Perspectives in Cardiology
Standardization of laboratory lipid profile assessment: A call for action with a special focus on the 2016 ESC/EAS dyslipidemia guidelines – Executive summary
Padronização da avaliação laboratorial do perfil lipídico: um apelo à ação com foco especial nas recomendações europeias de dislipidemia da ESC/EAS de 2016 – sumário executivo
Pedro Marques da Silvaa,
, João Sequeira Duarteb, Pedro von Hafec, Victor Gild, Jorge Nunes de Oliveirae, Germano de Sousaf
Corresponding author
a Núcleo de Investigação Arterial, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, EPE, Lisboa, Portugal
b Serviço de Endocrinologia, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, EPE, Lisboa, Portugal
c Serviço de Medicina Interna, Centro Hospitalar São João, Porto, Portugal
d Unidade Cardiovascular, Hospital Lusíadas Lisboa, Lisboa, Portugal
e Laboratório de Análises Clínicas Prof. Doutor Joaquim J. Nunes de Oliveira, Póvoa do Varzim, Portugal
f Grupo Germano de Sousa, Centro de Medicina Laboratorial, Polo Tecnológico de Lisboa, Lisboa, Portugal
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Nunes de Oliveira, Póvoa do Varzim, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Grupo Germano de Sousa, Centro de Medicina Laboratorial, Polo Tecnológico de Lisboa, Lisboa, Portugal" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:2 [ "titulo" => "Padronização da avaliação laboratorial do perfil lipídico: um apelo à ação com foco especial nas recomendações europeias de dislipidemia da ESC/EAS de 2016 – sumário executivo" "subtitulo" => "Um consenso endossado pelo Grupo de Prevenção e Risco Cardiovascular da Sociedade Portuguesa de Medicina Interna, Sociedade Portuguesa de Cardiologia, Sociedade Portuguesa de Medicina Laboratorial e Associação Portuguesa de Analistas Clínicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1795 "Ancho" => 2917 "Tamanyo" => 423032 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A possible example of a laboratory lipid test report.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiovascular disease (CVD) remains one of the leading causes of morbidity and mortality worldwide.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,2</span></a> In Portugal, diseases of the circulatory system accounted for 29.5% of deaths recorded in 2013, with a mortality of 54.6 per 100<span class="elsevierStyleHsp" style=""></span>000 for cerebrovascular disease and of 32.9 per 100<span class="elsevierStyleHsp" style=""></span>000 for ischemic heart disease.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Atherogenic dyslipidemias, particularly hypercholesterolemia, play an unquestionable role in the development of atherosclerotic CVD. Accurate and timely diagnosis of dyslipidemia is of crucial importance. For this diagnosis, it is essential to obtain an accurate laboratory assessment of the patient's lipid profile. This information, combined with thorough clinical history collection and physical examination, can be used to determine the patient's CV risk, a key tool in therapeutic management.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> The intensity of risk-reduction therapy should generally be adjusted to the patient's absolute risk for a CVD event. Appropriate screening, prevention, diagnosis, monitoring and treatment, combined with an accurate and standardized laboratory diagnosis, are essential to the management of dyslipidemias and CVD prevention in clinical practice.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In Portugal, a need has been identified to harmonize various aspects of laboratory lipid measurements. A meeting with specialists in clinical pathology, laboratory medicine, clinical analysis, cardiology, internal medicine and endocrinology was held with the purpose of preparing nationwide recommendations for lipid profile assessment and reporting in adult patients, based on the latest guidelines for CVD prevention and treatment. The recommendations presented herein reflect the debate and consensus reached by this expert panel. This proposal reflects the most recent European guidelines on CVD prevention<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> and the management of dyslipidemias.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> They should serve as a foundation for standardizing lipid assessment strategies, as well as laboratory lipid assessment reports, in all national clinical analysis laboratories. These recommendations are divided into four main topics: CVD prevention and treatment guidelines; dyslipidemia screening; lipid biomarker assessment; and reporting of laboratory lipid assessments.