Transforming Outcomes with Lipid Clinics in Malaysia: Enablers and Barriers for the Implementation of Multidisciplinary Approach Clinics for the Management of Dyslipidaemia

Cardiovascular diseases (CVDs) are the leading cause of mortality globally, and Malaysia is no exception, as indicated by the National Health and Morbidity Survey 2019.^1,2 There is a pressing need for proactive diagnosis and management of dyslipidaemia, a key risk factor for CVDs, characterised by abnormal lipid levels, such as cholesterol, LDL cholesterol (LDL-C), triglyceride and HDL cholesterol (HDL-C).^3,4 Dyslipidaemia, potentially stemming from genetic predisposition, dietary habits or tobacco consumption, is alarmingly prevalent in Malaysia.^2,4 The National Health and Morbidity Survey 2019 estimates that 40% (approximately 8 million) of the adult population in Malaysia have elevated total cholesterol levels, with a concerning one-quarter of this demographic being unaware of their condition.²

While primary care suffices for many patients, some individuals may experience medication side-effects or have underlying severe lipid conditions, rendering management more challenging.⁵ In such cases, specialised care is necessary to achieve lower cholesterol and triglyceride levels, ultimately reducing the risk of CVD.⁵

In Malaysia, healthcare services are widely accessible.⁶ Despite modest public health expenditure, the vast majority of households are shielded from the financial impact of high healthcare costs.⁶ According to the World Bank, only 1.4% of households in Malaysia face catastrophic health expenditure.⁷ The majority of both outpatient and inpatient services are provided by public facilities.² However, an uneven distribution of specialists exists between the public and private settings, with only 30% of specialists serving in public facilities, where 70% of complicated cases requiring specialist care are treated.⁶ This leads to shortages of critical staff in an overstretched public healthcare system, contributing to issues such as increased overcrowding, extended waiting times, postponed consultations and delays in emergency admissions.⁶ This situation underscores the need for preventive measures in lipid management, such as the establishment of lipid clinics.

Lipid clinics are important for managing dyslipidaemia and mitigating the risk of CVD.⁸ They specialise in providing more refined clinical diagnoses and treatment plans for individuals with dyslipidaemia, especially those with complex and hard-to-control dyslipidaemia.⁵ These clinics use evidence-based treatments, including lifestyle modifications, such as dietary changes, exercise regimens and weight management programmes, alongside pharmacological interventions, as needed.⁹ Regular follow-ups with healthcare providers at lipid clinics ensure continuous monitoring of patient progress and facilitate timely adjustments to treatment plans.⁹ By focusing on early detection and effective management of dyslipidaemia, lipid clinics play a pivotal role in reducing the global CVD burden.

This narrative review examines and assesses the current body of literature about the establishment of lipid clinics for the treatment of dyslipidaemia. Although studies suggest the potential benefits of lipid clinics, there is limited knowledge about the factors affecting their long-term impact. We aim to offer insights into the factors that support or impede the establishment and long-term functioning of lipid clinics. We provide evidence-based recommendations for optimising the management of dyslipidaemia and enhancing patient health outcomes through a collaborative and integrated healthcare approach.

Methods

The PICO (patients, intervention, comparison, outcome) strategy and keywords for the literature search were adopted, as outlined in Table 1.¹⁰ A literature search was conducted on PubMed, focusing on publications from the past decade.¹¹ The primary focus was on original articles to understand the role of lipid clinics in the management of all lipid conditions. Additional relevant publications that contributed to the discussion were also considered.

After removing duplicates from the search results across the database, two reviewers independently assessed the titles and abstracts of the articles. From the literature search, 24 articles were selected for inclusion. A total of 10 articles that were identified in the bibliographies of the reviewed articles and deemed relevant to our objectives were also included.

