Guidelines - Dyslipidemia and Cardiovascular Disease

This guideline aims to provide information on clinical decision-making and therapeutic recommendations for the management of youth and adults with dyslipidemia.

Focused examination for clinical decision-making

1. Patient History 

  • Identify 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

Nontraditional 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​

2. Physical Examination

  • Determine the existence of diastasis recti

    • women who develop diastasis recti should avoid abdominal strengthening exercises as this may worsen the condition, increasing the likelihood of requiring postnatal repair

    • continuing aerobic exercise, such as walking, is associated with decreased odds of developing diastasis recti

  • women considering athletic competition or exercising significantly above the recommended guidelines should speak to their obstetric care provider prior to doing so

  • elite athletes who continue to train during pregnancy are advised to seek supervision from an obstetric care provider with knowledge of the impact of vigorous-intensity physical activity on maternal, fetal, and neonatal outcomes

Diastasis Recti:

  • Defined as the separation of the rectus abdominis muscles by an abnormal distance. Diastasis recti might cause a bulge in the middle of the abdomen where the two muscles separate

3. Management 

  • The Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for Pregnancy) is recommended for use as a health screening prior to participation in physical activity

  • Discuss the range of physical activity recommendations available with the patient and, together, select the option this is right for them


  • 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

  • A reasonable and feasible approach to fitness therapyi is recommended; suggested activities include brisk walking, riding a stationary bike, water aerobics, cleaning/scrubbing, mowing the lawn, and sporting activities

  • 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

  • In addition to aerobic activity, muscle-strengthening activity is recommended at least 2 days a week

  • 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

  • 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)

  • Primary preventive nutrition consisting of healthy lifestyle habits is recommended in all healthy children

  • Hormone replacement therapy for the treatment of dyslipidemia in postmenopausal women is not recommended

  • In individuals at risk for ASCVD, aggressive lipid-modifying therapy is recommended to achieve appropriate LDL-C goals

  • Statin therapy is recommended as the primary pharmacologic agent to achieve target LDL-C goals on the basis of morbidity and mortality outcome trials

  • 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

  • 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

  • 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

  • Extreme-risk individuals should be treated with statins to target an even lower LDL-C treatment goal of <55mg/dL

  • Fibrates should be used to treat severe hypertriglyceridemia (TG >500 mg/dL)

  • 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

  • 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

  • Niacin therapy is recommended principally as an adjunct for reducing TG

  • Niacin therapy should not be used in individuals aggressively treated with statin due to absence of additional benefits with well-controlled LDL-C

  • Bile acid sequestrants may be considered for reducing LDL-C and apoplipoprotein B and modestly increasing HDL-C, but they may increase TG

  • Ezetimibe can be used in combination with statins to further reduce both LDL-C and ASCVD risk

  • 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

  • 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

  • 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

  • Tobacco cessation should be strongly encouraged and facilitated

  • Tobacco cessation should be strongly encouraged and facilitated

4. Reevaluation and Discharge

  •  Reassess the patient at every visit 

5. Referrals and Collaboration

  • Refer the patient to a physician for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms

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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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