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Authors; Kendra Brett, and Danielle MacDougall.
Dyslipidemia refers to abnormal blood lipid values that are associated with disease or increased risk of disease, such as cardiovascular disease (CVD).1 Dyslipidemia is a risk factor for the development of atherosclerosis (i.e., the hardening or thickening of arteries due to plaque buildup).2 In patients with premature coronary heart disease (i.e., those younger than 60 years), the prevalence of dyslipidemia may be as high as 75% to 85% of patients.2
Lipid panels will typically measure total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides.3 They are frequently used to screen for lipid disorders (including familial lipid disorders) and for risk of CVD.3
Care providers can input the results from lipid panel screening into CVD risk calculators to estimate a patient’s risk of CVD, which can be used to initiate treatment to improve cardiovascular outcomes.1 Lipid panel screening can be conducted in the fasting and nonfasting state.1 While there are only small, clinically insignificant differences in total and HDL cholesterol levels between fasting and nonfasting states, triglyceride levels are influenced by recent food intake, particularly high-fat meals.3 Although LDL cholesterol can be measured directly, in clinical practice the value is usually calculated using equations (e.g., the Friedewald equation). As these equations rely on other lipid values, sources of error can be introduced based on lipid levels (e.g., the Friedewald formula is not valid if total triglycerides are greater than 4.5mmol/L).3
Traditionally, when screening for cardiovascular risk, lipid profiles have been measured in the fasted state.4 The reasons for this include: the potential change in some lipid components after eating; the limitations of the calculations to estimate LDL cholesterol; uncertainty in the cut-off values for nonfasted samples; and because fasting is the standard by which the testing has always been done.4 However, nonfasting lipid panel screening may be more suitable for some people, and many cardiovascular societies are moving toward changing their guidelines and recommending nonfasting lipids to assess for cardiovascular risk.4,5
There may be practical advantages of not requiring patients to fast before a lipid panel screening, as patients can present at any time for the blood sample, including immediately following their appointment with their care provider, which may increase the timeliness and convenience of lipid testing6 and result in fewer patients lost to follow-up.5 Requiring fasting samples may result in extended wait times while fasting if many people present to the laboratory early in the morning for testing,6 and nonfasting lipid testing may relieve the strain on collection centres in the morning.5 Removing the requirement to fast before lipid testing can also remove the risks associated with fasting due to the risk of hypoglycemia, including in patients living with diabetes.6 However, if there is a possibility that a patient may have high triglyceride levels, care providers may wish to consider starting with a fasting sample, as this would prevent having to return for a second test if a nonfasting test reveals high triglyceride levels.1
Assuming adequate test performance, assessing the risk of CVD using nonfasting lipid panel screening can help guide treatment decisions in adults living with chronic health conditions. The increased convenience of nonfasting lipid panel screening may be especially useful for people who may have increased risks associated with fasting (e.g., people with diabetes)6 or people who may have difficulty with attending a health care facility while fasted (e.g., people without access to reliable transportation, people living in rural or remote areas).
To support decision-making about lipid panel screening for dyslipidemia in adults living with chronic conditions, this Rapid Review summarizes and critically appraises available studies on the diagnostic test accuracy and clinical utility of nonfasting lipid panel screening, and evidence-based guidelines on lipid panel screening in these populations.
An information specialist conducted a literature search on key resources including MEDLINE, the Cochrane Database of Systematic Reviews, the International HTA Database, and the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search approach was customized to retrieve a limited set of results, balancing comprehensiveness with relevancy. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. Search concepts were developed based on the elements of the research questions and selection criteria. The main search concepts were dyslipidemia, lipid panels, and chronic conditions (type 1 and type 2 diabetes, hypertension, and coronary artery disease). CADTH-developed search filters were applied to limit retrieval to diagnostic test accuracy, health technology assessments, systematic reviews, meta-analyses, indirect treatment comparisons, any types of clinical trials, or observational studies. Clinical trials and observational studies retrieval was limited to the human population. A second search was completed with the main search concepts lipid panels and chronic conditions (type 1 and type 2 diabetes, hypertension, and coronary artery disease). CADTH-developed search filters were applied to limit retrieval to guidelines. Searches were completed on June 27, 2023, and limited to English-language documents published since January 1, 2018.
