Guía de práctica clínica para la prevención, detección temprana, diagnóstico, tratamiento y seguimiento de las dislipidemias en la población mayor de 18 años

Objectives

Provide an evidence-based national clinical practice framework for preventing, detecting early, diagnosing, treating and following up dyslipidaemias among adults aged over 18 within Colombia’s health system, across relevant levels of care. The guidance aims to reduce variation in care, support rational resource use, inform health professionals, and enable patients and families to make informed decisions.[1][2][3][4]

• Improve nutritional practice, physical activity, cardiovascular-risk assessment, screening, diagnostic assessment, pharmacological management and clinical follow-up for adults with dyslipidaemia.[3][5]
• Reduce cardiovascular and cerebrovascular morbidity and mortality by identifying people at high absolute risk and providing risk-appropriate lipid-lowering treatment.[6][7][8]
• Apply recommendations to adults at risk of, or diagnosed with, dyslipidaemia, while excluding people under 18 and the specific management of dyslipidaemia associated with conditions requiring separate guidance, including hypothyroidism, diabetes, nephrotic syndrome, chronic kidney disease, renal replacement therapy, alcoholism and HIV/AIDS.[9][4][10]
• Promote healthier dietary patterns, including fruit, vegetables, legumes, wholegrains, nuts, monounsaturated fats and omega-3-rich foods, while limiting refined carbohydrates, saturated fats, visible meat fat, sugar and caloric sweeteners.[11][12][13]
• Encourage regular moderate-to-vigorous cardiovascular and resistance exercise, tailored to individual capacity, preferences, risks and barriers.[14][15]
• Standardise lipid screening and cardiovascular-risk classification, including use of the Framingham scale recalibrated for Colombia in primary prevention.[16][17][18]
• Support treatment choices based on cardiovascular risk rather than low-density lipoprotein cholesterol targets alone, prioritising statin therapy for people at high risk.[7][8][19]

Implementation

Implement the guidance through multidisciplinary, evidence-based clinical recommendations, practical algorithms and shared decision-making. Development involved the Ministry of Health and Social Protection, the Department of Administrative Science, Technology and Innovation, known as Colciencias, academic institutions, professional associations, patients and other interested groups.[20][21][22][5]Recommendations draw on systematic evidence review, explicit assessment of evidence quality and the Grading of Recommendations Assessment, Development and Evaluation, known as GRADE, approach, which considers benefits, harms, patient preferences, local availability, resource use and costs.[4][10]

• Deliver care principally through primary-care and specialist clinicians, cardiovascular-risk and prevention staff, nutrition professionals, insurers, providers, patient-support groups, patients and the wider public.[9][3]
• Use venous blood tests for total cholesterol, high-density lipoprotein cholesterol and triglycerides; calculate low-density lipoprotein cholesterol using the Friedewald formula where triglycerides are below 400 mg/dL, and measure it directly above that threshold.[16][23]
• Start screening at age 45 for asymptomatic adults without risk factors, or at any age where relevant risk factors or conditions are present; repeat screening annually for people with additional risk factors and every two years for those without them.[17][24][25]
• Assess cardiovascular risk using the recalibrated Framingham estimate, calculated by multiplying the original score by 0.75, while treating established atherosclerotic cardiovascular disease, low-density lipoprotein cholesterol above 190 mg/dL and diabetes mellitus as high-risk states not requiring risk-table assessment.[18][6]
• Discuss healthy lifestyles at every clinical contact and provide dietary counselling and individually tailored exercise advice, including progressive activity increases and specialist assessment before exercise where cardiovascular disease, high risk or diabetes is present.[14][15][24]
• Use high-intensity statins for specified high-risk groups and moderate-intensity statins for eligible people with type 2 diabetes or selected other risk factors; tailor treatment in older adults and in people at elevated risk of adverse effects according to benefits, risks and patient preferences.[19][26][27]
• Reserve fibrates, prolonged-release niacin, pharmaceutical omega-3 preparations, bile-acid sequestrants and ezetimibe for selected circumstances, particularly where statins are contraindicated, not tolerated or insufficiently suitable.[28][29][30][31][32]
• Review adherence and therapeutic response eight weeks after pharmacological treatment begins, reinforce lifestyle and medication adherence, adjust treatment where needed, and continue annual follow-up where the expected response is achieved.[33][34][25]
• Monitor for muscular and hepatic adverse effects during statin therapy, avoiding routine creatine kinase or liver-enzyme testing in all asymptomatic patients while undertaking targeted testing when symptoms or relevant risk factors are present.[35][36]
• Use published algorithms for screening, cardiovascular-risk assessment, treatment, monitoring and follow-up, with a full guideline and patient-and-family information resource available through the Ministry’s website.[4][10][37][38]

