Borders Ref Help Toolkit
Prior to referral
Please ensure lipids have been checked at least twice (including at least once fasting if TGs are raised) and that secondary causes of hypercholesterolaemia (hypothyroidism, nephrotic syndrome, diabetes etc) have been excluded.
Lipid Targets
Primary prevention- 40% reduction in LDL or non-HDL cholesterol
Secondary prevention- aim for LDL <1.8 or non-HDL <2.5 mmol/L
Familial Hypercholesterolaemia- 50% reduction in LDL or non-HDL cholesterol
Who to refer:
1. Suspected Familial hypercholesterolaemia (FH)
FH affects 1 in 500 people in Scotland and over half of untreated men will have an MI before 50. Please refer any suspected cases to the lipid clinic for advice on management and genetic testing. Referral is recommended if the answers below are ‘yes’ to:
- (a) and (b),
- (a) and (d or e)
- (c) if further input needed from lipid clinic (i.e. target cholesterol not achieved)
Simon Broome Familial Hypercholesterolemia Register diagnostic criteria for familial hypercholesterolemia
| Criteria | Description |
| a |
Total cholesterol concentration above 7.5 mmol/litre (290 mg/dL) in adults or a total cholesterol concentration above 6.7 mmol/litre (259 mg/dL) in children aged less than 16 years, or Low-density lipoprotein cholesterol concentration above 4.9 mmol/litre (189 mg/dL) in adults or above 4.0 mmol/litre (155 mg/dL) in children |
| b |
Tendinous xanthomata in the patient or a first-degree relative |
| c | DNA-based evidence of mutation in the LDLR, PCSK9, or APOB gene |
| d | Family history of myocardial infarction before age 50 years in a second-degree relative or before age 60 years in a first-degree relative |
| e | Family history of raised total cholesterol concentration above 7.5 mmol/liter (290 mg/dL) in a first- or second-degree relative |
A "definite" FH diagnosis requires either criteria a and b, or criterion c. A "probable" FH diagnosis requires either criteria a and d, or criteria a and e.
FH: familial hypercholesterolemia.
Please note that below 16 years the corresponding cut-offs are total cholesterol >6.7 mmol/L, LDL-C >3.9 mmol/L. If your patient does not meet the above criteria but you still strongly suspect an inherited hyperlipidaemia, please contact the lipid clinic via e-mail for further advice.
2. Other suspected familial hyperlipidaemias
Familial combined hyperlipidaemia should be considered in patients with a mixed hyperlipidaemia and strong family history of premature IHD.
3. Hypertriglyceridaemia
Persistent fasting TGs > 10mmol/L, despite dietary and lifestyle measures and secondary causes excluded
Fasting TGs persistently 5–10mmol/L in a high cardiovascular risk patient not responding to statin treatment, especially in the absence of a secondary causes, despite dietary and lifestyle measures
4. Secondary prevention
Target not achieved and needing PCSK9 inhibitors as per SMC guidance
- patients at high risk due to previous cardiovascular events and LDL-C ≥4.0mmol/L or patients with
- Recurrent/poly-vascular disease and LDL-C ≥3.5mmol/L
Who not to refer:
- Advice on the management of patients who, for whatever reason, are unable to tolerate treatment, especially statin therapy unless they fulfil above referral criteria.
- Specific advice as to whether to use drug therapy in a patient with abnormal lipid results.
- Advice on the management of patients already under treatment but where there has apparently been a poor response to treatment and/or target lipid levels have not been achieved.
- Advice on the significance of abnormal liver function test results either prior to contemplating starting treatment or arising during drug therapy.
- Advice on the significance of raised CK results again either before initiating treatment or having been found to be elevated during drug treatment.
- Questions as to the significance of mildly raised triglyceride levels in patients and how these are best managed.
- Dyslipidaemia where secondary causes e.g. excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome has not been excluded/managed
How to refer: Refer through diabetes and endocrionology SCI gateway please. There is no specific SCI gateway for lipid referrals at present.