatic cholesterol
delivery - a mechanism which complements the action of statins. It
is indicated as monotherapy for primary hypercholesterolemia in
patients who cannot tolerate statin or fibrate. It can also be used in
combination with statins to further lower LDL-C. When used with
statins, the lipid lowering effects appears to be synergistic.
Recommended Dose:
Ezetimibe 10 mg daily
8.2.2. Recommended Drug Treatment for Dyslipidaemia
The choice of drugs will depend on the type of dyslipidaemia.
(Table 10, pg 45)
44
Table 10: Suggested Drug Therapy for Dyslipidaemia

Lipid Values
Initial Drug
Suggested Addition
(in order of preference)
LDL-C > 3.4 mmol/l

TG
< 2.3 mmol/l
Statins
Resin
Ezetimibe
Fibrates
Nicotinic Acid
LDL-C 3.4 mmol/l

TG
: 2.3-5.7 mmol/l
Statins
Fibrates
Nicotinic Acid
If:
LDL-C < 2.6 mmol/l
Statins
If:
LDL-C > 2.6 mmol/l
Fibrates
Nicotinic Acid
Statins
Fibrates
Nicotinic Acid
TG
Fibrates
Nicotinic Acid
Statins
Omega 3 FA
HDL-C < 1.0 mmol/l

TG
< 5.7 mmo/l
I,A
IIa, B
> 5.7 mmol/L
LDL-C reduction with statin treatment remains the cornerstone of

lipid lowering therapy to reduce risk of CVD. If target lipid goals
have not been achieved after 8-12 weeks of optimal monotherapy,
combination therapy is suggested (Table 10, pg 45). Combination
of statin and cholesterol absorption inhibitors have been shown
to reduce CV events and renal outcomes in patients with CKD.141
Some combination therapies carry a potential for adverse
effects, especially myositis (particularly combination of fibrates
plus statins) although the incidence is still low (0.5 - 2.5%). For
monotherapy, the incidence of myopathy is 0.1 - 0.5%.142,143 The
combination of gemfibrozil and statin is discouraged. If used,
caution and close monitoring should be stressed.
8.2.3. Monitoring and Duration of Therapy
It should be stressed that these individuals will be on lifelong
therapy. It is therefore important to assess them on a regular basis,
45
ie. in terms of response to treatment and to look out for possible

side-effects related to the drugs. After starting drug therapy, LDL-C
level should be measured at 6-8 weeks and drug doses titrated
if necessary. Once target lipid levels are achieved, a 4-6 monthly
follow up is recommended.
Monitoring of ALT is necessary if statins and fibrates are used
for treatment. Liver function tests should be carried out before
and within 1-3 months of starting treatment. Statins should be
discontinued if transaminase levels rise to at 3 times the upper
limit of normal. If the levels are elevated between 2 to 3 times
upper limit of normal, the trend should be monitored at monthly
intervals. If the levels are stable, they only need be checked
periodically or if the dose of statin or fibrate is increased. If myositis
is suspected, then creatine kinase levels should be measured. If
the level is more than 10 times the upper limit of normal, then the
drug should be discontinued.
8.2.4 Pharmacoeconomics of Lipid Lowering Therapy
The economic implication of treating dyslipidaemia should not
be judged only by the direct out of pocket cost. Dyslipidaemia
leads to major CV events which have economic implications. The
incidence of CVD and CKD in the country is on the rise and so is
the cost associated with it. As such the economic implication of
treating dyslipidaemia must be looked at from the perspective of
total cost (direct and intangible cost) instead of just direct out of
pocket cost. Local data is lacking at this present time.
Cost effective analysis of major lipid lowering trials have shown that
although direct short term cost may be higher, the incremental
cost effectiveness ratio (derived from the ratio of cost over Quality
Adjusted Life Years) is favorable even for patented statins.144
A substantial proportion of statin acquisition cost was offset by
reduction in health care resource use as a consequence of lesser
CV events. Even taking into consideration the cost of patented
statin and measurement of hs- CRP, statin use is cost effective even
in primary prevention of medium risk individuals. 145 This is also
true for fibrate treatment in T2DM.146
Cost effective analysis showed that prescribing generic statins may
not necessarily translate into the most cost effective option for
treating dyslipidemia.147
46
Key messages:
Statins are the drug of choice for reducing LDL-C in a
wide range of dyslipidaemic patients. I,A
Fibrates and nicotinic acid may be considered
for increasing HDL-C and reducing TG after LDL-C
treatment goal has been achieved. IIa,B
Some individuals may require combination therapy to
achieve lipid target goals
8.3 LDL-C APHERESIS
IIa,B
LDL-C apheresis is indicated in patients with homozygous familial

hypercholesterolemia (FH) who do not respond satisfactorily to
maximum multiple drug therapy.148-153
IIa,B
This form of treatment may also be considered in individuals with

severe heterozygous FH and progressive coronary artery disease
who do not achieve target lipid levels with maximal drug therapy
(high intensity statin at maximal dose with ezetimibe).148-153
In some patients with very high LDL-C levels, despite aggressive
treatment with medications plus LDL-C apheresis, progression of
atherosclerosis may occur but at a lesser extent.154,155
9. MANAGEMENT IN SPECIAL CONDITIONS
9.1. Specific Lipid Disorders
9.1.1. Elevated TG
There is evidence of a strong association between TG levels and
CVD.44,45,46 This may in part be due to its association with the
other CV risk factors found in the metabolic syndrome. Very high
serum TG (> 5.7 mmol/L) can give rise to acute pancreatitis and
needs urgent and definitive treatment. High (2.3-5.7 mmol/L)
and borderline high levels (1.7-2.3mmol/L) of TG are a common
association with low HDL cholesterol, small dense LDL particles
and insulin resistance.
47
9.1.1.1. Targets of therapy

