Elevated LDL cholesterol is one of the most important modifiable risk factors for coronary artery disease. LDL-C targets depend on overall cardiovascular risk — patients with established ASCVD or familial hypercholesterolaemia have lower targets than those in primary prevention.

Management includes lifestyle measures, statin therapy, ezetimibe, and where indicated, PCSK9 inhibitor therapy. Dr Tashi provides specialist assessment and management of complex cholesterol disorders including statin intolerance and refractory hypercholesterolaemia.

Familial hypercholesterolaemia (FH) is the most common inherited lipid disorder, affecting approximately 1 in 250 people. It causes severely elevated LDL cholesterol from birth and dramatically increases the lifetime risk of premature coronary artery disease.

FH is significantly underdiagnosed in Australia. Many patients with FH are managed suboptimally with standard statin doses when they require higher-intensity treatment. Diagnosis is based on the Dutch Lipid Clinic Network (DLCN) criteria, genetic testing, or clinical features including family history.

Dr Tashi provides specialist assessment, diagnosis and management of FH including genetic counselling referral, cascade family screening, and initiation of advanced lipid-lowering therapy including PCSK9 inhibitors where PBS criteria are met.

Lipoprotein(a) [Lp(a)] is a genetically determined lipoprotein particle associated with an independent and causal increase in cardiovascular risk. Unlike LDL cholesterol, Lp(a) levels are largely determined by genetics and are not significantly modified by diet or standard lipid-lowering therapies.

Current guidelines recommend Lp(a) measurement at least once during adulthood in all adults, and more frequently in those with established cardiovascular disease, premature ASCVD, or family history of elevated Lp(a) or premature heart disease.

Management of elevated Lp(a) involves aggressive control of all other cardiovascular risk factors, consideration of PCSK9 inhibitor therapy (which reduces Lp(a) by approximately 25–30%), and monitoring for novel Lp(a)-lowering therapies in development.

Statin intolerance — most commonly manifesting as myalgia (muscle pain or weakness) — is a common reason for suboptimal cholesterol management. True complete statin intolerance is less common than perceived, but even partial intolerance can complicate management of high-risk patients.

Management strategies include dose reduction, statin switching, alternate-day dosing, and non-statin alternatives including ezetimibe, bempedoic acid, and PCSK9 inhibitors. For patients with true statin intolerance who meet PBS criteria, evolocumab (Repatha) or inclisiran (Leqvio) may be available without statin co-prescription.

Dr Tashi provides specialist assessment of statin intolerance and develops individualised lipid management plans for patients who cannot tolerate standard therapy.

PCSK9 inhibitors are a class of injectable therapies that dramatically reduce LDL cholesterol — typically by 50–60% on top of background therapy. In Australia, two PCSK9 inhibitors are PBS-listed for eligible patients: evolocumab (Repatha) and inclisiran (Leqvio).

PBS criteria require patients to have either (A) symptomatic ASCVD with at least one additional high-risk feature and LDL-C >1.8 mmol/L despite maximally tolerated statin and ezetimibe, or (B) confirmed heterozygous familial hypercholesterolaemia with LDL-C >5.0 mmol/L (without ASCVD). A specialist assessment is required before PBS prescribing can commence.

Dr Tashi provides specialist PBS eligibility assessment for PCSK9 inhibitor therapy, including via an online review service for GPs managing suitable patients in Western Australia.

Cardiovascular disease remains the leading cause of death in Australia, but a significant proportion of events are preventable through proactive risk factor management. Preventive cardiology focuses on identifying high-risk individuals before symptoms develop and implementing evidence-based strategies to reduce lifetime cardiovascular risk.

Key modifiable risk factors include LDL cholesterol, blood pressure, blood glucose, smoking, physical inactivity, obesity and diet. Non-modifiable risk factors — including age, sex, family history, and genetic factors such as Lp(a) and FH — inform risk stratification and treatment targets.

At HeartWise Cardiology, Dr Tashi provides comprehensive cardiovascular risk assessment incorporating clinical history, lipid profile, blood pressure, metabolic parameters, coronary calcium scoring where indicated, and evidence-based preventive management tailored to each patient's individual risk profile and preferences.