One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1.
Selection Criteria.
Articles were excluded if they did not meet the selection criteria outlined in Table 1, if they were duplicate publications, or if they were published before 2018. Guidelines with unclear methodology were also excluded.
The included publications were critically appraised by 1 reviewer using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument7 as a guide. Summary scores were not calculated for the included studies; rather, the strengths and limitations of each included publication were described narratively.
This report includes 3 evidence-based guidelines.8-10 Study selection details are presented in Appendix 1. Additional references of potential interest are provided in Appendix 5.
Detailed characteristics of included publications are provided in in Appendix 2.
No relevant studies were identified for question 1; therefore, no summary can be provided.
No relevant studies were identified for question 2; therefore, no summary can be provided.
Three evidence-based guidelines8-10 provided recommendations regarding lipid panel screening for adults living with chronic conditions. These guidelines about CVD risk assessment and reduction and lipid management were developed by the National Institute for Health and Care Excellence (NICE) (2023),8 the Canadian Cardiovascular Society (CCS) (2021),9 and the Endocrine Society (2020).10 The guidelines were developed for adults at risk of CVD8,9 and with endocrine disorders, including diabetes.10 The NICE and CCS guidelines are both updates, and the recommendations relevant to this Rapid Review were developed in the previous iterations of the guidelines (2014 for NICE,11 and 2016 for CCS12) and carried forward as ongoing recommendations in the updated guidelines.8,9 The NICE guideline did not report the strength of the recommendation or quality of the evidence for the recommendations relevant to this Rapid Review, as a specific review was not conducted to inform these recommendations.8 The CCS and the Endocrine Society guidelines both used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework to rate the quality of the evidence informing the recommendations (ranging from very low-quality to high-quality evidence) and the strength of the recommendations (i.e., strong versus weak or conditional).9,10
All 3 guidelines8-10 had clear objectives, described the population and target users of the guideline, included individuals from relevant professional groups in the guideline development group, and had specific and unambiguous recommendations that were easily identifiable in the guidelines.
The CCS guideline9 reported the research questions addressed in the guideline (including the population, intervention, comparators, and outcomes covered), and considered patient values and preferences when developing the recommendations, although it was unclear how this information was collected (e.g., from the literature or from consultations with patients). The NICE guideline8 and the Endocrine Society guideline10 did not report the research questions that were used to develop the recommendations that were relevant to this Rapid Review, nor did they include the views and preferences of the target population when developing these recommendations.
None of the guidelines reported using systematic methods to search the literature for evidence for the recommendations relevant to this Rapid Review, which increases the likelihood that relevant literature was missed. The NICE guideline8 explicitly stated that a specific literature review was not conducted to develop the recommendations relevant to this report, and rather the evidence collected to develop other recommendations was used to inform these recommendations. While the method used to formulate these consensus-based recommendations was described in the NICE guideline,8 there was no explicit link between the supporting evidence and the recommendations, and the quality of the evidence was not assessed nor was the strength of the recommendation reported, limiting our confidence in these recommendations. Neither the CCS guideline9 nor the Endocrine Society guideline10 reported any details of their literature search, but they provide explicit links between the recommendations and the supporting evidence, and evaluate the quality of the evidence and the strength of the recommendations using the GRADE framework, which increases our confidence in these recommendations.
The guidelines were funded internally by their respective organizations (i.e., NICE, the CCS, and the Endocrine Society) and none received external funding. However, there were no explicit statements that the funding bodies did not influence the content of the guidelines; thus, it is unclear whether editorial independence was obtained between the guideline development groups and the funding organizations. The competing interests of the guideline development group members were disclosed and addressed in all 3 guidelines.
Additional details regarding the strengths and limitations of included publications are provided in Appendix 3.
Appendix 4 presents the main study findings.
No relevant evidence was identified regarding the diagnostic test accuracy of nonfasting lipid panel screening dyslipidemia in adults living with chronic conditions; therefore, no summary can be provided.
No relevant evidence was identified regarding the clinical utility of nonfasting lipid panel screening dyslipidemia in adults living with chronic conditions; therefore, no summary can be provided.
