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

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

Step 1: Statin Therapy
- High-potency: Atorvastatin 40 mg, Rosuvastatin 20 mg
- Moderate-potency: Simvastatin 20–40 mg, Atorvastatin 10–20 mg
Step 2: Add Ezetimibe 10 mg daily if LDL-C target not reached
Step 3: Assess Adherence to lifestyle modification and medications
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.