Management of Atherogenic Dyslipidemia

Introduction to Treatment

The American College of Cardiology recommends initiating aggressive lifestyle modifications immediately alongside pharmacological therapy with statins as first-line, adding fibrates or prescription omega-3 fatty acids based on triglyceride severity and cardiovascular risk for patients with atherogenic dyslipidemia pattern 1, 2.

Calculate 10-year ASCVD risk using Framingham scoring to determine treatment intensity 2.
Primary LDL-C goal is <100 mg/dL, consider <70 mg/dL for very high-risk patients 3, 1, 2.
HDL-C goal is >40 mg/dL in men, >50 mg/dL in women 1, 2.
Triglyceride goal is <150 mg/dL 1, 4.
Secondary target is Non-HDL-C <130 mg/dL when triglycerides ≥200 mg/dL 3, 2.

Target 5-10% body weight reduction, which produces a 20% decrease in triglycerides 1, 4.
Reduce saturated fat to <7% of total calories and eliminate trans fats completely 5, 2, 4.
Restrict added sugars to <6% of total daily calories 4.
Limit total fat to 30-35% of calories for moderate hypertriglyceridemia 4.
Increase soluble fiber to >10 g/day 2, 4.
Consume ≥2 servings (8+ ounces) per week of fatty fish rich in omega-3 fatty acids 4.
Limit or completely avoid alcohol 4.
Complete abstinence from alcohol is mandatory if triglycerides ≥500 mg/dL 4.
Engage in ≥150 minutes/week of moderate-intensity aerobic activity 5, 4.

Initiate moderate-to-high intensity statin as first-line therapy for triglycerides <200 mg/dL with elevated LDL-C 1, 2.
Statins reduce LDL-C by 30-50%, provide 10-30% dose-dependent triglyceride reduction, and increase HDL-C 2, 4.
Consider adding icosapent ethyl 2-4 g daily if triglycerides remain >200 mg/dL after 3 months 1, 4.
Consider adding fenofibrate 54-160 mg daily if icosapent ethyl criteria are not met 1, 4.
Initiate fenofibrate 54-160 mg daily immediately as first-line therapy for triglycerides ≥500 mg/dL 1, 4.

Reassess fasting lipid panel in 4-8 weeks after initiating or adjusting therapy 1, 4.
Monitor liver function tests and creatine kinase at baseline and periodically when using statins or fibrates 5, 1.
Once goals are achieved, monitor every 6-12 months 1.
Monitor for muscle symptoms and obtain CPK levels if symptoms develop 1, 4.
Monitor for atrial fibrillation if using prescription omega-3 fatty acids 4.