Modalités de prise en charge des dyslipidémies – Mise à jour 2020

Objectives

The 2020 update provides a risk-based framework for preventing cardiovascular and cerebrovascular mortality through early identification and management of dyslipidaemia across childhood, adolescence and adulthood. It bases 10-year risk assessment principally on low-density lipoprotein cholesterol and the Systematic COronary Risk Evaluation (SCORE) chart, while recognising that obesity, physical inactivity, family history and adverse living conditions can increase risk beyond that captured by SCORE.[1][2]

• Classify people into children and adolescents at cardiovascular risk, adults at very high risk, adults at high risk and other adults, with diabetes-specific considerations and risk-stratified lipid targets.[3][2]
• Reduce population cardiovascular risk by addressing smoking, unhealthy diet, obesity, physical inactivity and harmful alcohol use, while detecting and managing people at high risk at an early stage.[4]
• Identify familial hypercholesterolaemia, diabetes-associated dyslipidaemia and other lipid disorders early, including among children and adolescents, to prevent microvascular and macrovascular complications.[3][5]
• Achieve risk-specific low-density lipoprotein cholesterol goals: below 116 mg/dl for adults at low risk, 100 mg/dl for moderate risk, 70 mg/dl or at least a 50% reduction from baseline for high risk, and 55 mg/dl or at least a 50% reduction for very-high-risk adults.[6]
• Target low-density lipoprotein cholesterol below 130 mg/dl in children and adolescents at risk, with an ideal paediatric value below 100 mg/dl; for adolescents with type 2 diabetes, also target high-density lipoprotein cholesterol above 35 mg/dl and triglycerides below 150 mg/dl.[3][7][8]
• Lower triglycerides to below 150 mg/dl in adults and address moderate hypertriglyceridaemia through weight reduction, reduced alcohol intake and lower consumption of simple sugars.[6][9]
• Provide intensive lipid-lowering treatment for high-risk patients following atherosclerotic stroke or transient ischaemic attack and for adults at very high risk in both primary and secondary prevention.[6][10]

Implementation

The approach combines structured cardiovascular-risk assessment, repeated lipid measurement, lifestyle intervention, targeted medicines and specialist management for severe or inherited disorders. Adults with specified cardiovascular, cerebrovascular, peripheral arterial, diabetes, renal or familial hypercholesterolaemia conditions may be recognised as very high risk without SCORE assessment; other adults are assessed using SCORE alongside age and interacting risk factors.[7][6]

• Assess risk using SCORE, which incorporates total cholesterol, blood pressure, age, sex and smoking status, while supplementing this assessment with clinical judgement and relevant social, behavioural and hereditary risk factors.[3][2]
• Measure blood lipids at least twice, one to 12 weeks apart, before initiating lipid-lowering treatment unless immediate treatment is required, such as in acute coronary syndromes.[2]
• Use additional investigations where appropriate, including carotid or femoral ultrasound, cardiac computed tomography calcium scoring and measurement of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, non-high-density lipoprotein cholesterol and, for selected patients, lipoprotein(a).[6]
• Provide dietary treatment for any lipid abnormality or cardiovascular risk factor, including for low-risk patients; where appropriate, use dietary treatment alone for at least three months in primary prevention, while initiating medicines earlier in secondary prevention and maintaining dietary measures long term.[11]
• Promote dietary measures that limit total fat to below 35 to 40% of total energy, saturated fat to below 12%, dietary cholesterol to below 300 mg daily and salt to below 6 grams daily, while encouraging fruit and vegetable consumption, healthier unsaturated fats, physical activity and weight reduction when appropriate.[11][9]
• Use maximally tolerated statins as principal lipid-lowering treatment, add ezetimibe if targets are unmet or statins are not tolerated, and consider a proprotein convertase subtilisin/kexin type 9 inhibitor when combination treatment remains insufficient.[10]
• Investigate genetic, secondary and medicine-related causes of hypertriglyceridaemia; use fibrates for high-risk patients whose triglycerides remain above 200 mg/dl despite dietary measures, and monitor for muscle injury when combining statins and fibrates.[11]
• Refer people with triglycerides above 1,000 mg/dl or chylomicronaemia for specialist assessment and nutritional guidance, including marked dietary fat restriction.[9]
• Provide lifelong follow-up for confirmed heterozygous familial hypercholesterolaemia and manage homozygous familial hypercholesterolaemia through a specialist centre with access to lipid apheresis.[9][8]
• Screen children with type 1 diabetes from age 11, or after diagnosis once metabolic control has stabilised, and from age 2 where there is a relevant or unknown family history; repeat normal screening every five years.[5]
• Use dietary change, physical activity and improved metabolic control for children with elevated low-density lipoprotein cholesterol, and consider statins from age 11 where cholesterol remains above 130 mg/dl despite these measures.[5]
• Recheck lipids around eight weeks after treatment initiation or adjustment until targets are achieved, then monitor annually, with more frequent review where adherence or clinical circumstances warrant it.[2]
• Use a formal evidence framework in which strong and weak recommendations are distinguished by their expected applicability, evidence levels A to C follow the European Society of Cardiology framework, and level E reflects working-group consensus.[12]
• Coordinate guideline development through a multidisciplinary working group comprising cardiology, general practice, paediatrics, neurology, pharmacy, Directorate of Health, methodological and Scientific Council representation; members declared no conflicts of interest and the Scientific Council secretariat serves as the administrative contact.[12][13]

