Review of referral criteria to lipid clinics and outcomes of treatment in four UK centres

Abstract

Summary Background Little data exist on the referral patterns and effectiveness of lipid clinics. Methods An audit was conducted in four clinics of 100 consecutive referrals each. Data were recorded on referral criteria, cardiovascular disease (CVD) risk factors, drug history, investigations, diagnoses, therapies, results and referrals. Results Patients were aged 56 ± 14 years, 47% were male and 87% were primary prevention. Risk factors included smoking (16%), type 2 diabetes (13%) and hypertension (13%). Referrals were made for hypercholesterolaemia (68%), diagnosis of FH (31%), statin intolerance (23%) and hypertriglyceridaemia (23%). Initial total cholesterol (TC) was 7.65 ± 2.64 mmol/L, triglycerides (TG) 2.17 (0.41‐76.9 mmol/L) mmol/L, HDL‐C 1.53 ± 0.71 mmol/L, LDL‐C 4.57 ± 1.66 mmol/L with non‐HDL‐C 5.90 ± 2.09 mmol/L. Criteria for FH were met in 21% with genetic testing in 13% and lipid cascade testing in 30% of index cases. Triglycerides >20 mmol/L were present in 4%. The diagnosis was changed in 21%: hypercholesterolaemia (7%), mixed hyperlipidaemia (7%) and hypertriglyceridaemia (7%). Hepatic steatosis was identified in 14.5%. Lipoprotein(a) levels >125 nmol/L occurred in 41% in one clinic. Therapy changes included altered statins (40%), addition of a fibrate (11%) or ezetimibe (8%). These reduced TC by 1.92 mmol/L (19%; P = 0.0001), LDL‐C 1.07 mmol/L (15%; P = 0.02), non‐HDL‐C 1.50 mmol/L (16%; P < 0.001), and TG 2.3 (−4 to 38) mmol/L (16%; P < 0.001) with 11% extra achieving TG <5 mmol/L while HDL‐C increased by 7% (P = 0.37). Conclusions Lipid clinics have diverse functions including diagnosis of FH, managing severe hypercholesterolaemia, mixed hyperlipidaemia and statin intolerance. Effectiveness criteria of average reductions of 1.5 mmol/L in TC or non‐HDL‐C, 1 mmol/L in LDL‐C and 2 mmol/L in TG would be reasonable for newly referred patients.

Lipid Clinic is an Efficacious Model of Preventive Medicine

“…Более половины пациентов, обратившихся в ЛК, имели низкий (24,7%) или умеренный (27,7%) ССР. Подобные результаты представлены в исследовании, анализировавшем работу четырех ЛК Великобритании: 87% направленных в ЛК пациентов не имели ССЗ атеросклеротического генеза [23]. Полученные данные могут указывать на наличие мотивации у пришедших пациентов вести здоровый образ жизни и заниматься первичной профилактикой.…”

Noncoronary Artery Disease in Familial Hypercholesterolemia: Underdiagnosis of Peripheral Arterial Disease?

“…4 However, clinically this does not seem to be the case as presentations with claudication to lipid clinics seem to be infrequent. 11,13 Whether an unrecognized referral bias exists that reduces rates of referrals to specialist lipid clinics from vascular surgery units in many centers remains to be explored but might be suspected given the results of this study.…”

“…While lipid clinics in the United Kingdom commonly see patients for diagnosis and management of FH, presentations with PAD seem to be rare as only 1% of presentations were for PAD. 13 Furthermore, as screening for FH becomes more common and genetic testing is introduced, cascade screening is becoming routine and the historical selection bias toward greater severity abates; thus rates of diagnosed CAD are falling in clinic FH populations. 14 The extent of referral bias can be seen in the fact that many reported clinic cohorts have untreated LDL-C 6.0-8.0 mmol/L (240-320 mg/dL) with a treated LDL-C around 4.5 mmol/L (180 mg/dL).…”

“…16,17 Rates of smoking are often lower in patients with FH than the general population with rates of 13% reported in a recent UK audit compared to up to 20% in the general population. 13 Diabetes is commonly associated with PAD 16,17 and the prevalence of this disease is increasing in the general population in line with the occurrence of obesity, yet there is a suggestion that patients with FH may be protected against developing diabetes (OR: 0.62 [0.55-0.69]) compared to the general population. 18 Raised lipoprotein (a) concentrations are common in FH 19 and are independently associated with PAD but are predominantly genetically inherited.…”