South Africa (SA) is home to a heterogeneous population with a wide range of cardiovascular risk factors. Cholesterol reduction in combination with aggressive management of modifiable risk factors, including nutrition, physical activity, blood pressure and smoking, can help to reduce and prevent morbidity and mortality in individuals who are at increased risk of cardiovascular events. This updated consensus guide to management of dyslipidaemia in SA is based on the updated European Society of Cardiology and European Atherosclerosis Society dyslipidaemia guidelines published in 2016. For individuals who are not considered to be at high or very high cardiovascular risk, the decision whether to treat and which interventional strategy to use is based on a cardiovascular risk score calculated using total cholesterol, high-density lipoprotein cholesterol (HDL-C), gender, age and smoking status. The cardiovascular risk score refers to the 10-year risk of any cardiovascular event and includes 4 categories of risk (low, moderate, high and very high). People with established cardiovascular disease, diabetes mellitus, chronic kidney disease and genetic or severe dyslipidaemias are considered to already be at high or very high risk and do not require risk scoring. Therapeutic lifestyle change is the mainstay of management for all patients. The need for and intensity of drug therapy is determined according to baseline low-density lipoprotein (LDL-C) levels and the target LDL-C concentration appropriate to the individual. LDL-C treatment targets are based on pre-treatment risk and are as follows: <3 mmol/L in low- and moderate risk cases; <2.5 mmol/L and a reduction of at least 50% if the baseline concentration is 2.5 - 5.2 mmol/L in high-risk cases; and <1.8 mmol/L and a reduction of at least 50% if the baseline concentration is 1.8 - 3.5 mmol/L in very high-risk cases. A statin is usually recommended first-line; the specific agent is based on the required degree of cholesterol reduction, comorbidities and co-prescribed medication. Special attention should be paid to children with a family history of genetic or severe dyslipidaemia, who should be screened for dyslipidaemia from 8 years of age. In SA, HIV infection is not considered to be a significant cardiovascular risk factor and treatment recommendations for HIV-positive individuals are the same as for the general population, with careful choice of pharmacotherapy to avoid potential adverse drug-drug interactions. The benefit of statins in individuals older than 70 years is uncertain and clinical judgement should be used to guide treatment decisions and to avoid side-effects and overmedication in this group.
E Klug, Netcare Sunninghill and Sunward Park Hospitals, Division of Cardiology, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg,
F J Raal, Carbohydrate and Lipid Metabolism Research Unit, Division of Endocrinology and Metabolism, Faculty of Health Sciences, University of the
A D Marais, Lipid Laboratory, Division of Chemical Pathology, Department of Clinical Laboratory Sciences, Faculty of Health Sciences, University of Cape
Town, Cape Town, South Africa
C M Smuts, Centre of Excellence for Nutrition, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
C Schamroth, Milpark Hospital, Johannesburg, South Africa
D Jankelow, Linksfield Clinic, Johannesburg, South Africa
D J Blom, Division of Lipidology and Hatter Institute for Cardiovascular Research in Southern Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
D A Webb, Pattacus Medical Consulting, Johannesburg, South Africa
Cite this article
South African Medical Journal 2018;108(11b):973-1000.
Date submitted: 2018-10-26
Date published: 2018-10-26
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