The Living Guidelines: Lipid Management Suggest Revisions to the CLASS I Guidelines

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Goal: LDL-C substantially <100 mg/dL. (If triglycerides are ≥200 mg/dL, non–HDL-C should be <130 mg/dL)

1. A fasting lipid profile should be assessed in all patients and within 24 hours of hospitalization for those with an acute cardiovascular or coronary event. For hospitalized patients, initiation of lipid lowering medication is indicated as recommended below before discharge according to the following schedule:


 * LDL-C should be < 100 mg/dL. (Class I Level of Evidence: A)


 * Further reduction of LDL-C to <70 mg/dL is reasonable. (Class IIa Level of Evidence: A)


 * If baseline LDL-C is ≥100 mg/dL, LDL-lowering drug therapy should be initiated. (Class I Level of Evidence: A)


 * If on-treatment LDL-C is ≥100 mg/dL, intensify LDL lowering drug therapy (may require LDL lowering drug combination) is recommended. (Class I Level of Evidence: A)


 * If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat to LDL-C <70 mg/dL. (Class IIa Level of Evidence: B)


 * If triglycerides are ≥150 mg/dL or HDL-C is <40 mg/dL, weight management, physical activity, and smoking cessation should be emphasized. (Class I Level of Evidence: B)


 * If triglycerides are 200 to 499 mg/dL, non–HDL-C target should be less than 130 mg/dL. (Class I Level of Evidence: B)


 * If triglycerides are 200 to 499 mg/dL, further reduction of non–HDL-C to <100 mg/dL is reasonable. (Class IIa Level of Evidence: B)

2. Therapeutic options to reduce non–HDL-C include:


 * More intense LDL-C–lowering therapy is indicated. (Class I Level of Evidence: B)


 * Niacin (after LDL-C–lowering therapy) can be beneficial. (Class IIa Level of Evidence: B)


 * Fibrate therapy (after LDL-C–lowering therapy) can be beneficial. (Class IIa Level of Evidence: B)

3. If triglycerides are ≥500 mg/dL, therapeutic options indicated and useful to prevent pancreatitis are fibrate or niacin before LDL lowering therapy, and treat LDL-C to goal after triglyceride-lowering therapy. Achieving a non–HDL-C of <130 mg/dL is recommended. (Class I Level of Evidence: C)

4. Starting dietary therapy is recommended. Reduce intake of saturated fats (to <7% of total calories), trans fatty acids, and cholesterol (to <200 mg/day). (Class I Level of Evidence: B)

5. Promotion of daily physical activity and weight management is recommended. (Class I Level of Evidence: B)