I,A
In individuals with elevated TG, the primary target of therapy remains achieving LDL-C goal depending upon the individuals global
risk. (Table 8, pg 34)
I,A
In individuals where the TG > 2.3 mmol/L, non HDL-C is more representative of all atherogenic lipoproteins than LDL-C. (see also
section 2 and 4.4) In these individuals, the secondary target of
therapy is non HDL-C as listed in Table 11, pg 48.
Another secondary target of therapy is TG < 1.7 mmol/L.
Table 11: Targets of LDL-C and non HDL-C
Global Risk
Target LDLC
levels
(mmol/L)
non HDL-C levels

corresponding to
LDL-C goals (mmol/L)
0-1 risk factor
< 4.1
< 4.9
2 or more risk
factors*
< 3.4**
< 4.1
2.0 to < 2.6

< 2.0
< 3.4
< 2.6
CHD and CHD risk

Equivalents
*
**
These include individuals with multiple risk factors but a 10 year risk of CVD of
< 20%
Optional target <2.6mmol/L in certain high risk individuals. See Flowchart II &
III
9.1.1.2. Classification of TG (see Table 12, pg 48)

With reference to Table 12, pg 50:
Factors contributing to elevated TG include: obesity and
overweight, physical inactivity, cigarette smoking, excessive
alcohol intake, high carbohydrate intake (>60% of energy
intake), T2DM, chronic kidney disease, nephrotic syndrome,
Cushings disease, lipodystrophy, pregnancy and various drugs
{corticosteroids, beta-blockers, retinoids, oral estrogens (not
transcutaneous estrogen), tamoxifen, protease inhibitors for
AIDS}.
48
Genetic disorders associated with high TG (familial combined

hyperlipidaemia, familial hypertriglyceridaemia and familial
dysbetalipoproteinaemia)
9.1.1.3. Management of elevated TG (see Appendix VI, pg 78)

I,A
In individuals with mixed hyperlipidaemia, the primary target of

therapy is to achieve LDL-C goal.
In those individuals with:
TG between 2.3 and 4.5mmo/l the secondary target of
therapy is non HDL-C
TG > 4.5mmol/L, the primary target of therapy is non HDL-C.
Once LDL-C target has been achieved, the next step is to target TG
< 1.7 mmol/L.
a) Borderline high TG (1.72.3 mmol/L)
A target value of TG < 1.7 mmol/L can usually be achieved by:

I,B
Lifestyle changes of weight reduction, low carbohydrate diet,

control of diabetes or insulin resistance, exercise, reduction
of alcohol intake and cessation of smoking.106,109,112,113,118-121
Medications are rarely required.
b) High TG ( 2.35.7 mmol/L)

I,B
I,B
I,A
IIa,B
Treatment should include:

Lifestyle changes as outlined above.
Ensure diabetes if present is controlled.
Drug therapy should be considered in high risk individuals.
There are two options to achieve targets139:

- intensifying statin therapy if LDL-C target not achieved156

- adding fibrates or niacin as a combination therapy

to statin157,158,159

- caution should be exercised when gemfibrozil is used

in combination with statins because of the significant

risk of rhabdomyolysis.141,142
49
Table 12: Classification of TG (Adapted from ATPIII)139

Classification
of serum TG
Causes of elevated TG
Clinical significance
Borderline
High TG
(1.7-2.3
mmol/L)
Acquired causes
- Overweight and obesity
- Physical inactivity
- cigarette smoking
- excess alcohol intake
- high carbohydrate intake
(> 60% of total energy)
Secondary causes
Genetic causes
various genetic
polymorphism
Marker for atherogenic

dyslipidemia
- elevated small LDL
particles
- Low HDL-C
Marker for the
metabolic syndrome
- elevated BP
- insulin resistance and
glucose intolerance
- prothrombotic state
- proinflammatory state
High TG
(2.3-5.7
mmol/L)
Acquired causes
- same as for borderline
high TG (usually combined
with foregoing causes)
Secondary causes
Genetic causes
- familial combined
hyperlipidemia
-familial
hypertriglyceridemia
-polygeneic
hypertriglyceridemia
- familial
dysbetalipoproteinemia
Elevated atherogenicremnant
lipoproteins
Marker for other
components of
atherogenic
dyslipidemia (see above)
Marker for the
metabolic syndrome (see
above)
Very high TG
(
5.7mmol/L)
Usually combined causes

- same as for high TG
Familial lipoprotein lipase
deficiency
Familial apolipoprotein
C-11 deficiency
Metabolic syndrome,T2DM and

increased risk for CHD
Increased risk for acute
pancreatitis
Chylomicronemia
syndrome
- eruptive skin xanthomas
- hepatic steatosis
- lipemia retinalis
- mental changes
- high risk for pancreatitis
Normal TG
(< 1.7
mmol/L)
50
There are no clinical trial evidence that show a reduction in CVD

events with drug therapy in individuals with only elevated TG both
in primary and secondary prevention. (Appendix VI, pg 84)
c) Very high TG > 5.7 mmol/L:
When TG is extremely high (>10mmol/L) treatment goal is to

prevent acute pancreatitis.
I,B
I,B
I,B
IIa,B
Treatment include:
Start with a fibrate or nicotinic acid

