Guidelines - Cardiovascular Disease

Scope and Purpose of Guideline

Objective: This guideline provides recommendations regarding the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease.

CCGI Guideline Summary

 

Target Population: Individuals with various lipid disorders including individuals with diabetes, familial hypercholesterolemia, women and youth with dyslipidemia.

Target Users: Endocrinologists and other health care professionals, health-related organizations, and regulatory bodies. This summary of recommendations is tailored toward rehabilitation professionals.

Outcomes: This guideline provides guidance on screening, risk management, and treatment recommendations to reduce the risks and consequences of dyslipidemia.

NOTE: Recommendations regarding screening tests, follow-up, and cost-effectiveness have been omitted from this summary as they are beyond the scope of practice of rehabilitation professionals. Some of the included recommendations are beyond the scope of practice of rehabilitation professionals; however, they were included for informational purposes. It is the responsibility of healthcare providers to comply with their scope of practice. 

Reporting of Recommendations

 

Grade: referring to the strength of the recommendation

 

Evidence Level: 1: Strong evidence: Meta-analysis of randomized controlled trials, randomized controlled trial; 2: Intermediate evidence: Meta-analysis of nonrandomized prospective or case-controlled trials, nonrandomized controlled trial, prospective cohort study, retrospective case-control study; 3: Weak evidence: Cross-sectional study, surveillance study (registries, surveys, epidemiologic study, retrospective chart review, mathematical modeling or database); 4: No evidence: Theory, opinion, consensus, review, or preclinical study.

 

Subjective Factors: factors influencing the validity of the study design (e.g., allocation concealment, blinding), data analysis (e.g., intention-to-treat, appropriate statistics), and interpretation of results (e.g., generalizability, validity).

*Recommendations with ratings of C4, D4, D3, D1,2,3,4 have been omitted from this recommendation summary due to weak evidence, no evidence, or where consensus was not reached.

Key Recommendations

 

Risk Factors

Risk factors for atherosclerotic cardiovascular disease:

  • Major risk factors: advancing age; ↑ total serum cholesterol level; ↑ non-high-density lipoprotein cholesterol; ↑ low-density lipoprotein cholesterol (LDL-C); low high-density lipoprotein cholesterol (HDL-C); diabetes mellitus; hypertension; chronic kidney disease; cigarette smoking; family history of atherosclerotic cardiovascular disease (ASCVD)

  • Additional risk factors: obesity, abdominal obesity; family history of hyperlipidemia; ↑ small, dense LDL-C; ↑ apolipoprotein B; ↑ LDL particle concentration; fasting/post-prandial hypertriglyceridemia; polycystic ovary syndrome, dyslipidemic triad

  • Non-traditional risk factors: ↑ lipoprotein; ↑ clotting factors; ↑ inflammation markers (hsCRP; Lp-PLA2); ↑ homocysteine levels; apo E4 isoform; ↑ uric acid; ↑ triglyceride (TG)-rich remnants

Special considerations:

Women:

  •  High total cholesterol, ↑ LDL-C, and ↑ TG, as well as low HDL-C in women

  • Lowering LDL-C significantly reduces ASCVD in women, however, the unique roles of hormonal change over the lifetime of a woman, HDL-C, and TG must also be addressed

  • Hormonal changes of menopause are associated with an increasingly atherogenic lipid profile

Children and adolescents:

  • Intensive lifestyle modification with an emphasis on normalization of body weight and improved dietary intake is recommended as a first-line approach for elevated lipid levels

 

Global Risk Assessment 

  1. Identify risk factors that enable personalized and optimal therapy for dyslipidemia (Level 1, Grade A)

  2. Dyslipidemia in childhood and adolescence should be diagnosed and managed as early as possible to reduce the levels of LDL-C that may eventually increase risk of cardiovascular events in adulthood (Level 1, Grade A)

  3. Individuals with type 1 diabetes (T1DM) and duration more than 15 years or with 2 or more major cardiovascular risk factors* should be considered to have risk-equivalence to individuals with type 2 diabetes (Level 2, Grade B)

  4. When HDL-C concentration is >60mg/dL, 1 risk factor should be subtracted from an individual’s overall risk profile (Level 2, Grade B)

  5. A classification of elevated TG should be incorporated into risk assessments to aid in treatment decisions (Level 2, Grade B)

  6. Individuals with type 2 diabetes (T2DM) should be considered as high, very high, or extreme risk for ASCVD (Level 3, Grade B)

* Factors were albuminuria, chronic kidney disease [CKD] stage ¾, initiation of intensive control >5 years after diagnosis

