Dyslipidemia & Hyperlipidemia: A Primary Care Guide for NPs

Managing cholesterol is a big part of preventing cardiovascular disease in primary care. Here’s a streamlined approach to terminology, screening, treatment decisions, and medication choices.

Key Terminology

• Dyslipidemia → Broad term describing abnormal cholesterol/lipid levels that increase cardiovascular disease risk. Medications may be useful.

• Hyperlipidemia → Specifically refers to elevated total cholesterol, LDL cholesterol, or triglycerides.

When to Start Screening

Recommendations vary depending on the guideline you follow. In general:

• High-risk patients (family history, metabolic syndrome, diabetes, smoking): start screening around age 20–30.

• Low-risk patients: begin screening at age 35–40.

• Men: higher baseline risk, so earlier screening may be reasonable.

When to Start a Statin

Start statin therapy if any of the following are present:

• History of stroke or coronary heart disease

• LDL ≥ 190 mg/dL

• Diabetic patients age ≥40 with LDL 70–189 mg/dL

• LDL 70–189 mg/dL + ASCVD 10-year risk ≥7.5%

💡 Tip: ASCVD risk = 10-year risk of stroke or heart attack. Most EMRs calculate this automatically. You can also use the free ASCVD Plus app by entering age, gender, race, BP, lipid levels, and history.

Choice of Medication

• First-line: Atorvastatin 10–20 mg daily

  • Recheck labs in ~2 months. Adjust as needed.

• If statin side effects (e.g., muscle cramps): Switch to Rosuvastatin 5–10 mg daily.

• If statins not tolerated: Consider Ezetimibe 10 mg daily.

Clinical Pearls for Busy NPs

• Coverage matters → Medicare often won’t cover a lipid panel purely as “screening.” Use Hyperlipidemia or Z13.220 (Screening for Lipid Disorders). “Annual physical” can sometimes work too.

• Baseline labs → Always check baseline liver function (AST/ALT) before starting a statin.

• Follow-up → Repeat lipid panel 4–12 weeks after initiating or changing dose, then every 3–12 months.

• Intensity matters → High-intensity statins (atorvastatin 40–80 mg, rosuvastatin 20–40 mg) lower LDL >50%. Moderate intensity lowers 30–49%. Match the dose to ASCVD risk.

• Statin intolerance → True statin allergy is rare. Many patients tolerate a different statin or a lower dose.

• Lifestyle is key → Statins work best when combined with diet changes, exercise, weight management, and smoking cessation.

• Don’t undertreat → Patients with ASCVD or LDL ≥190 almost always need pharmacologic therapy — lifestyle alone won’t be enough.

• Special note for diabetics → Nearly all adults ≥40 with diabetes should be on a statin unless contraindicated.

References

Pignone, M., & Cannon, C. (2024). Low-density lipoprotein cholesterol-lowering therapy in the primary prevention of cardiovascular disease. UpToDate .