- Gemfibrozil and Fenofibrate lower TG by about 70%.43,47,160,161

- Nicotinic acid is effective at doses of above 2gm per day.139,162
very low fat diets (< 15% of calorie intake) and lifestyle
changes (See Section 8.1)106,111,139
Severe hypertriglyceridaemia associated with uncontrolled
diabetes warrants initiation of insulin therapy. The TG level
will improve but may not normalize.
Fish oils which contain long chain omega-3 polyunsaturated
fatty acids can also lower TG. Doses of 3 to 9 gm per day can
lower TG by up to 50%.139,163 They can be considered as an
addition to fibrate or nicotinic acid.
Statins are not useful as a first line therapy in this situation.
In these individuals, it is difficult to achieve target values of TG
(< 1.7mmol/L).
Levels of TG < 2.3 mmol/L are acceptable.
9.1.2. Low HDL-C and High TG:
Low HDL-C and high TG are seen in insulin resistance states and
very high carbohydrate intakes.
I,A
IIa,B
I,A
Treatment of this dyslipidaemia in individuals with CVD or CHD risk

equivalents is aimed at lowering LDL-C to target.164 The choice of
anti lipid drug will depend upon the level of LDL-C (Table 10, pg
45). If the HDL-C is still low despite adequate TLC then consider,
fibrates or niacin if LDL-C is < 2.6mmol/L.43,47,160,161,162
statin if LDL-C is > 2.6mmol/L 165,166
51
9.1.3. Isolated Low HDL-C

Individuals with isolated low HDLC have HDL-C < 1.0 mmol/L and
TG < 1.7 mmol/L. Low HDL-C is an independent major risk factor
for CVD.18,38,39 The major causes are obesity, physical inactivity,
cigarette smoking and genetic factors. There are however no large
outcome studies to date showing that increasing HDL-C improves
CVD outcomes. 164
Treatment for isolated low HDL-C is mainly aimed at those
individuals with CVD or CHD risk equivalent.
I,A
Statin is still the mainstay of treatment even in patients with low

LDL-C (<2.6 mmol/L). Statin trials have showed that lowering LDLC in persons with isolated low HDL-C, significantly reduces CVD
risk.166
IIa,B
Fibrates have also been shown to reduce major CVD events in

persons with isolated low HDL-C.43,47,160,161 This benefit has been
attributed in part to the HDL-C raising effects of fibrates.
Key messages:
In patients with isolated hypertriglyceridemia, isolated
low HDL-C or its combination, the primary goal of
treatment is lowering LDL-C to target.I,A
The other targets of therapy are lowering non HDL-C
(if TG > 2.3mmol/L) to target, maintaining TG < 1.7
mmol/L and HDL-C > 1.0 mmol/L.
9.2. Diabetes Mellitus (T2DM)

Diabetes (T2DM) is a CHD risk equivalent. Recent long-term follow
up studies showed that the benefits of intensive glucose control
was not apparent early on but a legacy effect of a significant
reduction in CV events was realized only 9-10 years after good
glycaemic control.167,168 Despite this, the CV risk still remains
high when compared to non-diabetics. Thus efforts must also be
directed to control hypertension, lipids and other abnormalities.
169
52
Optimal Lipid values in individuals with diabetes are:
I,A
Primary target :
- LDL-C < 2.6 mmol/L (<1.8 mmol/L for DM with established
CVD)
Secondary target:
- Non-HDL-C < 3.4 mmol/L (when TG > 2.3 mmol/L)
- HDL-C > 1.0 mmol/L (male) and > 1.2 mmol/L (female)
- TG < 1.7 mmol/L
These targets are usually not achievable by TLC or glucose control.

Improvement of glycaemic control alone will not fully correct the
atherogenic dyslipidaemia. (See Table 13, pg 53)
Table 13: Lipid Lowering Drug Therapy In Diabetics
Lipid Goal
Initial Drug
Suggested Addition
In order of preference
Statins
Fibrates
Ezetimibe
Resins
Increase HDL-C
Fibrates* or,
Nicotinic Acid**
Statins***
Lower TG
Fibrates
Treat Combined
Hyperlipidemia
Statins***
Lower LDLC
Fibrates
Nicotinic Acid
*
statins should be the initial drug if LDL-C goal is not achieved.
** with careful monitoring and keeping the dose < 1.5 gm / day.
*** high doses may be required.
I,A
I,A
Statins should be initiated for all individuals above the age of 40

years with T2DM regardless of baseline LDL-C.170
Target should be to LDL-C <2.6 or 30-40% below baseline LDLC.169,170 For those with T2DM and with established CVD, LDL-C
should be <1.8 mmol/L.169
53
I,B
If drug-treated patients do not reach targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 3040% from
baseline is an alternative therapeutic goal.170
I,B
In patients with high TG, reduction of carbohydrate intake is emphasized.112,113
IIa,B
Sub group analysis of recent outcome studies using combination

therapy of statins and fibrates to achieve lipid targets have shown
benefit in atherogenic dyslipidaemia.170
Key messages:
Control of glycaemia alone is inadequate in preventing
CV events. Concomitant treatment of dyslipidaemia,
hypertension and other metabolic abnormalities are
also important.I,A
Target LDL-C goal in individuals with diabetes is <2.6
mmol/L. I,A In the presence of established CVD, LDL-C
should be <1.8 mmo/L. I,A
9.3 Coronary Heart Disease (CHD)

Patients with CHD may present as stable angina or as acute
coronary syndromes (ACS). ACS is a spectrum of disease ranging
from unstable angina (UA), non ST elevation myocardial infarction
(NSTEMI) to ST elevation myocardial infarction depending on the
acuteness and severity of the coronary occlusion.
9.3.1. Acute Coronary Syndromes (ACS)
I,A
Early initiation of statin therapy soon after admission for ACS is

safe and improves outcome regardless of baseline LDL-C levels in
patient with ACS.32,171-175 These benefits are independent of the
lipid lowering effects of statins.
I,A
Patient with ACS should be treated with a higher intensity statins.