Screening

  1. In the absence of ASCVD risk factors, screen middle-aged individuals for dyslipidemia at least once every 1-2 years. More frequent lipid testing is recommended when multiple global ASCVD risk factors are present (Level 1, Grade A)

  2. Annually screen older adults with 0 to 1 ASCVD risk factor for dyslipidemia (Level 1, Grade A)

  3. Screening for this group is based on age and risk, but not sex; therefore, older women should be screened in the same way as older men (Level 1, Grade A)

  4. Annually screen all adult individuals with T1DM or T2DM for dyslipidemia (Level 2, Grade B)

  5. In children at risk for familial hypercholesterolemia*, screening should be at 3 years of age, again between ages 9 and 11, and again at age 18 (Level 3, Grade B)

  6. Screen adolescents older than 16 years every 5 years or more frequently if they have ASCVD risk factors, have overweight or obesity, have other elements of the insulin resistance syndrome, or have a family history of premature ASCVD (Level 3, Grade B)

* Familial hypercholesterolemia examples include family history of premature cardiovascular disease or elevated cholesterol

 

Treatment goals

  1. Treatment goals for dyslipidemia should be personalized according to levels of risk (Level 1, Grade A)

  2. For individuals at low risk*, an LDL-C goal < 130mg/dL is recommended (Level 1, Grade A)

  3. For individuals at moderate risk⁰ an LDL-C goal <100mg/dL is recommended (Level 1, Grade A)

  4. For individuals at high riskª an LDL-C goal <100mg/dL is recommended (Level 1, Grade A)

  5. For individuals at very high riskⁿ an LDL-C goal <70mg/dL is recommended (Level 1, Grade A)

  6. For individuals at extreme risk‡ an LDL-C goal <55mg/dL is recommended (Level 1, Grade A)

  7. HDL-C should be >40mg/dL but also as high as possible primarily through the use of lifestyle interventions, and if risk factors are present, also through the use of pharmacotherapy primarily focused on reducing LDL-C¨ (Level 1, Grade A)

  8. For individuals at extreme risk, a non-HDL-C goal 25mg/dL higher than the individual-specific LDL-C goal is recommended (Level 1, Grade A)

  9. For individuals at increased risk of ASCVD, including those with diabetes, an optimal apolipoprotein B goals is <90mg/dL, while for individuals with established ASCVD or diabetes plus 1 or more additional risk factor(s), an optimal apolipoprotein B goal is <80mg/dL, and for individuals at extreme risk, an optimal apolipoprotein B goal is <70mg/dL (Level 1, Grade A)

  10. TG goals <150mg/dL are recommended (Level 1, Grade A)

* low risk: no risk factors

moderate risk: 2 or fewer risk factors and a calculated 10-year risk of less than 10%

ª high risk: with an ASCVD equivalent including diabetes or stage 3 or 4 chronic kidney disease with no other risk factors, or individuals with 2 or more risk factors and a 10-year risk of 10%- 20%

ⁿ very high risk: with established or recent hospitalization for acute coronary syndrome; coronary, carotid or peripheral vascular disease; diabetes or stage 3 or 4 chronic kidney disease with 1 or more risk factors; a calculated 10-year risk greater than 20%; or heterozygous familial hypercholesterolemia

‡ extreme risk: with progressive ASCVD, including unstable angina that persists after achieving an LDL-C <70 mg/dL, or established clinical ASCVD in individuals with diabetes, stage 3 or 4 chronic kidney disease, and/or heterozygous familial hypercholesterolemia, or in individuals with a history of premature ASCVD (<55 years of age for males or <65 years of age for females

¨ lifestyle interventions: weight loss, physical activity, tobacco cessation. Risk factors: borderline elevated LDL-C levels, a family history of premature ASCVD, or a personal history of ASCVD.

 
 

Treatment recommendations

  1. A comprehensive strategy to control lipid levels and address associated metabolic abnormalities and modifiable risk factors is recommended primarily using lifestyle changes and patient education with pharmacotherapy as needed to achieve evidence-based targets (Level 1, Grade A)

  2. A reasonable and feasible approach to fitness therapy* is recommended; suggested activities include brisk walking, riding a stationary bike, water aerobics, cleaning/scrubbing, mowing the lawn, and sporting activities (Level 1, Grade A)

  3. Daily physical activity goals can be met in a single session or in multiple sessions throughout the course of a day (10 minutes minimum per session); for some individuals, breaking activity up throughout the day may help improve adherence with physical activity programs (Level 1, Grade A)

