Lipid Management: Guidelines From the Canadian PEER Group for Primary Care

Cardiovascular disease (CVD) is the leading cause of death globally, and lipid level testing is one aspect of screening to assess risk. Options for testing and treatment have grown complex as more tests and lipid-lowering agents become available. The Canadian PEER group for primary care released guidelines for preventing and managing CVD through lipid management. Acknowledging the many competing demands on family physicians, the guideline considers the “time needed to treat,” meaning the time clinicians spend implementing recommendations.

The guideline is summarized in a two-page reference (https://www.cfp.ca/content/cfp/suppl/2023/10/10/69.10.675.DC1/Figure_1_2-page_Guideline_Summary.pdf) and a free online tool (https://decisionaid.ca/cvd) can facilitate shared decision-making conversations about risks and interventions.

For patients without known CVD who are not taking statins, lipid testing is recommended when men reach 40 years of age and women reach 50 years of age. Earlier testing can be considered for patients with CVD risk factors, such as smoking and diabetes mellitus.

Frequent (e.g., yearly) lipid measurement is not useful in estimating risk. Without treatment, lipid levels vary about 1% per year, which is dwarfed by a variation of up to 20% due to testing inaccuracy. Frequent lipid measurements will likely reflect testing variability instead of changes in overall risk. Lipid screening is recommended no more than every 5 years and preferably every 10 years unless new risk factors are identified. Fasting lipid testing is not needed because nonfasting results accurately estimate risk.

The PEER group discourages assessing risk beyond lipid levels and the presence of risk factors. Coronary artery calcium scores only slightly increase accuracy and are not recommended. Lipoprotein(a) and apoprotein B tests are not helpful in determining risk.

For patients with cardiac disease, risk calculation and lipid testing and monitoring are unnecessary because statin therapy is universally recommended.

Physical activity is beneficial for primary and secondary prevention. Commitment to an exercise routine is more important than the type, duration, or intensity of exercise. The strongest evidence is for exercise-based cardiac rehabilitation, which reduces all-cause mortality, cardiovascular mortality, and myocardial infarction after a cardiac event.

The PEER group recommends the Mediterranean diet for patients with and without CVD. Compared with lowfat diets, the Mediterranean diet decreases cardiovascular events over 5 to 7 years.

For primary prevention, the 10-year cardiovascular risk estimation determines treatment recommendations. Patients with a 10-year risk of 20% or greater benefit from high-intensity statin therapy. Those with a 10-year risk between 10% and 19% may benefit from moderate-intensity statins. Once treatment is started, the PEER group recommends against repeat lipid testing or treating to a target cholesterol level. For patients with a 10-year risk less than 10%, statin therapy is not recommended and lipid levels should be reassessed in 5 to 10 years.