More aggressive lipid lowering further lowers cardiovascular event
rates.32,171,172,176-179
54
I,C
I,A
Lipid management includes:

Assessment of a fasting lipid profile for all patients, within 24
hours of hospitalization.
Statins, in the absence of contra-indications, regardless of
baseline LDL-C and diet modifications, should be initiated soon
after admission and continued indefinitely to provide life long
benefits.180-182 Statin treatment should not be delayed until lipid
levels are available or management of other modifiable risk
factors.
Lipids should be re-tested about 2-3 months after the start of
statin therapy.
I,A
IIa,B
LDL-C level should be targeted <2.0mmol/L for most patients.

Patients with low HDL-C may benefit from fibrates or nicotinic
acid.43,162
9.3.2. Coronary Revascularizations
IIa,B
Pre-treatment with statins 7 days prior to elective PCI has been

shown to reduce post-procedure MI.183
IIa,B
A loading dose of statins pre-procedure has also been shown to

reduce post procedure MI in individuals who are statinnave and
those already on regular statins.184,185
IIa,A
All cardiac patients post-revascularization (CABG, PCI) should be

on long term statin therapy, the dose being adjusted to achieve
target lipid levels.186,187
9.3.3 Stable CAD
Stable CAD refers to stable angina, asymptomatic myocardial
ischemia and coronary atherosclerosis detected by coronary or CT
Angiogram.
In individuals with stable CAD, PCI did not confer additional CV
benefits when added to optimal medical therapy as an initial
management strategy.188. Those individuals who had undergone
55
PCI however, had improvement in their quality of life during follow

up.189
I,A
Irrespective of the baseline LDL-C level, statin therapy reduces the

risk of major CV events by 24%.29
I,A
Individuals with stable CAD should be treated with optimal medical therapy using a combination of antiplatelet agents, statins,
-blockers and angiotensin converting enzymes inhibitors.190
I,A
Statin therapy should always be considered for individuals with

stable coronary artery disease .
I,A
Therapy should aim at statin dosages documented to reduce

morbidity and mortality in clinical trials.
Key messages:
Statins should be started early in individuals with
ACS, and on all post revascularisation individuals
irrespective of their baseline cholesterol levels.I,A
In high risk individuals, high intensity statin treatment
confers more benefit. I,A
Statins are an integral component of optimal medical
therapy in CAD individuals. I,A
9.4. Hypertension
CV risk depends not only on blood pressure but also on associated
risk factors, clinical conditions and target organ damage.191
I,A
Hypertensive individuals without established CVD but with

moderate to high CV risk ( 10% risk of events in 10 years) should
also be considered for statin therapy irrespective of baseline LDL-C
levels.192
The choice of antihypertensive agent should be individualized.
Certain antihypertensive agents may have an adverse effect on
lipid levels eg high dose thiazides increases TC, LDL-C and TG levels,
-blockers with no intrinsic sympathetic activity reduce HDL-C and
increase serum TG. These effects are modest and should not affect
the selection of an antihypertensive agent.139
56
Key messages:
Hypertension and elevated cholesterol levels often
coexist and synergistically increase the risk of
developing CVD and treatment of both conditions
reduces CVD events.
Statins should be considered in high risk hypertensive
individuals. I,A
9.5 Stroke
Recent studies have shown an association between raised serum
lipids and risk of ischaemic stroke.193
I,B
Statins have been shown to prevent ischaemic stroke in high risk

individuals.29,194
I,B
Individuals with Ischaemic stroke or transient ischaemic attacks

benefit from lipid modifying therapy.181,194,195 High intensity statins
has been found to prevent recurrent stroke7.
In-hospital lipid testing should be performed in individuals with
ischaemic stroke and TIA.196,197
I,A
Statin therapy should be considered in individuals with LDL-C 2.6

mmol/L 198,199.
Key messages:
Statins have been shown to reduce the incidence of
ischaemic strokes when used in high risk individuals. I,B
Lipid lowering therapy with statins should be
considered in all individuals with previous ischaemic
stroke or transient ischaemic attack. I,B
57
9.6. Renal disease

Chronic Kidney Disease (CKD) is associated with significant CV
morbidity and mortality.200,201 Mortality increases progressively
with worsening renal function. The risk of death from CVD is
higher than the risk of eventually requiring renal replacement
therapy.202,203 Currently, there are differing views about recognizing
CKD as a CHD Risk Equivalent although all stages of CKD including
individuals with asymptomatic microalbuminuria are at increased
CVD risk. 139,200,204-209 They should be screened for traditional risk
factors and treated according to their determined risk.
Dyslipidaemia occurs in all stages of CKD, on dialysis, after renal
transplantation and in individuals with the nephrotic syndrome.
In individuals with CKD and in those on dialysis, the main lipid
abnormalities are elevated levels of TG, low levels of HDL-C and
elevated levels of Lp (a).The TC is usually normal or low. A number
of studies have shown that in these individuals, lower levels of
TC are associated with increased mortality most likely due to the
adverse effects of malnutrition and chronic inflammation.210-217
In the nephrotic syndrome both TC and LDL-C are elevated. The
lipid abnormalities may improve or resolve following resolution
of the nephrosis. If the dyslipidaemia still persists, drug therapy
should be considered.
Caution must be exercised when starting anti lipid drug therapy in
individuals with renal insufficiency.
The use of fibrates in these individuals carries a higher risk of
rhabdomyolysis and there is no proven long term CV benefits.218
IIb,B
In individuals with very high TG levels (more than 5.7 mmol/L),

low dose fibrates may be initiated cautiously to prevent
pancreatitis.43,47,160,161
IIa,B
Omega 3 Fish oils (at a dose of 4 gm/day) may also be used.219
IIa,B
Statins have been shown to have differential effects on the kidney.

