Reasoning GP · Algorithm · 1-page summary
Abnormal lipid profile in adults
For: adults with an abnormal cholesterol, HDL or triglyceride (TG) result in primary care. Not for: children (paediatric FH pathways) or treatment detail (High cholesterol protocol). TG-led results → High triglycerides pathway.
Core rule: a lipid result is a long-term risk factor, not an emergency — except TG with abdominal pain or vomiting. Exclude secondary causes and suspected FH before you reach for QRISK3; QRISK3 never applies to FH or established CVD.
0Stop — act now — the lipid result never lowers the urgency
- Acute, ongoing or recent chest pain → 999 as possible ACS, whatever the cholesterol shows.
- Raised TG with abdominal pain or vomiting, any level (can occur below 10 mmol/L) → Same-day hospital, 999 if unwell. Do not wait for a fasting repeat.
- Thirst, polyuria, weight loss or vomiting with raised TG → capillary glucose and ketones now; raised or unwell → Same-day hospital (DKA/HHS).
- Heavy proteinuria, oedema, low albumin (nephrotic syndrome) → Urgent medical assessment; AKI, thrombosis, infection or instability → Same-day hospital.
1Triage by result — numbers that change the pathway (mmol/L)
| Result | Action |
|---|---|
| TC <7.5, no FH features | Interpret through CVD risk (QRISK3, block 4). Routine |
| TC >7.5 or LDL >4.9 | Assess for FH (block 2), especially with premature CHD. |
| TC >9.0 or non-HDL >7.5 | Specialist assessment, even without a family history. |
| LDL >13 (adult) | Possible homozygous FH → Urgent specialist FH centre |
| HDL <1.0 (M) / <1.2 (F) | Risk marker; no specific drug; lifestyle; QRISK3 decides. |
| TG 4.5–9.9 | Fasting repeat; secondary causes; non-HDL >7.5 → specialist advice. |
| TG 10–20 | Fasting repeat after 5 days but within 2 weeks; still >10 → specialist advice. |
| TG >20 | Not due to alcohol or poor glycaemic control → Urgent specialist review |
2Screen for FH — NICE CG71, before any risk score
- Suspect FH: TC >7.5 or LDL >4.9, and/or CHD before 60 in the patient or a first-degree relative; tendon xanthomata.
- Assess: exclude secondary causes, 2 LDL measurements, family history, then Simon Broome or DLCN.
- Possible or definite Simon Broome, or DLCN >5 → specialist FH service for DNA testing and cascade testing of relatives.
- Records search: under 30, TC >7.5; 30 or over, TC >9.0.
3Assess — is it real, and why?
☐ Non-fasting full profile is enough; fasting only if TG ≥4.5 or unexpected ☐ Repeat when well (acute illness lowers cholesterol); pregnancy raises lipids ☐ TSH, HbA1c, eGFR + urine ACR, LFTs + GGT, alcohol (AUDIT-C), BMI and BP ☐ Drugs: antipsychotics, corticosteroids, retinoids, HIV antiretrovirals, ciclosporin, amiodarone, thiazides, beta-blockers, oestrogens
TG >4.5: calculated LDL is unreliable — use non-HDL (total minus HDL).
4Classify — frame the patient, then risk
- Secondary cause — hypothyroidism, diabetes, CKD or nephrotic syndrome, cholestasis, alcohol, obesity, drugs → treat it, then recheck.
- Established CVD → secondary prevention; no risk score.
- Suspected FH → block 2; QRISK3 underestimates risk.
- Type 1 diabetes, CKD (eGFR <60 and/or albuminuria) → disease-specific criteria, not QRISK3. Aged 85 or over → individualise.
- Primary prevention, 25–84 → QRISK3 (may underestimate in severe mental illness, HIV, antipsychotics, steroids).
- Uncertain — unexpected or discordant result → repeat with secondary-cause tests before labelling.
5Treat today — doses per SPC and local formulary
- QRISK3 ≥10%: offer atorvastatin 20 mg after an informed discussion. <10%: lifestyle; do not rule out a statin if preferred.
- Established CVD: atorvastatin 80 mg. CKD: atorvastatin 20 mg. FH: lipid clinic.
- Targets: primary >40% fall in non-HDL; secondary LDL ≤2.0 or non-HDL ≤2.6; FH ≥50% LDL fall.
- Monitor: lipids at 2–3 months; transaminases baseline, within 3 months and at 12 months. CK only if muscle symptoms. ALT below 3× ULN is no reason to withhold a statin.
6Refer routinely
- Lipid specialist: TC >9.0 or non-HDL >7.5; TG still >10 on repeat; suspected familial combined hyperlipidaemia.
- Specialist advice: TG 4.5–9.9 with non-HDL >7.5.
- Lipid clinic: not at target on maximum tolerated treatment, or statin intolerance (local lipid pathway).
7Never reassure by
- A "normal" cholesterol in a patient with chest pain.
- A low QRISK3 in suspected FH, CKD or type 1 diabetes.
- A normal calculated LDL when TG is >4.5 mmol/L.
- A high HDL when LDL or non-HDL is raised.
- A cholesterol taken during acute illness.
- One result, without a secondary-cause check or family history.
8Safety-net — say it, then document it
999 “Chest pain means 999, whatever your cholesterol. Severe tummy pain or being sick — call 999 or go to A&E.” On a statin: “Severe muscle pain or weakness, or dark urine — stop the tablet and contact us the same day.”
FH: explain that relatives need cascade testing through the specialist service. Remote or OOH: any TG with abdominal pain or vomiting → same-day hospital assessment, not a repeat test.
✓Safe to leave primary care only if — all five, documented
No chest pain, abdominal pain or vomiting (block 0)
Result confirmed; secondary causes checked
FH screened; specialist route if criteria met
Patient framed; QRISK3 only where valid
Target, 2–3 month recheck and safety-net set
Summary of the full Reasoning GP abnormal lipid profile algorithm, which holds the detail, causes, monitoring rules and evidence. Sources: NICE NG238, CG71, QS100; QRISK3; HEART UK; NHS England statin intolerance pathway. Clinical reference — follow local lipid pathways and check doses in the SPC and your local formulary.