Dyslipidaemia Management: Present Setup

Significance of Cholesterol Reduction

Lowering lipid levels has been shown to prevent CVD both in individual cases and across broader populations.¹² It has been reported that a 30% decrease in the incidence of coronary heart disease could be achieved with a 10% reduction in total cholesterol levels.¹³ Each reduction of 1 mmol/l in LDL-C levels is associated with a 22% proportional decrease in the risk of major vascular events.¹⁴

Pharmacological Interventions

In certain patients, lipid-modifying agents are necessary to help them reach the desired lipid levels.¹⁵ It is particularly important to initiate the pharmacological treatments early for those identified as being at very high or high cardiovascular risk.¹⁵

Statins

Statins are the foundation of lipid-lowering therapy (LLT) to minimise the risk of CVD.¹⁵ They work by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A reductase, the key enzyme in the hepatic cholesterol synthesis.¹⁵ Statins are recommended as the first-line class of lipid-lowering drugs for both primary and secondary prevention of cardiovascular events.¹⁶ Notably, statins are the only pharmacological intervention that has been studied for primary prevention.¹⁵ A comprehensive meta-analysis by the Cholesterol Treatment Trialists’ Collaboration involving >170,000 participants across 26 trials found that for every 1 mmol/l reduction in LDL-C achieved with statin therapy, the relative risk of major vascular events (non-fatal MI, coronary death, stroke or coronary revascularisation) was reduced by approximately 22%.¹⁴

Fibrates

Fibrates, acting as peroxisome proliferator-activated receptor-α agonists, play a significant role in the oxidation of fatty acid.¹⁵ They are capable of reducing plasma triglyceride by up to 50% and increasing plasma HDL-C by up to 20%.¹⁷ When lifestyle modification and optimal LDL-C-lowering therapy fail to achieve sufficient triglyceride reduction, introducing fibrates as a combination therapy with statins can be a subsequent treatment strategy.¹⁵ In a follow-on analysis of the ACCORD trial with 4,644 participants over a median 9.7-year follow-up period, no significant difference was observed in the primary composite cardiovascular outcome among participants originally randomised to fenofibrate versus placebo (HR 0.93; 95% CI [0.83–1.05]; p=0.25).¹⁸ However, a subgroup of participants with baseline dyslipidaemia (defined as triglyceride levels >204 mg/dl and HDL-C <0.88 mmol/l) showed a significant reduction in cardiovascular events (HR 0.73; 95% CI [0.56–0.95]), supporting selective use of fenofibrate in patients with residual dyslipidaemia despite statin therapy.¹⁸

Niacin

Niacin, also known as nicotinic acid, acts in the liver to reduce the mobilisation of the free fatty acids from the adipose tissues.¹⁵ Daily intake of niacin at doses of 2–3 g can reduce plasma LDL-C levels by up to 20%, increase plasma HDL-C by up to 25% and reduce plasma triglyceride by up to 45%.¹⁷ However, niacin is associated with common side-effects, such as skin flushing, light-headedness and pruritus.¹⁷ Large randomised controlled trials, such as AIM-HIGH and HPS2-THRIVE, also failed to demonstrate additional cardiovascular benefit from adding niacin to statin therapy despite improvements in HDL-C, leading to a significant decline in its use.^19,20

Bile Acid Sequestrants

Bile acid sequestrants (BAS) are orally administered basic anion-exchange resins that interrupt the enterohepatic recirculation of bile acids.¹⁷ By binding to bile acids, BAS promote the excretion of bile acids into the intestines.¹⁵ This process leads to a depletion of bile acid, causing the liver to increase cholesterol uptake from the blood, lowering LDL-C levels.¹⁵

A recent large-scale pharmacovigilance study analysing 5,286 adverse event reports from the Food and Drug Administration Adverse Event Reporting System (2004–2024) updated the safety profile of BAS (cholestyramine, colestipol, colesevelam).²¹ The study found that gastrointestinal adverse events, such as constipation and diarrhoea, were the most common across all BAS.²¹ Notably, cholestyramine was associated with oropharyngeal irritation, colestipol with mechanical risks including dysphagia and choking, and colesevelam with musculoskeletal toxicities, such as myalgia and muscle spasms.²¹ Moreover, novel adverse events, such as dysgeusia and gastro-oesophageal reflux disease, were identified.²¹ Time-to-onset analysis revealed that most adverse events occurred within the first month of therapy, with approximately 15–16% persisting beyond 6 months, supporting the importance of drug-specific and temporal considerations for personalised monitoring.²¹

Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors

This group of drugs works by preventing proprotein convertase subtilisin/kexin type 9 (PCSK9) from binding to the LDL receptors.¹⁵ This interaction decreases the degradation of the LDL receptors and increases their availability to remove the LDL-C from the blood, leading to lower LDL-C levels.¹⁵ Data from clinical trials of PCSK9 inhibitors have shown that these agents can reduce LDL-C levels by up to 62% when added to statin therapy.^22–24

Cholesterol Absorption Inhibitors

Cholesterol absorption inhibitors selectively target the intestinal absorption of both dietary and biliary cholesterols without affecting the absorption of fat-soluble nutrients.¹⁵ This action leads to a decreased delivery of cholesterol to the liver, prompting an increase in LDL receptor activity.²⁵ As a result, more LDL-C is cleared from the blood, lowering the overall LDL-C levels.²⁵ The IMPROVE-IT trial evaluated the effect of adding ezetimibe to statin therapy in 18,144 patients with recent acute coronary syndrome.²⁶ Over a median follow-up period of 6 years, the addition of ezetimibe to simvastatin resulted in a modest but statistically significant reduction in cardiovascular events compared with simvastatin alone.²⁶ The primary endpoint (a composite of cardiovascular death, major coronary events or nonfatal stroke) occurred in 32.7% of the simvastatin–ezetimibe group and 34.7% of the simvastatin-monotherapy group (absolute risk reduction 2.0%; HR 0.936; p=0.016).²⁶

Small Interfering RNA

Inclisiran, a first-in-class small interfering RNA molecule, facilitates lipid management by targeting the production of PCSK9.¹⁵ By binding to hepatic PCSK9 messenger RNA, inclisiran prevents the synthesis of PCSK9 in the liver, in contrast to monoclonal antibodies, which act by inhibiting PCSK9 after it has been produced.^17,27 This mechanism results in a prolonged reduction of both PCSK9 and LDL-C levels in the bloodstream.^17,27 Inclisiran is administered via a subcutaneous injection at baseline, again at 3 months and subsequently every 6 months.^17,27 In the Phase III ORION-10 and ORION-11 trials, inclisiran reduced LDL-C levels by 52.3% and 49.9%, respectively, at day 510 among patients with atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk equivalent who had elevated LDL-C levels despite receiving statin therapy at the maximum tolerated dose.²⁸ Recent meta-analysis also demonstrates that inclisiran provides LDL-C reductions comparable to PCSK9 monoclonal antibodies and superior to ezetimibe and bempedoic acid.²⁹

Bempedoic Acid

Bempedoic acid is an oral small molecule that interferes with the cholesterol biosynthetic pathway by inhibiting the adenosine triphosphate citrate lyase.¹⁷ This mechanism results in a reduction of LDL-C levels by 20–24% when used alone, and even more when combined with a statin (an additional 18% reduction) or with ezetimibe (by 38–40%).¹⁵ In the CLEAR Outcomes trial, treatment of statin-intolerant patients with bempedoic acid produced a 21.1% decrease in LDL-C relative to placebo, and a 13% relative reduction in the risk of major adverse cardiovascular events.³⁰ A recent meta-analysis encompassing >17,700 patients from seven randomised controlled trials has confirmed that bempedoic acid not only significantly lowers LDL-C by approximately 22.5%, but also reduces the risk of major adverse cardiovascular events by 14% (OR 0.86; 95% CI [0.78–0.95]; p=0.03) and decreases the risk of non-fatal MI (OR 0.72; 95% CI [0.61–0.85]; p<0.0001).³¹ Notably, it also lowers the incidence of new-onset or worsening diabetes (OR 0.55; 95% CI [0.30–0.98]; p=0.04), which is a key consideration in metabolic risk management.³¹ At the time of writing of this manuscript, bempedoic acid has not yet been registered for use in Malaysia.