The extract does not specify wider service-delivery responsibilities, named implementing institutions beyond the guideline-development bodies, financing, programme indicators, reporting systems, surveillance arrangements or formal accountability mechanisms.[1][4][12][13]

Monitoring & Evaluation

Monitoring centres on cardiovascular risk stratification, lipid measurements and treatment follow-up, using the Systematic Coronary Risk Estimation (SCORE) chart alongside clinical factors that are not fully captured by SCORE. The extracts provide clinical monitoring intervals and lipid targets, but do not establish a population surveillance system, routine reporting framework, formal programme indicators or explicit accountability arrangements.[1][6][2][12]

• Assess 10-year cardiovascular and cerebrovascular mortality risk using low-density lipoprotein cholesterol and the SCORE chart, while considering obesity, physical inactivity, family history, hereditary factors and unfavourable living conditions as additional determinants of overall risk.[1][2]
• Apply SCORE using total cholesterol, blood pressure, age, sex and smoking status for adults not already identified as high or very high risk through specified clinical conditions.[3][7][6]
• Measure blood lipids at least twice, one to 12 weeks apart, before lipid-lowering treatment, except where immediate treatment is indicated, including acute coronary syndromes.[2]
• Recheck lipid concentrations eight weeks after treatment initiation or adjustment, allowing a four-week margin, and continue follow-up until target values are reached.[2]
• Measure lipids every three months until target values are achieved and annually thereafter; conduct more frequent examinations where adherence difficulties or another specific reason warrants closer review.[6][2]
• Monitor for muscle injury when statins and fibrates are combined for mixed hyperlipidaemia.[11]
• Repeat lipid screening every five years for children and adolescents with type 1 diabetes when results are normal, and obtain a fasting lipid profile where a non-fasting test identifies low-density lipoprotein cholesterol above 100 milligrams per decilitre or triglycerides above 400 milligrams per decilitre.[5]
• Assess adolescents under 25 years with type 2 diabetes for dyslipidaemia after metabolic stabilisation or three months after treatment starts, and annually thereafter.[8]
• Repeat the lipid profile after six months where low-density lipoprotein cholesterol is elevated in adolescents with type 2 diabetes, with targets of low-density lipoprotein cholesterol below 100 milligrams per decilitre, high-density lipoprotein cholesterol above 35 milligrams per decilitre and triglycerides below 150 milligrams per decilitre.[8]
• Review lipid-lowering treatment four to six weeks after acute coronary syndrome and add a proprotein convertase subtilisin/kexin type 9 inhibitor where the target remains unmet.[10]
• Use evidence grades to support selected recommendations: levels A to C align with the European Society of Cardiology evidence table, while level E reflects working-group expert consensus.[12]
• Recognise that the supplied extracts do not specify formal monitoring indicators, aggregate reporting requirements, evaluation methods, surveillance arrangements or accountability mechanisms beyond risk assessment, clinical follow-up and evidence grading.[1][3][6][10][2][12]

Costing & Financing

No costs, budgets, financing sources, resource-mobilisation arrangements, funding gaps or economic assumptions are specified in the supplied extracts.[1][3][6][5][2][12]

• Note that the clinical approach may require lipid testing, complementary imaging and laboratory examinations, specialist assessment, medicines and lipid apheresis access for selected patients, but the extracts provide no associated prices, allocations, reimbursement arrangements or resource estimates.[6][9][8][10]
• Recognise that the working group included representatives from the Directorate of Health and the Scientific Council secretariat was identified as administrative contact, but no institutional financing role or budgetary responsibility is described.[12][13]