Some statins reduce proteinuria and slow the rate of progression
of renal disease while others have been neutral.220,221
58
I,B
In individuals with CHD and mild to moderate CKD, statins have

been shown to be beneficial.29,218
IIa,B
A recently presented large prospective trial in patients with

stages 3-5 CKD without CHD, showed that the use of a statin
and ezetimibe combination resulted in a significant reduction in
atherosclerotic events.
IIb,B
A third of these patients were on dialysis and they did not show any
benefit, a finding consistent with that of previous studies.141,222,223
The immunosuppresive drugs used post renal transplants or
for underlying renal disease are associated with dyslipidaemia.
Individuals receiving statins and fibrates in combination with
cyclosporin should be closely monitored for myositis.
The initiating dose of anti lipid drugs in patients with CKD should
be lower. (Table 14, pg 60).
Key messages:
Individuals with CKD have high CV Risk.
Statins have been found to be beneficial in individuals
with CHD and mild to moderate CKD.I,B
In individuals on dialysis, the benefits of lipid lowering
therapy are doubtful.IIb,B
Statins are safe in CKD.I,B
Fibrates should be used cautiously in individuals with
CKD and very high TG.IIb,B
59
Table 14. Dosing Modifications for Lipid-Lowering Drugs in CKD224

Agent
Mild
GFR
6090
ml/
min/1.73
m2
Moderate
GFR
1559 ml/
min/1.73 m2
Severe
GFR
<15 ml/
min/1.73
m2
Notes
STATINS
Atorvastatin
No
No
No
Fluvastatin
No
Not defined
Not
defined
dose to one-half
at GFR <30 ml/
min/1.73 m2
Lovastatin
No
to 50%
to 50%
dose to one-half
at GFR <30 ml/
min/1.73 m2
Pravastatin
No
No
No
Start at 10 mg/day
for GFR <60 ml/
min/1.73 m2
Rosuvastatin
No
510 mg
Avoid
Contraindicated
for GFR <30 ml/
min/1.73 m2, max
dose 10 mg/day
Simvastatin
No
No
to 50%
Start at 5 mg if GFR
<10 ml/min/1.73
m2
Nicotinic acid
No
No
to 50%
34% kidney
excretion
Cholestyramine
No
No
No
Not absorbed
Colesevelam
No
No
No
Not absorbed
Ezetimibe
No
No
No
Fenofibrate
to 50%
to 25%
Avoid
Gemfibrozil
No
No
No
NONSTATINS
60
May serum
creatinine
NLA recommends
a dose of 600 mg/
day for GFR 1559
ml/min/1.73 m2
and avoiding use
for GFR <15 ml/
min/1.73 m2
10. MANAGEMENT IN SPECIAL GROUPS

10.1. Women
Women develop heart disease about 10 to 15 years later than
men.225 There are no gender differences in the risk factors that
predispose to CVD although women with T2DM are at higher risk
of CVD than men.226-230 In premenopausal women, CVD tends to
occur in those with T2DM and multiple risk factors.
I,A
III,C
IIb,B
I,B
IIa,C
IIa,B
In secondary prevention, women have similar benefits on CVD

outcomes as men.29,33,231 Statins should be the drug of first
choice.29,33,231
Statins should not be used in women who are pregnant, intend to
become pregnant or who are breast feeding.

In women who have normal LDL-C but low HDL-C and high TG,
fibrates may be used.47

In primary prevention, the cornerstone of management is lifestyle
modification with advice on a healthy diet and physical activity.
Women at high risk who do not achieve their target levels should
be considered for pharmacological intervention although there is
little data on the effect of lipid lowering therapy on CVD events for
primary prevention in women. Current practice is to treat these
women in the same manner as men based on extrapolation of
benefit in men at similar risk.232

Women with genetic dyslipidaemias such as familial hypercholesterolemia with very high levels of TC or LDL-C may be considered
for lipid lowering therapy from the outset.
10.2. Children & Adolescents
Atherosclerosis begins in childhood, the rate of progression
depending on the presence and number of risk factors and their
severity.233-237 Risk factors for atherosclerosis in children include:
61
obesity and the metabolic syndrome238

T2DM
post organ transplantation
systemic lupus erythematosis
nephrotic syndrome
HIV infections
These risk factors have been shown to persist into adult life and
lead to premature CVD.
Screening begins with an assessment of family history for CVD
or genetic dyslipidaemia.239 In addition, obese and overweight
children and those with the risk factors mentioned above should
also have a full lipoprotein profile, BP measurement and a fasting
glucose assessment.
Children whose lipid levels are significantly elevated should be
referred to specialists interested in this field.
I,B
The main approach is a healthy lifestyle with appropriate diet,

maintenance of desirable weight and regular exercise.
I,A
In children with elevated cholesterol levels, statins are the drug

of choice.240
IIb,B
There has been limited data on the use of niacin, fibric acid
derivatives and ezetimibe in children.
When prescribing drugs in children, the need for life long
therapy and its associated health risks and drug exposure during
unplanned pregnancy in individuals of child bearing age need to
be considered. Patients should be extensively counseled prior to
initiation of drug therapy.
I,A
10.3. Elderly (> 65 years)