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Cardiovascular disease prevention and treatment guidelines</span><p id="par0020" class="elsevierStylePara elsevierViewall">There are various national and international guidelines on the prevention and treatment of CVD. This expert panel recommends adopting the recommendations of the European Atherosclerosis Society (EAS) and European Society of Cardiology (ESC) for the management of dyslipidemias<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> and for CVD prevention in clinical practice,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> and following the three specific standards of good clinical practice (GCP) published by the Portuguese Directorate-General of Health (DGS) on this matter,<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6–8</span></a> specifically in terms of CVD risk stratification and target lipid values. These GCP standards from the DGS should be sources of guidance and instruments of clinical decision support in the National Health Service to promote the development of excellence in health care and its evaluation in the hospital network, health centers, family health units and continuous care.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We advocate appropriate screening, diagnosis, monitoring and treatment of dyslipidemias, as a crucial part of CVD prevention in clinical practice. For assessment of total CV risk, we support the SCORE risk chart for determination of 10-year risk of a first fatal atherosclerotic CV event (e.g. myocardial infarction, stroke or other occlusive arterial disease, including sudden cardiac death), in apparently healthy people with no recognized CVD. Individuals with a history of a CV event, type 1 or 2 diabetes, very high levels of individual risk factors (e.g. familial hypercholesterolemia or blood pressure ≥180/110 mmHg), or chronic kidney disease, have very high or high total CV risk and no further risk estimation is required.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The SCORE data indicate that total risk for CV events is about three times higher than the risk of fatal CVD in men, and four times higher in women, but somewhat less in the elderly. In older patients the likelihood of a first fatal CV event is naturally higher. In older people (>60 years of age), the SCORE risk threshold should not be applied strictly, because their age-specific risk is normally around these levels, even when other CV risk factor levels are normal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Young people with high levels of risk factors deserve particular consideration. Lifetime risk is probably the best approach to evaluate the impact of risk factors in this population, but there are still insufficient epidemiological cohort data to support its application. In young people, an estimate of their relative risk – rather than their absolute risk, which is presumably low – or the use of ‘CV risk age’ may be helpful.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Recommendations for the screening of dyslipidemia</span><p id="par0040" class="elsevierStylePara elsevierViewall">Screening for dyslipidemia is indicated in all adults (men aged ≥40 years and women aged ≥50 years or postmenopausal), particularly in the presence of other classic CV risk factors; in patients with clinical CVD (secondary prevention) or with clinical conditions associated with increased CV risk (primary prevention), especially in patients with obesity, metabolic syndrome and/or diabetes; and in HIV-infected patients (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, adapted from<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a>). It is also recommended to screen offspring of patients with severe dyslipidemia and family members of patients with premature CVD.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The rationale of CVD risk assessment is to convince individuals without treatable risk factors and low CV risk to maintain a healthy lifestyle, to recommend individuals with treatable CV risk factors or unhealthy behaviors to modify their attitudes and to treat and manage modifiable risk factors, and to identify subjects who will likely derive most benefit from pharmacotherapy and concomitant lifestyle interventions.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We recommend that CV risk reduction should be individualized and treatment goals should be identified. Low-density lipoprotein cholesterol (LDL-C) is the primary treatment target, but total cholesterol (TC) can be accepted if other lipid parameters are not available. Non-high-density lipoprotein cholesterol (non-HDL-C) and/or apolipoprotein B (ApoB) can be used as secondary treatment targets. We strongly suggest that lipid treatment goals take total CV risk into consideration. LDL-C treatment targets should be:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">For low- and moderate-risk individuals: <115 mg/dl (<3.0 mmol/l)</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">For high-risk patients: <100 mg/dl (<2.6 mmol/l), or a reduction of at least 50% if baseline LDL-C is between 100 and 200 mg/dl (2.6-5.2 mmol/l).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">For very high-risk patients: <70 mg/dl (<1.8 mmol/l) or a decrease of at least 50% if baseline LDL-C is between 70 and 135 mg/dl (1.8-3.5 mmol/l).</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">The diagnosis of dyslipidemia should always be confirmed by subsequent laboratory assessment of lipid profile, carried out in a minimum of four weeks, prior to the beginning of any pharmacological therapy (in line with the DGS's standard no. 019/2011).