Prior to referral to the lipid clinic a full CVD assessment should be undertaken to:

• assess the patients cardiovascular risk factor profile using QRISK3 where possible or QRISK2 if unavailable (primary prevention)

OR

• identify any pre-existing cardiovascular conditions (secondary prevention)

A family history of CVD or very high cholesterol levels may alert to the possibility of Familial Hypercholesterolaemia (see FH pathway for further evaluation)

Differential Diagnosis

Secondary causes of raised cholesterol should be excluded, including:

• Uncontrolled diabetes
• Obesity
• Excessive consumption of alcohol
• Untreated Hypothyroidism
• Medications such as thiazide diuretics, corticosteroids, oral oestrogens, non-cardio-selective beta blockers, clozapine/olanzapine and protease inhibitors
• Nephrotic Syndrome
• Cholestasis
• Pregnancy

Refer urgently if:

• Triglycerides exceed 20mmol/L (if not due to alcohol or poor glycaemic control)
• Patients with known CVD who cannot be prescribed oral lipid lowering therapy

• Fasting lipid profile (including TG)
• Renal Function Tests (RFT)
• Liver Function Tests (LFT)
• Thyroid Function Tests (TFT)
• HbA1c
• Urine albumin/creatinine ratio (ACR)
• QRISK2/3 score

Secondary causes of raised cholesterol should be excluded, including:

• Uncontrolled diabetes
• Obesity
• Excessive consumption of alcohol
• Untreated Hypothyroidism
• Medications such as thiazide diuretics, corticosteroids, oral oestrogens, non-cardio-selective beta blockers, clozapine/olanzapine and protease inhibitors
• Nephrotic Syndrome
• Cholestasis
• Pregnancy

1. Lifestyle Advice and risk factor modification

All patients with raised lipids will benefit from lifestyle advice and review of modifiable cardiovascular risk factors. This should be addressed at first consultation irrespective of whether medication is to be started.

Lifestyle advice includes:

• Dietary changes to reduce cholesterol intake and lose weight (link to Heart UK)
• Promotion of increased exercise
• Reduction of excess alcohol consumption
• Identify and address cardiovascular risk factors: raised blood pressure, hyperglycaemia, smoking

Do not delay starting lipid lowering treatment in secondary prevention patients.

2. Start lipid-regulating medication in primary care as outlined in:

• South & West Devon

• North & East Devon

Aim to achieve lipid targets with maximal tolerated lipid modifying therapy:

• Primary prevention target: greater than 40% reduction in non-HDL

• Secondary prevention target: LDL equal to/lower than 2.0 mmol/l or non-HDL-C equal to/lower than 2.6mmol/l

Referral Indications:

Referral is appropriate for patients with the following clinical presentations:

1) Failure to achieve lipid targets despite maximal tolerated lipid modifying therapy:

• Primary prevention target: 40% reduction in non-HDL
• Secondary prevention target: LDL equal to/greater than 2.0 mmol/l or non-HDL-C equal to/greater than 2.6mmol/l

2) Fasting Triglycerides greater than 10mmol/l

(having ruled out secondary causes – see ‘Investigations’)

3) Total cholesterol greater than 9mmol/l or LDL greater than 6.5 mmol/l or non-HDL-C greater than 7.5mmol/l

(having ruled out secondary causes – see ‘Investigations’)

4) Patients with suspected Familial Hypercholesterolaemia

(see FH referral guideline)

Referral Criteria:

a) Referral Indication (see above)

b) Secondary causes excluded (see ‘Investigations’ section)

c) Investigations results (within the last 12 months)

• Fasting lipid profile (including TG)
• Renal Function Tests (RFT)
• Liver Function Tests (LFT)
• Thyroid Function Tests (TFT)
• HbA1c
• Urine albumin/creatinine ratio (ACR)
• QRISK2/3 score

d) Names and doses of all lipid lowering drugs that have not been tolerated

Referrals without this information may be returned.

Once a referral is received it will be triaged by a member of the Lipid team. The patient will either be offered an outpatient ‘face-to-face’ appointment or assigned to our virtual clinic.

Referral Instructions

e-Referral Service Selection

Specialty: Endocrinology

Clinic Type: Lipid Clinic

Service: DRSS-Western-Endocrinology- Devon ICB- 15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon

Publication date: September 2024