Increasing age is a major risk factor for CVD and death. For
secondary prevention, the elderly derive a greater absolute
benefit from lipid lowering therapy.241,242
62
Thus, they should not be deprived from lipid lowering therapy

solely on the basis of their age although there is limited clinical
trial data in patients over the age of 80 years.
Renal function should be assessed and drug dosages adjusted
accordingly.
The benefits of lipid lowering therapy for primary prevention in
elderly individuals with no other risk factors besides dyslipidaemia
are less well established. Global risk assessment using standard
risk factors as mentioned earlier is generally less reliable in older
persons. Clinical judgement and consideration of co-morbid
factors, co-existing disease and functional age become essential
in deciding the need for drug therapy in this situation. (see Table
8, pg 34)
Key messages:
Women and the elderly with CHD and CHD risk
equivalent should be treated in the same manner as
man. I,A
Children with very high cholesterol levels benefit from
statin therapy. I,A
11. ADHERENCE, COMPLIANCE AND QUALITY ASSURANCE
It has been well documented that there is a lack of adherence to
cardiovascular preventive therapy. This is due to both physician
factors (not initiating treatment, not achieving treatment goals,
not checking on drug compliance) and patient factors (non
compliance).
Lack of adherence threatens the success of the guideline
recommendation and implementation. Clinical trials have shown
that the amount of risk reduction achieved is related to the
level of adherence to treatment.243,244,245 More importantly, lack
of adherence leads to missed opportunity for the risk reducing
benefits of the treatment, thus creating enormous costs to
the health system for treating CV events that could have been
prevented.
63
To improve adherence and compliance the following are

recommended:

Patient factors
- Simplify medication regimens using wherever possible
drugs with a single daily or twice daily dosing
- Give clear instructions
- Encourage the support of the family
- Involve patients in their care through self-monitoring
- Remind patients that lipid lowering drugs are not a
substitute for dietary and lifestyle interventions
Physician Factors
- Teach physicians to implement lipid treatment guidelines
- Educate patients to prompt preventive care
- Remind patients of appointments and follow-up missed
appointments
Health Delivery System

- Involve pharmacists and other health care deliverers in
patient education
- Use mass media for patient education
- Disseminate clinical guidelines and clinical pathways to
health care providers
- Standardize reference values in all laboratories to
recommended Malaysian guidelines
Adherence to therapy should be checked periodically. Some

suggested
indicators as audit for lipid lowering therapy are:
Measurement of lipid values
Risk categorization of patients
Appropriate usage of drug therapy
Achieving primary lipid target goal: LDL-C to target
Achieving secondary lipid target goals: HDL-C and TG to target
64
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levels and systolic blood pressure to early atherosclerosis: the Bogalusa Heart
Study. N Engl J Med. 1986; 314: 138144.
236. Mc Crindle BW, Ose L, Marais AD. Efficacy and safety of atorvastatin in children
and adolescents with familial hypercholesterolemia or severe hyperlipidemia: a
multicenter, randomized, placebo controlled trial. J Pediatr 2003;142:74-80.
237. Berenson GS, Srinivasan SR, Bao W et al. Association between multiple
cardiovascular risk factors and atherosclerosis in children and young adults: the
Bogalusa Heart Study. N Engl J Med. 1998; 338: 16501656.
238. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight
to cardiovascular risk factors among children and adolescents: the Bogalusa
Heart Study. Pediatrics. 1999; 103 (pt 1): 11751182.
239. American Academy of Pediatrics. National Cholesterol Education Program: report
of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents.
Pediatrics. 1992; 89: 525584.
240. McCrindle BW, Urbina EM, Dennison BA et al. Drug Therapy of High-Risk Lipid
Abnormalities in Children and Adolescents: A Scientific Statement From the
American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth
Committee, Council of Cardiovascular Disease in the Young, With the Council on
Cardiovascular Nursing. Circulation 2007;115:1948-1967.
241. Secondary Prevention of Coronary Heart Disease in the Elderly (With Emphasis
on Patients >=75 Years of Age): An American Heart Association Scientific
Statement From the Council on Clinical Cardiology Subcommittee on Exercise,
Cardiac Rehabilitation,and Prevention. Circulation 2002; 105:17351743.
242. Streja D, Streja E. Management of dsyslipidemia in the elderly. In: Hershman J,
ed. Endocrinology of Aging. www.endotext.org/aging/aging4/agingframe4.htm
Accessed 2nd April, 2010.
243. Anonymous. Coronary Drug Project Research Group. Influence of adherence
to treatment and response of cholesterol on mortality in the Coronary Drug
Project. N Engl J Med 1980;303: 1038-41.
244. Anonymous. Compliance and adverse event withdrawal: their impact on the
West of Scotland Coronary Prevention Study. Eur Heart J 1997;18:1718-24.
245. Chia YC. Review article. Understanding patient management: the need for
medication adherence and persistence. Malaysian Family Physician 2008: 3 (1):
1985-2274. Assessed at www.e-mfp.org.my/2008v3n1/index.htm
246. Hu FB, Stampfer MJ, Rimm EB et al. A prospective study of egg consumption and
risk of cardiovascular disease in men and women. JAMA 1999; 281 : 1387-1394
247. Scrafford CG, Tran NL, Barraj L, Mink P. Egg consumption and CHD and Stroke
mortality: A prospective study of US adults. Public Health 2011; 14 : 261- 270.
79
APPENDIX I: APOLIPOPROTEINS : MAJOR CATEGORIES