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The frequency of testing depends on the person's CV risk profile. After 4-12 weeks from the start of drug treatment a second fasting lipid panel should be performed. Subsequently, assessments should be performed every three months until the lipid goals are achieved, and thereafter every 12 months, as clinically indicated. However, when LDL-C lowering therapy is adapted (e.g. any intensification of lifestyle interventions, titration of statin therapy, or adding of non-statin therapies), we recommend a new lipid panel, again 4-12 weeks after treatment adjustment, followed by resumption of the above regimen.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Recommendations for lipid biomarker assessment</span><p id="par0080" class="elsevierStylePara elsevierViewall">We recommend that a baseline lipid assessment should include estimation of TC, triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), LDL-C (calculated with the Friedewald formula, based on fasting plasma TC, TG, and HDL-C values, or determined directly), and non-HDL-C. Fasting and non-fasting lipid levels have similar prediction strength and should be regarded as complementary. Non-fasting lipid levels can be applied in screening and risk estimation; however, in general, a 12-hour fasting period is still considered optimal when lipoprotein measurements are used in CV risk screening and estimation and for characterizing dyslipidemias before treatment.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We are aware of the significant limitations of the Friedewald formula.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10,11</span></a> Its estimates are not valid when TG >400 mg/dl (>4.5 mmol/l), in patients with type III hyperlipoproteinemia (dyslipidemia with accumulation of cholesterol-rich remnants) or chylomicronemia, or in nonfasting specimens. Recently, novel LDL-C estimation formulas such as (non-HDL-C) - (TG/adjustable factor mg/dl) have been proposed,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> in which an adjustable factor was established as the strata-specific median TG:very low density lipoprotein cholesterol (VLDL-C) ratio. Although this new method appears to provide a better estimate of LDL-C (particularly in patients with LDL-C ≤70 mg/dl in the presence of high TG levels), it needs to be more widely validated, and the formula selected in each laboratory determination should be clearly stated.</p><p id="par0090" class="elsevierStylePara elsevierViewall">If available, and in particular clinical circumstances, ApoB and lipoprotein(a) (Lp(a)) can also be estimated. Non-HDL-C is an umbrella term for all plasma atherogenic lipoproteins (VLDL, VLDL remnants, intermediate-density lipoproteins, LDL, and Lp(a)). It is calculated as TC minus HDL-C, and is associated with ApoB levels. A powerful CV risk predictor, non-HDL-C is simple to compute and does not need fasting conditions.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> This is the reason for including non-HDL-C, unlike ApoB, in the standard lipid profile assessment.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Measurement of Lp(a) is not currently recommended, and should only be performed in specific patients<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4,14,15</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). CV risk is significant when Lp(a) >50 mg/dl. In patients at risk with high Lp(a) levels the treatment of modifiable CV risk factors should be intensified, particularly LDL-C (with intensive lipid-lowering therapy). The effect on CVD events of targeting Lp(a) has not been established and Lp(a) should not be a lipid target in CV prevention.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Recommendations for the reporting of laboratory lipid assessments</span><p id="par0100" class="elsevierStylePara elsevierViewall">The expert panel recommends including the methods used for lipid biomarker quantification, as well as the specific equipment employed to that end and the associated variation coefficients, in all laboratory lipid reports.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We strongly emphasize the importance of lipid test reports including specific information on target LDL-C values, according to the different CV risk levels (<70 mg/dl, <100 mg/dl and <115 mg/dl), in line with the DGS's standard no. 005/2013.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> This should be accompanied by a supporting statement, such as “CV risk to be determined by the attending physician” (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). We also propose that laboratory reports should flag nonstandard lipid values based on desirable concentration cut-points, defined by guidelines and consensus statements.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4,5,9,16</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Final word</span><p id="par0110" class="elsevierStylePara elsevierViewall">Atherosclerotic CVD is preventable. We and our scientific societies wish to promote the best health care for individuals of both sexes and all ages who are at CV risk. We are aware that effective CV prevention is frequently overlooked in our daily practice. CV prevention is in fact an ethical obligation. It is important to recognize CV risk, to stress the importance of laboratory reports, and to identify clinical situations that warrant judicious intervention.