Lipid management: focus on cardiovascular risk ACG

Published on 15 Dec 2023 (amended, see below for version history)

This ACE Clinical Guideline (ACG) highlights lifestyle and pharmacological management for patients with hyperlipidaemia to reduce overall cardiovascular (CV) risk. The ACG offers evidence-based recommendations on tailoring the intensity of lipid lowering, with considerations by CV risk and other patient characteristics. Principles of managing statin-associated adverse effects are also discussed. An additional resource on the updated Singapore-modified Framingham Risk Score supplements the ACG.

Download the ACG

Lipid management: focus on cardiovascular risk (Dec 2023) - v1.1 [PDF]

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ACG recommendations

1. Assess overall CV risk to inform initial and ongoing management of hyperlipidaemia.

2. Individualise management goals, including use of LDL-C targets, in the context of patient-specific risk factors.

3. Encourage and support healthy diet, physical activity, weight management, or smoking cessation, tailored to the patient’s circumstances.

4. Select intensive lipid-lowering therapy, using maximally-tolerated statin and adding ezetimibe as needed, for patients with:

   1. Atherosclerotic cardiovascular disease (ASCVD);

   2. Familial hypercholesterolaemia (FH).
      
      Consider adding a PCSK9 monoclonal antibody or inclisiran for further risk reduction based on LDL-C level and clinical need.

5. Select a statin for patients with diabetes mellitus (DM), chronic kidney disease (CKD), or high 10-year CV risk (>20%). Consider adding ezetimibe for further risk reduction if needed.

6. Consider prescribing a statin for patients with 10-year CV risk between 10-20%, especially in the presence of risk enhancers.

7. Provide education and a lifestyle management plan for patients with 10-year CV risk below 10%; consider assessing risk enhancers for patients with borderline risk to discuss the clinical need for a statin.

8. For patients with elevated triglycerides (TG):

   1. Assess and manage lifestyle-related and secondary causes;

   2. At higher levels exceeding 4.5 mmol/L (400 mg/dL), consider fibrates to lower the risk of pancreatitis.

9. Encourage statin adherence by providing patient education, managing adverse effects, and optimising treatment to improve tolerability as needed.

ACG references

Lipid management: focus on cardiovascular risk references (Dec 2023) [PDF]

Healthier SG cardiovascular risk calculator

Click here to access an online calculator to compute SG-FRS-2023 scores for the general population, originally developed as part of Healthier SG Care Protocols resource. The calculator additionally generates target levels for LDL cholesterol (and blood pressure) for patients at various levels of cardiovascular risk.

Additional resource for cardiovascular risk assessment using SG-FRS-2023 [PDF]

Message to healthcare professionals

With our nation’s move to Healthier SG, the optimal management of hyperlipidaemia has assumed critical importance. Numerous clinical trials have continued to examine the value of more intensive treatments and newer medications across a range of settings and add to the wealth of medical evidence supporting the role of effective lipid management in reducing cardiovascular risk. For the busy clinician, staying current with this latest evidence can be challenging, especially as international guidelines are not uniform in their recommendations. Hence it is timely that local guidelines on lipid management be updated.

As the national-level guideline, the MOH ACE Clinical Guideline on lipid management considers this broad variety of new evidence within the context of local practice to ensure it is relevant for all healthcare professionals caring for patients with hyperlipidaemia, especially those in primary or generalist care. Simultaneously, the Academy of Medicine, Singapore has developed their Clinical Practice Guideline, to cover the detailed needs of specialist management.

While all guidelines recommend using risk stratification for global ten-year cardiovascular risk to guide lipid management, there is a need to tailor these risk scores to our local population. Notably, guidelines should support, not negate, flexibility for healthcare professionals to customise treatment according to each patient's unique needs and profile.

We are grateful to Saw Swee Hock School of Public Health, National University of Singapore, and Ministry of Health Singapore, for the recalibration of the SG-FRS-2023 risk score. We are very grateful for the efforts of all who have contributed to crafting this guideline.

Clin Prof Terrance Chua Siang Jin | Dr Ian Phoon Kwong Yun
ACG Expert Group co-chairpersons

Version History