MAJOR CLASSES
Apo A
Apo B
Apo C
Apo D
Apo E
Apo H
SUBCLASSES/ISOFORMS
apo A-I, apo-II, apo A-IV, apo A- V
apo B-48, apo B-100
apo C-I, apo C-II, apo C-III, apo C-IV
apo E-2, apo E-3, apo E-4
APPENDIX II: RISK FACTORS FOR MI AND STROKE IN THE

INTERHEART AND INTERSTROKE STUDIES*
Hypertension
INTERSTOKE
(all stroke; 3000
cases, 3000
controls)*
34.6% (30.4-39.1)
INTERHEART
(acute myocardial
infarction; 15152
cases, 14820 controls)**
17.9% (15.7-20.4)
Smoking
18.95 (15.3-23.1)
35.7% (32.5-39.1)
Waist-to-hip
(abdominal obesity)
26.5% (18.8-36.0)
20.1% (15.3-26.0)
18.8% (11.2-29.7)
..

13.7% (9.9-18.6)
28.5% (14.5-48.5)
12.2% (5.5-25.1)
5.0% (2.6-9.5)
9.9% (8.5-11.5)
3.8% (0.9-14.4)
6.7% (2.0-20.2)
..
4.6% (2.1-9.6)
5.2% (2.7-9.8)
32.5% (25.1-40.8)
..
..
6.7% (4.8-9.2)
24.9% (15.7-37.1)
..
49.2% (43.8-54.5)
Diet
Diet risk score
Fruits and vegetables
daily
Regular physical activity

Diabetes

Alcohol intake
Psychosocial factors
All psychosocial
factor
Psychosocial stress
Depression
Cardiac causes
Ratio of apolipoproteins
B to A1
* Yusuf S, Hawken S, Ounpuu S, on behalf of the INTERHEART Study Investigators. Effect of

potentially modifiable risk factors associated with myocardial infarction in 52 countries
(the INTERHEART study): case-control study. Lancet. 2004; 364:937-952.
** O Donnel MJ, Xavier D, Liu L et al on behalf of the INTERSTROKE Investigators. Risk
factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the
INTERSTROKE study): a case-control study. Lancet 2010;376 : 112-123
80
APPENDIX III: BODY MASS INDEX

Calculation of body mass index (BMI) is one way of determining
the ideal weight for an individual. BMI is the relationship of body
weight to height. Increased BMI is associated with increased
mortality and morbidity. The predictive value of BMI is enhanced
by taking the waist circumference into consideration as well.
Body Mass Index = (Weight in kg)
(Height in m)2
CLASSIFICATION OF WEIGHT BY BMI
CLASSIFICATION
BMI (Kg / m2)
Risk of co-morbidities
Underweight
< 18.5
Low (but increased risk of

other clinical problems)
Normal range
18.5-22.9
Average
Overweight
> 23.0
Pre-Obese
23.0-27.4
Increased
Obese I
27.5-34.9
Moderate
Obese II
35.0-39.9
Severe
Obese III
> 40.0
Very Severe
(Adapted from Malaysian Clinical Practice Guidelines on the

Management of Obesity 2003. Assessed at www.acadmed.org.my)
81
82
Sample size
Fatal CHD
http://www.
heartscore.
org/pages/
welcome.aspx
CHD (MI and CHD

death)
http://hp2010.
nhlbihin.net/
atpiii/calculator.
asp?usertype=prof
Endpoints
URLs for risk

calculators
Age, sex,
total-HDL
cholesterol
ratio, smoking,
systolic blood
pressure
Age, sex, total

cholesterol, HDL
cholesterol,
smoking, systolic
blood pressure,
antihypertensive
medications
13
Mean : 46
12
Mean: 49
205,178
19 to 80;
30 to 74;
5,345
SCORE
Risk factors
considered
Mean follow-up ,y
Age (y)
Framingham
http://www.chdtaskforce.com/
coronary_risk_
assessment.html
Fatal/nonfatal MI
or sudden cardiac
death (CHD and
CVD combined)
Age, LDL
cholesterol, HDL
cholesterol,
smoking, systolic
blood pressure,
family history,
diabetes,
triglycerides
10
Mean: 47
35 to 65;
5,389
PROCAM (Men)
http://www.
reynoldsriskscore.org/
MI, ischemic
stroke, coronary
revascularization,
cardiovascular
death (CHD and CVD
combined)
Age, HbA1C (with

diabetes), smoking,
systolic blood pressure,
total cholesterol, HDL
cholesterol, hsCRP,
parental history of MI at
<60 y of age
10.2
Mean: 52
>45;
24,558
Reynolds (Women)
http://www.
reynoldsriskscore.org/
MI, stroke, coronary

revascularization,
cardiovascular
death (CHD and CVD
combined)
Age, systolic blood

pressure, total
cholesterol, HDL
cholesterol, smoking,
hsCRP, parental history
of MI at <60 y of age
10.8
Mean: 63
>50;
10,724
Reynolds (Men)
APPENDIX IV: COMPARISON OF GLOBAL CORONARY AND CARDIOVASCULAR RISK SCORES94
APPENDIX V: LIPID LOWERING DIET