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">No external funding was used in the preparation of this manuscript.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">PMS has received lecture honoraria or consulting fees from Bayer, Jaba Recordati, Merck Sharp and Dohme Portugal, Kowa Pharmaceuticals, Novartis, Daiichi Sankyo, Amgen, Sanofi-Regeneron, and Tecnimede. JSD has received lecture honoraria or consulting fees from Novo-Nordisk, Merck Sharp and Dohme Portugal, Sanofi-Regeneron, Novartis Oncology, Boehringer-Ingleheim, and Tecnimede. VG has received honoraria from AstraZeneca, Merck Sharp Dohme Portugal, Bial, Jaba Recordati, and Amgen. The other members have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1031674" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec988786" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1031673" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec988787" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Cardiovascular disease prevention and treatment guidelines" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Recommendations for the screening of dyslipidemia" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Recommendations for lipid biomarker assessment" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Recommendations for the reporting of laboratory lipid assessments" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Final word" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack348394" "titulo" => "Acknowledgment" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-04-02" "fechaAceptado" => "2017-07-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec988786" "palabras" => array:6 [ 0 => "Dyslipidemia" 1 => "Cardiovascular risk" 2 => "Laboratory procedures" 3 => "Laboratory reports" 4 => "Harmonization" 5 => "Standardization" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec988787" "palabras" => array:6 [ 0 => "Dislipidemia" 1 => "Risco cardiovascular" 2 => "Procedimentos laboratoriais" 3 => "Relatórios laboratoriais" 4 => "Harmonização" 5 => "Padronização" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Even with improvements in lifestyle interventions, better control of cardiovascular (CV) risk factors, and improvements in CV outcomes, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in Portugal and Europe. Atherogenic dyslipidemias, particularly hypercholesterolemia, have a crucial causal role in the development of atherosclerotic CVD. The clinical approach to a patient with dyslipidemia requires an accurate diagnosis, based on harmonized and standardized lipid and lipoprotein laboratory assessments. Results and reports of these tests, together with assessment of total CV risk and the respective therapeutic targets, will help ensure that clinical guidelines and good clinical practices are followed, increasing the reliability of screening for lipid disorders, producing more accurate diagnoses and CV risk stratification, and improving CV prevention. To this end, this consensus aims to provide clinicians with practical guidance for the harmonization and standardization of laboratory lipid tests, focusing on the most recent dyslipidemia management guidelines.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Apesar da melhor intervenção nos estilos de vida, do melhor controlo dos fatores de risco cardiovascular (CV) e da melhoria dos resultados CV, a doença cardiovascular (DCV) continua a ser a principal causa de morbilidade e mortalidade em Portugal e na Europa. A dislipidemia aterogénica, nomeadamente a hipercolesterolemia, tem um papel causal no desenvolvimento de DCV aterosclerótica. A abordagem clínica de um doente com dislipidemia preceitua um diagnóstico atento, sustentado em procedimentos laboratoriais harmonizados e padronizados. Os resultados e relatórios dos testes de lipídios se ajuntarem o risco CV total e os respetivos alvos terapêuticos garantem que as diretrizes clínicas e as boas práticas clínicas estão a ser seguidas e respeitadas, o que aumenta a segurança no rastreio e no diagnóstico das alterações lipídicas e da estratificação de risco e melhora a prevenção CV. Nesse sentido, este consenso tem como objetivo fornecer aos clínicos orientações práticas para a harmonização e padronização dos testes laboratoriais lipídicos, com foco nas diretrizes mais recentes da abordagem das dislipidemias.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1795 "Ancho" => 2917 "Tamanyo" => 423032 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A possible example of a laboratory lipid test report.