When screening for CVD risk in adults living with diabetes, hypertension, or clinical evidence of atherosclerosis, the following guidance is available:
For adults at risk of CVD, the following is recommended:
No evidence was found on the following; therefore, no conclusions can be formed on these research questions:
None of the guidelines reported using systematic literature search methods to inform recommendations relevant to this Rapid Review, which limits the quality of these guidelines, and some of the recommendations were based on evidence that was of low or moderate quality, or not assessed for quality, which reduces the certainty of the recommendations summarized in this report.
None of the guidelines described the populations for the evidence from which the recommendations were developed, thus it is unclear whether the guidelines had representative populations with respect to factors that may affect the development of CVD (e.g., sex, race, comorbidities).
This report comprises 3 evidence-based guidelines8-10 regarding lipid panel screening for adults living with chronic conditions. No relevant evidence was identified regarding the diagnostic test accuracy or clinical utility of fasting versus nonfasting lipid panel screening in these populations.
When screening for CVD risk, a nonfasting lipid panel is recommended (2 guidelines).9,10 A fasting lipid panel is recommended for people with a history of elevated triglyceride levels or if the initial nonfasting lipid screening results in high triglyceride levels.9,10 In adults at risk of CVD, fasting or nonfasting lipid panel screening should be conducted before starting lipid modification therapy (1 guideline).8 If a nonfasting sample returns high triglyceride levels, it is recommended to repeat with a fasting sample.8
The recommendations included in this Rapid Review were informed in part by evidence demonstrating little to no difference in lipid values between the fasting samples and nonfasting samples after eating normal meals.9 Similar findings were reported in a 2020 study in adults living with and living without type 2 diabetes, where small and insignificant changes in total, HDL, and LDL cholesterol were observed between fasting and nonfasting lipid panels, but statistically significant differences were observed in triglyceride levels.13 However, as this study did not report diagnostic test accuracy outcomes (e.g., sensitivity, specificity) nor did it report clinical utility findings (e.g., time to treatment, incidence of CVD), it was not directly relevant to the research questions of this review.13
Screening for CVD risk using either a fasting or nonfasting lipid panel, and repeating with a fasting sample if the initial nonfasting sample results in high triglyceride levels, is also recommended for other populations outside the scope of this review, including adults aged 20 years or older,14 and in some consensus-based guidelines.15
The recommendations summarized are generalizable to the Canadian health care context; the guidelines are meant to apply to Canada,9 the UK,8 and globally,10 and the target populations include people at risk of CVD8,9 and people with endocrine disorders.10
To better inform decisions around fasting versus nonfasting lipid panel screening, researchers should consider looking at the clinical utility of nonfasting lipid panel screening (e.g., cardiovascular-related outcomes, morbidity, quality of life, and time to treatment associated with receiving the results of the screening).
For adults living with chronic conditions, it is recommended that a fasting or nonfasting lipid panel be used for initial screening of CVD risk (3 guidelines).8-10 If the initial nonfasting sample reveals high triglyceride levels, or in people with a history of hypertriglyceridemia, a fasting lipid panel can be conducted.8-10
Decision-makers may wish to consider that fasting may be a barrier for lipid panel screening for some people, and that a nonfasting sample may be more convenient for patients, especially when sample collection can occur at the point-of-care at the time the care provider requests the lipid panel screening. However, decision-makers should consider the possibility that a patient with high triglyceride levels would require a second test if a nonfasting sample is used initially, and whether starting with a fasting or nonfasting sample would best suit each individual’s circumstances.
Canadian Cardiovascular Society
cardiovascular disease
Grading of Recommendations, Assessment, Development, and Evaluation
high-density lipoprotein
low-density lipoprotein
National Institute for Health and Care Excellence
Contributors: Kristen Moulton
Selection of Included Studies.
Note that this appendix has not been copy-edited.
Characteristics of Included Guidelines.
Note that this appendix has not been copy-edited.
Strengths and Limitations of Guidelines Using AGREE II.
Note that this appendix has not been copy-edited.
Summary of Recommendations in Included Guidelines.
Note that this appendix has not been copy-edited.
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