PRINCIPLE
AMOUNT
COMMENT
Decrease
dietary
cholesterol
< 200 mg / day
Reduce intake of organ meat (offal) eg

liver, heart, brains, kidney. Limit to 3
oz once fortnightly. A small amount of
prawn / crab / oysters / cockles may be
taken once or twice a week if desired.
Decrease
total fat/oil
< 30% of total

energy
Modify cooking methods grill /steam

/ boil / bake / microwave to reduce use
of oils and fats. Avoid oily / fatty food eg
deep fat fried foods.
Types:
a) saturated
fat
7-10% (not
more than 10%
of total calorie
intake)
Minimize the use of following butter,

hard margarine, full cream milk (including
condensed milk) cream, high fat cheese,
fatty meats, bacon and sausages,
coconut oil, santan, products containing
hydrogenated oil and some non dairy
creamers.
b)mononunsaturated
and polyunsaturated
oils/margarine
Not more
than 6
teaspoonsfuls
per day to be
used in cooking
or as a spread
Choices may include the following:

olive oil, sunflower oil, corn oil,
palm oil, soybean oil, peanut oil and
polyunsaturated margarine.
Increase
intake of
complex
carbohydrate
/ grains and
fiber
20-25 gm fiber
/ day. Include
2-3 servings
of fruit and
3-4 servings of
vegetables and
5 -7 servings
per day of
grains
Sources of complex carbohydrates/grains:

rice, bread, pasta, noodles and tuber
Sources of fiber: fruits, vegetables,
pulses, legumes and unrefined cereals.
Choose food
high in
protein but
low in
saturated fat
2-3 servings
per day
Choices may include: chicken without

skin, fish, Legumes and pulse (tofu, dhal,
green peas and beans), egg whites, lean
meat, skim milk and milk products (low
fat milk may be used but some low fat
milk may contain up to 50% of its original
fat).
Consuming an egg a day does not substantially increase CVD risk.246,247 The method of cooking the egg is important.
*Adapted and modified from Lichtenstein AH, Appel LJ, Brands M et al. Diet and Lifestyle
Recommendations Revision 2006. A Scientific Statement From the American Heart Association Nutrition Committee Circulation 2006;114:82-96.
83
APPENDIX VI: CONVERSION TABLE
(<1.14mmol/L) (<1.7mmol/L)
(1.7-2.3mmol/L)
(2.3-5.7mmol/L)
(5.7mmol/L)
*Adapted from Miller M, Stone NJ, Ballantyne C et al Triglycerides and Cardiovascular Disease: A Scientific Statement from the American Heart Association. Circulation 2011; 123:
2292-2333
84
ACKNOWLEDGMENTS
The committee of this guideline would like to express their gratitude and appreciation to the following for their contribution:
Technical Advisory Committee, Clinical Practice Guidelines,
Ministry of Health for their valuable input and feedback
Panel of external reviewers who reviewed the draft
DISCLOSURE STATEMENT
The panel members have no potential conflict of interest to disclose.
SOURCES OF FUNDING
This CPG was made possible by an unrestricted educational grant
to NHAM from Pfizer (M) Sdn Bhd. There was total editorial independence and the funding body did not influence the content of
this guideline.
85

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I

Reduction of LDL-C. Increase dose

As monotherapy to increase HDL-C

Table 3 : Recommendations for Therapeutic Lifestyle Changes

< 7% of calorie intake

< 200 mg /day

Omega 3 fatty acids

A dose of 3-9 gm/day to lower TG

A dose of 0.75-1 gm/day as

About 15% of calories

Assess BMI and waist circumference

Encourage aerobic exercises such as

Enquire about smoking status at

FLOWCHART I: HIGH RISK INDIVIDUALS

TLC + Control Other

LDL-C < 2.6mmol/L

TLC Therapeutic Lifestyle Changes

FLOWCHART II: INTERMEDIATE RISK INDIVIDUALS

LDL-C < 3.4mmol/L

Control other Risk

LDL-C < 3.4mmol/L

TLC Therapeutic Lifestyle Changes

FLOWCHART III: LOW RISK INDIVIDUALS

LDL-C < 3.4mmol/L

Control other Risk

LDL-C < 4.1mmol/L

TLC Therapeutic Lifestyle Changes

FLOWCHART IV: LOW RISK INDIVIDUALS

LDL-C < 4.1

LDL-C 4.1-< 4.9mmol/L

MESSAGE FROM THE AMERICAN COLLEGE OF CARDIOLOGY

Ralph Brindis, MD, MPH, MACC, FSCAI

Members of the Expert Panel

Members (in alphabetical order)

Dr Khoo Kah Lin

Dr Rosli Mohd Ali

External Reviewers (in alphabetical order):

Dr Chia Yook Chin

Consultant Primary Care Physician

Dr Ghazali Ahmad Kutty

Dr Lee Chuey Yan

Dr Lee Fatt Soon

Family Medicine Specialist,

Dr Wong Kai Fatt

RATIONALE AND PROCESS OF GUIDELINE DEVELOPMENT

group members met several times throughout the development of

Implementation of the Guidelines:

increasing public awareness of CVD and its prevention

GRADES OF RECOMMENDATIONS AND LEVELS OF EVIDENCE

Weight of evidence/opinion is in favor of its usefulness/efficacy.

Usefulness/efficacy is less well established by evidence/opinion

2. MEASUREMENT OF LIPIDS AND APOLIPOPROTEINS

Measurements made from whole blood differs slightly from that

Low HDL Cholesterol

Table 5: Primary Dyslipidaemia

Dyslipidaemias may be primary or secondary in etiology. (Tables

When TC exceeds 7.0 mmol/l, exclude conditions such as

4.2. Low HDL-C levels

The risk of developing CVD is directly related to the number of

Table 7: Major Risk Factors for CVD (Other than LDL

Figure 1A: Estimation of 10 year CVD Points for MEN

Grand Total :_____________points

Figure 1B: CVD Risk for Men100