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Clinical Guide to the Screening and Management of Dyslipidemia (Thai Guidelines 2024)

Updated: Jun 30

Introduction

Dyslipidemia remains a significant risk factor for cardiovascular disease (CVD), the leading cause of morbidity and mortality globally. The 2024 Thai Clinical Practice Guidelines offer a clear, evidence-based framework for the assessment, diagnosis, and management of dyslipidemia to reduce CVD risk.

Section 1: Screening Recommendations

Who Should Be Screened?

According to the 2024 guidelines, lipid profile screening is recommended for the following groups:

  • Individuals aged >35 years

  • Patients with established CVD

  • Those at high cardiovascular risk, such as patients with:

    • Diabetes mellitus (DM)

    • Chronic kidney disease (CKD)

    • Suspected familial hypercholesterolemia (e.g., tendon xanthomas, family history of premature ASCVD)

Key Parameters

  • Primary Marker: LDL-C (calculated or directly measured)

  • Additional Marker: Non-HDL-C (total cholesterol - HDL) for individuals with elevated triglycerides (TG), diabetes, or obesity

Section 2: Risk Assessment & Diagnosis

Initial Workup in High-Risk Patients

For patients with high TG, diabetes, or obesity, perform:

  • Full lipid profile to determine dyslipidemia type

  • Assessment for genetic dyslipidemia (e.g., xanthoma, family history of early ASCVD)

  • Investigation of secondary causes, including:

    • Hypothyroidism

    • Nephrotic syndrome

    • Cushing syndrome

Risk Stratification

  • Secondary Prevention: Identify patients with established ASCVD and initiate high-potency statin therapy

  • Primary Prevention: Assess 10-year CV risk using the Thai CV Risk Score and classify into treatment intensity categories

Section 3: Treatment Targets

Primary Target: LDL-C Goals

Clinical Scenario

LDL-C Reduction Goal

LDL-C Target

ASCVD

≥50%

<55 mg/dL

LDL-C ≥190 mg/dL (With FH)

≥50%

<70 mg/dL

LDL-C ≥190 mg/dL (Without FH)

≥50%

<100 mg/dL

Diabetes + ≥2 RFs

≥50%

<70 mg/dL

Diabetes + <2 RFs or Age <40

≥30%

<100 mg/dL

CKD

≥30%

<100 mg/dL

10-year CV risk ≥10% or subclinical atherosclerosis

≥30%

<100 mg/dL

Secondary Target: Non-HDL-C = LDL-C Goal + 30

Section 4: Pharmacologic Management

Stepwise Approach

  1. Step 1: Statin Therapy

    • High-potency: Atorvastatin 40 mg, Rosuvastatin 20 mg

    • Moderate-potency: Simvastatin 20–40 mg, Atorvastatin 10–20 mg

  2. Step 2: Add Ezetimibe 10 mg daily if LDL-C target not reached

  3. Step 3: Assess Adherence to lifestyle modification and medications

  4. Step 4: Specialist Referral

    • Consider PCSK9 inhibitors or bempidoic acid for LDL-C lowering

    • Icosapent ethyl for elevated TG

Section 5: Monitoring and Follow-up

  • After starting statin: Check LDL-C and ALT at 4–12 weeks

  • If target met: Reassess lipid profile every 3 months initially, then every 6 months

  • If target unmet: Evaluate adherence and adjust therapy, recheck LDL-C in 3 months

  • Check Total CK only if muscle symptoms are present

Conclusion

Timely identification and structured management of dyslipidemia can significantly reduce CVD risk. The Thai 2024 guideline emphasizes risk-based therapy and patient-specific targets, aligning pharmacologic strategies with individualized care plans.

By incorporating these recommendations into daily practice, clinicians can optimize outcomes for patients at risk of cardiovascular disease.

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Additional Considerations in Risk Stratification and Management

CKD and Familial Hypercholesterolemia (FH)

  • CKD (eGFR <60 ml/min/1.73m², non-dialysis): These patients are at high cardiovascular risk. Recommended LDL-C goal is either a ≥30% reduction or achieving <100 mg/dL.

  • Familial Hypercholesterolemia (FH): In patients with LDL-C ≥190 mg/dL:

    • With FH: Target is ≥50% reduction and LDL-C <70 mg/dL

    • Without FH: Target is ≥50% reduction and LDL-C <100 mg/dL

Risk Factors (RFs)

"RFs" refer to traditional risk-enhancing factors that modify lipid goals:

  • Diabetes duration >10 years

  • Family history of premature CVD

  • Obesity/Overweight

  • Smoking

  • Hypertension (HT)

  • CKD with albuminuria

Patients with multiple RFs are stratified into higher risk groups requiring more aggressive LDL-C reduction strategies.

Subclinical Atherosclerosis Markers

  • CAC (Coronary Artery Calcium) >100 and ABI (Ankle-Brachial Index) <0.9 are considered indicators of subclinical atherosclerosis.

    • In such cases, even if the 10-year CV risk is <10%, treat to reduce LDL-C ≥30% and achieve <100 mg/dL.

Secondary Lipid Targets

  • Non-HDL-C is a secondary target in dyslipidemia management and is calculated as:

    Non-HDL-C = Total Cholesterol−HDL-C = LDL-C Goal+30

This marker is especially useful in patients with elevated TG or metabolic syndrome.

Hypertriglyceridemia Management

For patients with Triglyceride (TG) >200 mg/dL, initiate:

  • Lifestyle Modification (LSM) as first-line treatment: includes weight loss, exercise, dietary changes, and glycemic control in diabetics

For patients with TG >500 mg/dL:

  • Consider fibrate therapy only to prevent acute pancreatitis after lifestyle measures.

  • Do not routinely use fibrates with statins to prevent ASCVD events, as current evidence does not support cardiovascular benefit from this combination.


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