  4. In addition to aerobic activity, muscle-strengthening activity is recommended at least 2 days a week (Level 1, Grade A)

  5. For adults, a reduced-calorie diet consisting of fruits and vegetables (combined ≥5 servings/day), grains (primarily whole grains), fish, and lean meats is recommended (Level 1, Grade A)

  6. For adults, the intake of saturated fats, trans-fats, and cholesterol should be limited, while LDL-C-lowering macronutrient intake should include plant stanols/sterols (~2g/day) and soluble fiber (10-25g/day) (Level 1, Grade A)

  7. Primary preventive nutrition consisting of healthy lifestyle habits is recommended in all healthy children (Level 1, Grade A)

  8. Hormone replacement therapy for the treatment of dyslipidemia in postmenopausal women is not recommended (Level 1, Grade A)

  9. In individuals at risk for ASCVD, aggressive lipid-modifying therapy is recommended to achieve appropriate LDL-C goals (Level 1, Grade A)

  10. Statin therapy is recommended as the primary pharmacologic agent to achieve target LDL-C goals on the basis of morbidity and mortality outcome trials (Level 1, Grade A)

  11. For clinical decision-making, mild elevations in blood glucose levels and/or an increased risk of new-onset T2DM associated with intensive statin therapy do not outweigh the benefits of statin therapy for ASCVD risk reduction (Level 1, Grade A)

  12. In individuals within high-risk and very high-risk categories, further lowering of LDL-C beyond established targets with statins results in additional ASCVD event reduction and may be considered (Level 1, Grade A)

  13. Very high-risk individuals with established coronary, carotid, and peripheral vascular disease, or diabetes who also have at least 1 additional risk factor should be treated with statins to target a reduced LDL-C treatment goal of <70mg/dL (Level 1, Grade A)

  14. Extreme-risk individuals should be treated with statins to target an even lower LDL-C treatment goal of <55mg/dL (Level 1, Grade A)

  15. Fibrates should be used to treat severe hypertriglyceridemia (TG >500 mg/dL) (Level 1, Grade A)

  16. Fibrates may improve ASCVD outcomes in primary and secondary prevention when TG concentrations are ≥200 mg/dL and HDL-C concentrations are <40 mg/dL (Level 1, Grade A)

  17. Prescription omega-3 oil, 2-4g daily, should be used to treat severe hypertriglyceridemia (TG >500mg/dL). Dietary supplements are not FDA-approved for treatment of hypertriglyceridemia and generally are not recommended for this purpose (Level 1, Grade A)

  18. Niacin therapy is recommended principally as an adjunct for reducing TG (Level 1, Grade A)

  19. Niacin therapy should not be used in individuals aggressively treated with statin due to absence of additional benefits with well-controlled LDL-C (Level 1, Grade A)

  20. Bile acid sequestrants may be considered for reducing LDL-C and apoplipoprotein B and modestly increasing HDL-C, but they may increase TG (Level 1, Grade A)

  21. Ezetimibe can be used in combination with statins to further reduce both LDL-C and ASCVD risk (Level 1, Grade A)

  22. Proprotein convertase subtilisin/kexin type 9 inhibitors should be considered for use in combination with statin therapy for LDL-C lowering in individuals with familial hypercholesterolemia (Level 1, Grade A)

  23. Proprotein convertase subtilisin/kexin type 9 inhibitors should be considered in individuals with clinical cardiovascular disease who are unable to reach LDL-C/non-HDL-C goals with maximally tolerated statin therapy. They should not be used as monotherapy except in statin-tolerant individuals (Level 1, Grade A)

  24. Combination therapy of lipid-lowering agents should be considered when the LDL-C/non-HDL-C level is markedly increased and monotherapy (usually with a statin) does not achieve the therapeutic goal (Level 1, Grade A)

  25. Tobacco cessation should be strongly encouraged and facilitated (Level 2, Grade A)

  26. Ezetimibe may be considered as monotherapy in reducing LDL-C and apoplipoprotein B, especially in statin-intolerant individuals (Level 2, Grade B)

* Reasonable and feasible approach to fitness therapy: exercise programs that include at least 30 minutes of moderate-intensity physical activity [consuming 4-7 kcal/min] 4 to 6 times weekly, with an expenditure of at least 200 kcal/day

Referrals and Collaborations

 
  • Practitioners should refer individuals who are non-adherent to fitness therapy to instructor-led exercise classes

  • Pharmacologic therapy should be performed very carefully in conjunction with expert referral and appropriate consultation​

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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