Lifestyle Modifications

Alongside pharmacological interventions, therapeutic lifestyle changes are critical, serving both as a preventive strategy and a complementary approach to LLTs.¹⁵ Covering a wide range of healthy behaviours and habits, therapeutic lifestyle changes involve quitting smoking, reducing alcohol intake, adhering to a nutritious diet, maintaining a healthy weight and engaging in regular physical activity.¹⁵ These practices should be advocated for all individuals, regardless of their use of lipid-lowering medications.

Challenges and Limitations

Underlying Causes

Addressing the underlying causes of dyslipidaemia goes beyond merely managing its symptoms with medications. While pharmacological interventions can effectively reduce the lipid levels, they often fall short of tackling the root causes contributing to dyslipidaemia, such as genetic predispositions.

Adverse Reactions

A significant challenge in lipid management is the adverse reactions associated with the medications. For instance, statins, despite their efficacy, can cause side-effects, such as muscle symptoms, diabetes, proteinuria and neurocognitive side-effects.¹⁵

Insufficient Response

Some individuals may not adequately respond to statin therapy.¹⁵ In these cases, combination therapies become essential to meet LDL-C targets (Figure 1 ).^15,32 Options include combinations of statins with ezetimibe or PCSK9-targeted therapy, and triple therapies involving statins, ezetimibe and PCSK9-targeted therapy.^15,32 For statin-intolerant individuals, combinations can be considered, such as ezetimibe with bempedoic acid or PCSK9-targeted therapy.^15,32

Non-adherence

The effectiveness of LLT is greatly diminished by non-adherence, exposing patients to a high risk of cardiovascular events.³³ Numerous factors contribute to this issue, including the high costs of medications, polypharmacy, forgetfulness, the quality of the doctor–patient relationship and a lack of understanding about the medication instructions or the necessity of the treatment.³³

Cost

The continuous demand for innovative and effective medications is a global challenge, compounded by the rising costs associated with introducing new treatments and the increasing prevalence of non-communicable diseases.³⁴ This financial strain is particularly acute in low- and middle-income countries, where a significant portion of the population struggles with access to essential medicines due to limited availability and the high cost of prescriptions.³⁵

Addressing All Lipid Factors

While many medications effectively lower LDL-C levels, raising HDL-C and reducing triglyceride levels can be challenging.¹⁵ For example, BAS do not significantly impact HDL-C and may even increase triglyceride levels in susceptible individuals, making their use inadvisable for patients with triglyceride ≥3.4 mmol/l.¹⁵

The Most Recent Update in the Local and International Guidelines

The local and international guidelines have established LDL-C targets for patients with dyslipidaemia, categorising them according to their cardiovascular risk (Table 2).^15,36,37

Significant Gap Between Guidelines and Practice

Despite proper management strategies, only a small proportion of patients achieved their LDL-C target. An observational study conducted across 18 European countries (n=5,888) revealed that only 33% of patients who received LLT for either primary or secondary prevention in various healthcare settings met the LDL-C goals set by the 2019 European Society of Cardiology/European Atherosclerosis Society.³⁸ Similarly, Blokhina et al., based on the data from the retrospective outpatient REKVAZA registry, found that no patients classified as high risk or extremely high risk had reached their LDL-C goal, as reported by Zagrebelnyi et al.^39,40 The Dyslipidaemia International Study II, which observed patients with acute coronary syndrome, reported that only 15.7% of patients managed to reach their LDL-C target.⁴¹ A local clinical audit in Malaysia, focusing on two urban public primary care clinics, showed that only 13% of patients achieved their LDL-C target.⁴² Collectively, these findings highlight a widespread gap in the attainment of the recommended LDL-C goals in clinical settings.