The supplied material does not specify a programme-level governance structure for implementation, formal performance indicators, reporting schedules, surveillance arrangements, accountability mechanisms, budgets, financing sources or quantified implementation costs. Cost, feasibility, local availability and acceptability are nevertheless recognised as considerations in selecting tests, technologies and recommendations.[4][16][17][6][23]

Monitoring & Evaluation

The guideline provides clinical monitoring and follow-up arrangements for adult dyslipidaemia, but does not establish a programme-level performance framework with reporting schedules, surveillance systems, audits or formal accountability mechanisms.[37][39]

• Use screening, cardiovascular-risk assessment, treatment, monitoring and follow-up algorithms, including sex-specific Framingham tables to estimate 10-year risk of acute myocardial infarction or coronary death.[40][38]
• Assess lipid status through venous total cholesterol, high-density lipoprotein cholesterol and triglycerides, calculating low-density lipoprotein cholesterol with the Friedewald formula where triglycerides are below 400 mg/dL and measuring it directly above this threshold.[16][23]
• Repeat lipid screening annually for people with a normal profile and additional risk factors, and every two years for those with a normal profile without additional risk factors.[17][25]
• Use the Framingham risk scale recalibrated for Colombia, applying a multiplier of 0.75 to the original estimate, for primary-prevention risk classification.[18][6]
• Review pharmacological treatment after eight weeks to assess adherence and therapeutic response, using expected low-density lipoprotein cholesterol reductions of more than 50% for high-intensity statins and 30% to 50% for moderate-intensity statins.[34]
• Continue follow-up at 12-month intervals when the expected response is achieved, while reassessing adherence, lifestyle measures and pharmacological treatment when it is not.[33][34]
• Monitor statin users for muscular symptoms and symptoms suggestive of hepatic toxicity, avoiding routine creatine kinase testing in asymptomatic patients and using targeted creatine kinase or liver-enzyme testing where clinically indicated.[35][36]
• Discuss healthy lifestyles and habits at every contact with professionals responsible for dyslipidaemia management and follow-up.[24][34]
• Assess mortality, cardiovascular and cerebrovascular events, lipid fractions, lipid-target attainment, exercise capacity, body weight, adverse effects and adherence as relevant clinical outcomes in the evidence base and therapeutic evaluation.[10][31]
• Interpret lifestyle evidence cautiously because exercise evidence lacked information on mortality and cardiovascular or cerebrovascular events, and observed lipid changes were statistically significant but not clinically relevant.[10][14]
• Recognise that screening-age and screening-interval recommendations were based largely on expert consensus because clinical evidence was limited.[16][17][24]

Evidence appraisal used systematic review, evidence-quality assessment and the Grading of Recommendations Assessment, Development and Evaluation approach, considering benefits, risks, patient preferences, resource use, local availability and costs.[4]Recommendation strengths range from strong to weak and may be based on moderate- or high-quality evidence, low-quality evidence or expert consensus, depending on the intervention.[6][19][37]

International lipid-target attainment figures are presented as contextual evidence of a management gap, with reported attainment of 45% in NHANES, 39% in L-TAP and 42% in CARPAT among adults, and lower attainment among people with coronary disease.[41]These figures are not presented as implementation indicators or national accountability targets.[41][2]

Costing & Financing

No budget, quantified implementation cost, financing source, resource-allocation mechanism, resource-mobilisation plan, funding-gap estimate or economic assumption is specified.[1][20]The guideline nevertheless incorporates resource use, local availability and associated costs into recommendation judgements.[4]

• Promote rational use of resources in dyslipidaemia diagnosis, treatment and follow-up by unifying diagnostic strategies, reducing unnecessary examinations and selecting tests according to age, risk and individual clinical circumstances.[2][9][3]
• Consider cost alongside feasibility, logistics, acceptability, sample preparation and test characteristics when selecting lipid-screening strategies.[16]
• Consider health-system costs and risks, the likelihood of detecting lipid abnormalities, cardiovascular risk, treatment potential and management implications when determining screening limits and strategies.[17]
• Avoid routine C-reactive protein, ankle-brachial index and coronary calcium-score measurement because their cost-effectiveness had not been demonstrated.[7]
• Recognise that exercise should be practical and should not create logistical or economic difficulties for the individual.[14]
• Recognise that combination lipid-lowering therapy has higher cost, while its clinical benefit is unclear and routine use is not considered appropriate.[27]

A dedicated economic-evaluation team participated in development, and the methodology followed Colombia’s guide for clinical practice guideline development with economic evaluation.[21][5]However, the supplied material does not provide the results of an economic evaluation, medicine prices, unit costs, affordability thresholds, budget-impact analysis or cost-effectiveness ratios.[21][5][4]