Simplified Canadian lipid guidelines for primary care providers

A panel of nine Canadian healthcare professionals has updated the 2015 PEER (Patients Experience Evidence Research) simplified lipid guidelines. The guidelines are designed to provide a simplified approach to lipid management in the prevention of cardiovascular disease for primary care providers and their patients. The guidelines focus on primary prevention, prioritize high-level evidence and incorporate shared decision making. The updated lipid guidelines provide 24 recommendations divided into five categories: screening and testing, nonpharmacologic and pharmacologic interventions, considerations in patients older than 75 years, statin intolerance, and follow-up. The following recommendations relate to nonpharmacologic and pharmacologic interventions: The guidelines suggest encouraging patients to participate in physical activity. Adherence is likely more important than the specific type, duration and intensity of exercise. The Mediterranean diet is recommended to reduce cardiovascular risk. Clinicians are recommended to discuss the initiation of statins (preferably high-intensity statins) with patients for primary prevention in patients with a 10-year cardiovascular disease risk of ≥ 20%. Clinicians are suggested to discuss the initiation of statins (preferably moderate-intensity statins) with patients for primary prevention in patients with a 10-year cardiovascular disease risk of 10%–19%. Retesting lipid levels in five years at the earliest and preferably in 10 years is suggested with risk estimation for primary prevention in patients with a 10-year cardiovascular disease risk of < 10%. The guidelines recommend against using nonstatin lipid-lowering drugs as monotherapy or in combination with statins for primary prevention. For secondary prevention, clinicians are recommended to encourage initiation of high-intensity statin therapy and discuss the risks and benefits with patients. For secondary prevention, if additional cardiovascular risk reduction is desired beyond maximized statin therapy, a discussion of ezetimibe or PCSK9 inhibitors is recommended. Adding icosapent to statins is suggested only after considering ezetimibe or PCSK9 inhibitors, given its potential adverse effects (atrial fibrillation, bleeding). Regarding statin intolerance, the guidelines recommend the following: When patients do not tolerate a specific statin regimen due to nonsevere muscle adverse effects, any statin intensity is recommended over nonstatin lipid therapy. This could include the same or different statins, doses or alternate daily dosing, based on shared decision making. For primary prevention in patients unable to tolerate any statin rechallenge, the guidelines suggest against use of nonstatin pharmacologic therapies. For secondary prevention in patients unable to tolerate any statin rechallenge, the guidelines suggest a discussion of ezetimibe, fibrates or PCSK9 inhibitors. Icosapent should be considered only when other options have been explored, due to its potential adverse events (atrial fibrillation, bleeding). In terms of follow-up, the guidelines recommend against the use of repeat lipid testing and cholesterol targets after a patient begins lipid-lowering therapy. Most clinical trials have used fixed-dose (mostly moderate-intensity) statins based on cardiovascular disease risk and have found benefit occurs irrespective of LDL levels achieved. The guidelines are accompanied by a two-page guideline summary, which includes a treatment algorithm, a chart of statin intensity doses, a summary of statin benefits (e.g., relative risk reduction, absolute risk reduction), a synopsis of prescribing considerations and relative risk reduction for the various categories of lipid-lowering agents, and a chart recapping how to manage statin muscle-related symptoms. Reference 1. Kolber MR, Klarenbach S, Cauchon M, et al. PEER simplified lipid guideline 2023 update: prevention and management of cardiovascular disease in primary care. Can Fam Physician 2023;69:675-86. (accessed October 19, 2023).

Simplified Canadian lipid guidelines for primary care providers

Register for free access or login.

Related Topics