Using Lipid Clinics for Enhanced Lipid Management

Lipid clinics represent a strategic measure to improve patients’ success in reaching their LDL-C targets.¹³ Evidence from multiple studies suggests that outcomes of lipid management, including the attainment of LDL-C targets, are notably improved for patients who receive care from the lipid clinics, as opposed to those being managed by primary care physicians.^43,44

Lipid Clinics: Benefits and Key Components

Benefits of a Lipid Clinic

Enhanced Patient Care and Reduction of Cardiovascular Risk

Significant intervention effects have been observed in a lipid clinic setting.⁵ These include a more accurate diagnosis of specific lipid conditions, such as familial hypercholesterolaemia, hypertriglyceridaemia and dyslipidaemia.⁵ This setting also saw an increase in the prescription of treatments recommended by guidelines, along with a clinically significant reduction in lipid levels.⁵

A study evaluating the LDL-C-lowering effect among very-high-risk patients, including those with or without statin-associated muscle symptoms treated at a specialised lipid clinic in accordance with European guidelines, demonstrated a clinically meaningful reduction in LDL-C levels.⁴⁵ For very-high-risk patients, this reduction is expected to translate to a CVD risk reduction of approximately 15–50%.⁴⁵

Improved Treatment Adherence and LDL Cholesterol Goals Attainment

Lipid clinics have been shown to improve treatment adherence, possibly due to enhanced patient awareness.¹³ A previous study indicated that patients reported a better understanding of their medications, felt that their concerns were more adequately addressed and noticed improvements in their cholesterol levels after visiting lipid clinics.¹³ Regular follow-ups at specialised lipid clinics have been shown to enhance the achievement of LDL-C goals and other risk factor treatment goals, largely attributable to increased patient adherence and a higher rate of medication usage.⁴⁶ Additionally, nearly two-thirds of patients diagnosed with dyslipidaemia and participating in a pharmacist-managed lipid clinic programme achieved LDL-C levels at or below the target set by the National Cholesterol Education Programme Adult Treatment Panel III, compared with only 16% of patients receiving usual care from their primary care provider.⁴⁷

Enhanced Familial Hypercholesterolaemia Screening and Detection

Lipid clinics facilitate genetic confirmation of familial hypercholesterolaemia in suspected cases. In a large-scale initiative, alerting physicians when lipid thresholds were exceeded led to a 14-fold higher identification rate compared with traditional cascade screening.⁴⁸ This improvement is achieved by rapid case identification, enhanced diagnostic activity and systematic cascade screening among family members.⁴⁸

Dealing with Lipid-lowering Therapy Side-effects

Lipid clinics perform regular monitoring for adverse effects of LLTs, including statins and newer agents, such as PCSK9 inhibitors or inclisiran.⁴⁹ This includes scheduled lipid panels, liver and renal function tests, and review of symptoms at each visit to promptly detect and manage adverse effects.⁴⁹

Key Components of Successful Lipid Clinics

Multidisciplinary Team Approach

A multidisciplinary lipid clinic brings together a team of experts, including lipid specialist physicians, advanced practitioners, cardiologists, pharmacists, dietitians and genetic counsellors.⁵ This diverse team collaborates to offer a synergistic approach to care, encompassing comprehensive diet management, patient education, diagnostic expertise, medication titration and adherence support to ensure improved outcomes.⁵

Patient and Healthcare Provider Satisfaction

Patients are able to receive enhanced care, such as closer monitoring, allowing for timely adjustments to their treatment plans.^13,45 This often results in higher patient satisfaction, which is closely linked to a better understanding of their lipid therapy and, consequently, improved medication adherence.¹³ In addition, healthcare providers informed of the successes achieved by patients in the lipid clinic are more inclined to continue referring new patients to the clinic and recognise the clinic’s value in achieving positive patient outcomes.¹³

Evidence-based Practices

Lipid clinics use treatment pathways that are clearly defined and grounded in the latest consensus diagnostic and treatment guidelines for lipid disorders.⁵⁰ These written treatment pathways ensure consistency across all staff members in the lipid clinic, providing a structured approach to patient care that is both efficient and effective.⁵⁰

Successful Implementation Stories

Real-world Examples of Lipid Clinics

A study by Larsen et al. demonstrated the efficacy of lipid clinics in achieving meaningful LDL-C reductions in very-high-risk patients, who present challenges for non-specialist treatment.⁴⁵ The study highlighted an average LDL-C reduction of 0.7 mmol/l, potentially lowering CVD risk by approximately 15%.⁴⁵ When considering their highest recorded LDL-C levels, these patients experienced a reduction of approximately 2.4 mmol/l, corresponding to a 50% lower risk of CVD.⁴⁵ Moreover, the proportion of very-high-risk patients meeting their LDL-C targets increased from 13% to 32.2%.⁴⁵ These improvements were largely attributed to the optimised medication management and patient education provided by the lipid clinic, enhancing understanding of some diseases, such as hyperlipidaemia and atherosclerosis, which, in turn, improved adherence and lifestyle.⁴⁵

