Lipid Disorders in Seniors (Cholesterol, Dyslipidemia)-Senior

Summary of Recommendations - Screening Men

Population	Recommendation	Grade (What's This?)
Men 35 and Older	The USPSTF strongly recommends screening men aged 35 and older for lipid disorders.	A
Men 20-35 at Increased Risk for CHD	The USPSTF recommends screening men aged 20-35 for lipid disorders if they are at increased risk for coronary heart disease.	B

Summary of Recommendations - Screening Women at Increased Risk

Population	Recommendation	Grade (What's This?)
Women 45 and Older at Increased Risk for CHD	The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.	A
Women 20-45 at Increased Risk for CHD	The USPSTF recommends screening women aged 20-45 for lipid disorders if they are at increased risk for coronary heart disease.	B

Importance

There is good evidence that high levels of total cholesterol and low density lipoprotein-cholesterol (LDL-C) and low levels of high density lipoprotein-cholesterol (HDL-C) are important risk factors for coronary heart disease. The risk for coronary heart disease is highest in those with a combination of risk factors. The 10-year risk for coronary heart disease is lowest in young men and in women who do not have other risk factors, even in the presence of abnormal lipids.

Detection

The USPSTF found good evidence that lipid measurement can identify asymptomatic men and women who are eligible for preventive therapy.

Benefits of Detection and Early Treatment

There is good evidence that lipid-lowering drug therapy substantially decreases the incidence of coronary heart disease in persons with abnormal lipids. The absolute benefits of lipid-lowering treatment depend on a person's underlying risk for coronary heart disease. Men over the age of 35 and women over the age of 45 who are at increased risk will realize a substantial benefit from treatment; younger adults with multiple risk factors for coronary disease, including dyslipidemia, will realize a moderate benefit from treatment; and younger men and women without risk factors for coronary heart disease will realize a small benefit from treatment, as seen in the risk reduction in 10-year CHD event rate.

Harms of Detection and Early Treatment

There is good evidence that the harms from screening and treatment are small and include possible labeling and the adverse effects associated with lipid-lowering therapy (e.g., rhabdomyolysis).

USPSTF Assessment

The USPSTF concludes that the benefits of screening for and treating lipid disorders in all men aged 35 and older and women aged 45 and older at increased risk for coronary heart disease substantially outweigh the potential harms.

The USPSTF concludes that the benefits of screening for and treating lipid disorders in young adults at increased risk for coronary heart disease moderately outweigh the potential harms.

The USPSTF concludes that the net benefits of screening for lipid disorders in young adults not at increased risk for coronary heart disease are not sufficient to make a general recommendation.

Lipid disorders, also called dyslipidemias, are abnormalities of lipoprotein metabolism and include elevations of total cholesterol, LDL-C, or triglycerides (TG), or deficiencies of HDL-C. These disorders can be acquired or familial (e.g., familial hypercholesterolemia). This recommendation applies to adults aged 20 and older who have not previously been diagnosed with dyslipidemia.
Increased risk, for the purposes of this recommendation, is defined by the presence of any one of the risk factors listed below. The greatest risk for CHD is conferred by a combination of multiple listed factors. While the USPSTF did not use a specific numerical risk to bound this recommendation, the framework used by the USPSTF in making these recommendations relies on a 10-year risk of cardiovascular events:¹
Diabetes.
Previous personal history of CHD or non-coronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis).
A family history of cardiovascular disease before age 50 in male relatives or age 60 in female relatives.
Tobacco use.
Hypertension.
Obesity (BMI ≥30).
The preferred screening tests for dyslipidemia are total cholesterol and HDL-C on non-fasting or fasting samples. There is currently insufficient evidence of the benefit of including TG as a part of the initial tests used to screen routinely for dyslipidemia. Abnormal screening test results should be confirmed by a repeated sample on a separate occasion, and the average of both results should be used for risk assessment.
Measuring total cholesterol alone is acceptable for screening if available laboratory services cannot provide reliable measurements of HDL-C; measuring both total cholesterol and HDL-C is more sensitive and specific for assessing coronary heart disease risk than measuring total cholesterol alone. In conjunction with HDL-C, the addition of either LDL-C or total cholesterol would provide comparable information, but measuring LDL-C requires a fasting sample and is more expensive. Direct LDL-C testing, which does not require a fasting sample measurement, is now available; however, calculated LDL (total cholesterol minus HDL minus TG/5) is the validated measurement used in trials for risk assessment and treatment decisions. In patients with dyslipidemia identified by screening, complete lipoprotein analysis is useful.
The optimal interval for screening is uncertain. On the basis of other guidelines and expert opinion, reasonable options include every 5 years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels.
An age to stop screening has not been established. Screening may be appropriate in older people who have never been screened; repeated screening is less important in older people because lipid levels are less likely to increase after age 65. However, because older adults have an increased baseline risk for coronary heart disease, they stand to gain greater absolute benefit from the treatment of dyslipidemia, compared with younger adults.
Treatment decisions should take into account a person's overall risk of heart disease rather than lipid levels alone. Overall risk assessment should include the presence and severity of the following risk factors: age, gender, diabetes, elevated blood pressure, family history (in younger adults), and smoking. Risk calculators that incorporate specific information on multiple risk factors provide a more accurate estimation of cardiovascular risk than tools that simply count numbers of risk factors.¹
Drug therapy is usually more effective than diet alone in improving lipid profiles, but choice of treatment should consider overall risk, costs of treatment, and patient preferences. Guidelines for treating lipid disorders are available from the National Cholesterol Education Program of the National Institutes of Health (http://www.nhlbi.nih.gov/about/ncep/This link goes offsite. Click to read the external link disclaimer).
Although lifestyle modifications (diet and physical activity) are appropriate initial therapies for most patients, a minority achieves substantial reductions in lipid levels from changes in diet alone; drugs are frequently needed to achieve therapeutic goals, especially for those at increased risk for coronary heart disease. Lipid-lowering treatments should be accompanied by interventions addressing all modifiable risk factors for heart disease, including smoking cessation, treatment of blood pressure, diabetes, and obesity, as well as promotion of a healthy diet and regular physical activity. Long-term adherence to therapies should be emphasized.