Diagnosis, management and prevention of the common dyslipidaemias in SouthAfrica - Clinical guideline, 2000

The optimum management of dyslipidaemia requires a comprehensive, diagnosti c work-up. This, minimally, includes: Characterisation of any hyperlipidaemic disorder present. Identification of additional risk factors so as to assess overall (global) risk of future coronary heart disease (CHD). The global risk is best assess ed by a calculation combining the risk factors in the individual. In severe monogenic dyslipidaemias and in patients with confirmed pre-existing CHD t he risk is usually high; in most such cases the use of lipid-modifying drug s (LMDs) is indicated. Assessment of psychosocial, economic and educational factors relevant to ma nagement. Prevention and cost-effective management of even moderately dyslipidaemic p atients require appropriate modification of lifestyle: avoidance of tobacco smoking, participation in regular exercise, and a health-promoting diet. D epending on individual circumstance, rigorous, personalised intervention an d expert assistance from dieticians, biokineticists and other health care p ersonnel may determine success. The correct choice of patient for drug treatment is a key therapeutic decis ion ar td is best done after full lifestyle modification. Recent evidence c onfirms that appropriately prescribed LMD therapy can lower morbidity and m ortality from CHD as well as an-cause mortality Patients with the following features are candidates for LMD therapy: have clinical CHD and a low-density Lipoprotein cholesterol (LDLC) level > 3.0 mmol/l despite optimum non-pharmacological intervention, suffer from familial hypercholesterolaemia (FH) or equivalent severe, monog enic disorder, or have a 10-year risk of an acute clinical coronary event of > 20% (or > 30% risk if extrapolated to the age of 60 years) owing to the presence of the h yperlipidaemia alone or in combination with contributory risk factors. The ideal target LDLC concentration is less than or equal to 3 mmol/l but a reduction of at least. 45% Should be regarded as a minimum target in sever e cases who do not reach this goal. Successful therapy requires on-going attention to compliance, therapeutic r esponse and side-effects, and may necessitate adjustment or reinforcement. Concurrent or contributory conditions, such as smoking, hypertension and di abetes mellitus, must also be treated along with the clinically manifest CH D. Severely hyperlipidaemic, complicated or unresponsive high-risk cases sh ould be referred to an appropriate specialist or lipid clinic. Prevention of CHD in the community should be encouraged through public and professional education the provision of community facilities for exercise a nd recreation, and legislation directed at reducing the use of tobacco prod ucts and ensuring the appropriate labelling of food products.