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">All patients with these conditions regardless of age: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="16" align="left" valign="middle">Men aged ≥40 years of age and women aged ≥50 years (or postmenopausal)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Clinical evidence of CVD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Abdominal aortic aneurysm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Diabetes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Current cigarette smoking \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Stigmata of dyslipidemia<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Family history of premature CVD<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Family history of dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• CKD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Obesity (BMI ≥30 kg/m<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• IBD and other inflammatory disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• HIV infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Erectile dysfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• COPD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>• Hypertensive disease or diabetes in pregnancy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1756417.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Arcus corneae, xanthelasma or xanthoma.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Men aged <55 years and women aged <65 years in a first-degree relative.</p> <p class="elsevierStyleNotepara" id="npar0015">BMI: body mass index; COPD: chronic obstructive pulmonary disease; CVD: cardiovascular disease; CKD: chronic kidney disease; HIV: human immunodeficiency virus; IBD: inflammatory bowel disease.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Who to screen for dyslipidemia in adults at risk.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Premature CVD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Familial hypercholesterolemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Family history of premature CVD and/or elevated Lp(a) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Recurrent CVD despite optimal lipid-lowering therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• ≥5% 10-year risk of fatal CVD according to SCORE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hemodialysis and CKD<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Intermediate (3-5%) 10-year risk of fatal CVD according to SCORE<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1756416.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Possible indications for Lp(a) determination, but not clearly stated in the current international guidelines.</p> <p class="elsevierStyleNotepara" id="npar0025">CVD: cardiovascular disease; CKD: chronic kidney disease; Lp(a): lipoprotein(a); SCORE: Systematic COronary Risk Evaluation.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Indications for Lp(a) screening.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular disease in Europe: epidemiological update 2016" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 2 | 8 |
| 2024 October | 50 | 30 | 80 |
| 2024 September | 63 | 26 | 89 |
| 2024 August | 66 | 23 | 89 |
| 2024 July | 64 | 29 | 93 |
| 2024 June | 67 | 22 | 89 |
| 2024 May | 63 | 27 | 90 |
| 2024 April | 55 | 37 | 92 |
| 2024 March | 78 | 22 | 100 |
| 2024 February | 55 | 15 | 70 |
| 2024 January | 69 | 24 | 93 |
| 2023 December | 58 | 25 | 83 |
| 2023 November | 62 | 24 | 86 |
| 2023 October | 40 | 18 | 58 |
| 2023 September | 52 | 17 | 69 |
| 2023 August | 45 | 13 | 58 |
| 2023 July | 59 | 13 | 72 |
| 2023 June | 52 | 9 | 61 |
| 2023 May | 68 | 27 | 95 |
| 2023 April | 54 | 8 | 62 |
| 2023 March | 87 | 24 | 111 |
| 2023 February | 71 | 22 | 93 |
| 2023 January | 46 | 24 | 70 |
| 2022 December | 83 | 22 | 105 |
| 2022 November | 81 | 32 | 113 |
| 2022 October | 47 | 41 | 88 |
| 2022 September | 79 | 44 | 123 |
| 2022 August | 87 | 30 | 117 |
| 2022 July | 40 | 47 | 87 |
| 2022 June | 33 | 29 | 62 |
| 2022 May | 37 | 33 | 70 |
| 2022 April | 33 | 44 | 77 |
| 2022 March | 31 | 49 | 80 |
| 2022 February | 50 | 34 | 84 |
| 2022 January | 37 | 35 | 72 |
| 2021 December | 39 | 30 | 69 |
| 2021 November | 53 | 36 | 89 |
| 2021 October | 63 | 50 | 113 |
| 2021 September | 41 | 24 | 65 |
| 2021 August | 45 | 34 | 79 |
| 2021 July | 34 | 20 | 54 |
| 2021 June | 41 | 26 | 67 |
| 2021 May | 54 | 36 | 90 |
| 2021 April | 45 | 32 | 77 |
| 2021 March | 48 | 21 | 69 |
| 2021 February | 34 | 14 | 48 |
| 2021 January | 32 | 16 | 48 |
| 2020 December | 38 | 11 | 49 |
| 2020 November | 27 | 13 | 40 |
| 2020 October | 14 | 20 | 34 |
| 2020 September | 54 | 8 | 62 |
| 2020 August | 26 | 9 | 35 |
| 2020 July | 42 | 10 | 52 |
| 2020 June | 27 | 10 | 37 |
| 2020 May | 41 | 5 | 46 |
| 2020 April | 31 | 17 | 48 |
| 2020 March | 38 | 11 | 49 |
| 2020 February | 93 | 23 | 116 |
| 2020 January | 28 | 7 | 35 |
| 2019 December | 27 | 5 | 32 |
| 2019 November | 27 | 14 | 41 |
| 2019 October | 29 | 5 | 34 |
| 2019 September | 35 | 16 | 51 |
| 2019 August | 38 | 7 | 45 |
| 2019 July | 38 | 8 | 46 |
| 2019 June | 63 | 18 | 81 |
| 2019 May | 42 | 5 | 47 |
| 2019 April | 41 | 16 | 57 |
| 2019 March | 146 | 8 | 154 |
| 2019 February | 138 | 14 | 152 |
| 2019 January | 133 | 7 | 140 |
| 2018 December | 116 | 12 | 128 |
| 2018 November | 67 | 15 | 82 |
| 2018 October | 78 | 15 | 93 |
| 2018 September | 38 | 13 | 51 |
| 2018 August | 35 | 11 | 46 |
| 2018 July | 22 | 13 | 35 |
| 2018 June | 43 | 17 | 60 |
| 2018 May | 42 | 37 | 79 |
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