Another study investigated the impact of enrolment in a multidisciplinary secondary prevention lipid clinic for ≥3 years, comparing it with usual care by cardiologists.⁹ The findings revealed that secondary prevention lipid clinic patients more frequently met LDL-C goals than those receiving standard cardiology care (for a goal of <2.6 mmol/l: 81.9% versus 72.8%; p<0.001; for an optional goal of <1.8 mmol/l: 41.9% versus 28.6%; p<0.001).⁹ After 3 years, secondary prevention lipid clinic-enrolled patients showed lower average total cholesterol, triglyceride and LDL-C levels, alongside higher HDL-C levels, demonstrating the long-term benefits of specialised lipid clinic care.⁹

The Effectiveness of a Cardiovascular Risk Reduction Clinic in Malaysia

A cardiovascular risk reduction clinic (CRRC) was established at the National Heart Institute (IJN) to provide risk management treatment for patients with CVD and primary lipid disorders, aiming to optimise ASCVD care (Figure 2). Patients are referred to the CRRC if they meet at least two of the following criteria:

• established ASCVD;
• diagnosed familial hypercholesterolaemia;
• total cholesterol >11 mmol/l without LLT;
• total cholesterol >6 mmol/l despite LLT;
• LDL-C >1.8 mmol/l in high- or very-high-risk patients despite LLT; or
• LDL-C >1.4 mmol/l in extremely high-risk patients despite LLT.

Referrals are typically driven by uncontrolled LDL-C levels in patients with ASCVD despite the use of oral LLTs, the presence of multiple comorbidities requiring coordinated multidisciplinary management or the identification of premature ASCVD. The referred population commonly includes individuals aged 30–90 years with ASCVD or ASCVD-risk equivalent conditions. Most are categorised as high to extremely high cardiovascular risk and often present with comorbidities, such as hypertension, ischaemic heart disease, diabetes and chronic kidney disease.

An observational retrospective study investigated LDL-C goal attainments and LLT patterns in patients with ASCVD or ASCVD-risk equivalent conditions 6 months before and 3 months after enrolment in the CRRC, and it found that 40% of patients achieved the LDL-C goal of <1.4 mmol/l after participating in the CRRC, whereas no patients met this goal before their CRRC participation.⁵¹ Furthermore, more patients (53.3 versus 3.3%) were able to achieve ≥50% LDL-C reduction from baseline after joining the CRRC.⁵¹ Following enrolment in the CRRC, 43.3% of patients received dual therapy (statin + ezetimibe or inclisiran), and 50% were treated with triple therapy (statin + ezetimibe + inclisiran or PCSK9 inhibitor), resulting in a 48% reduction in LDL-C levels 3 months after CRRC involvement.⁵¹ These results underscore the CRRC’s effectiveness and the need for broadening patient inclusion criteria for early CVD risk prevention.

A self-developed, voluntary, self-administered survey was conducted online to understand the impact of CRRC on enhancing patients’ awareness of lipid management. A total of 92 patients participated in this study. The survey results revealed that 100% of patients who attended the CRRC understood the health risks posed by high LDL-C. All of the patients surveyed had a positive experience during their CRRC visit (excellent 41%; very good 38%; good 21%), noting benefits from CRRC consultations, such as better control of their cholesterol and diabetes, improved adherence, motivation to change their lifestyle, and a better understanding of their condition and treatment. Notably, all surveyed patients expressed intent to continue follow-ups at the CRRC and would recommend it to friends and family, highlighting their confidence in and satisfaction with the services provided. Overall, this survey underlines the positive impacts CRRC had on patients’ behaviours, attitudes and understanding of lipid management, marking a step towards evaluating the CRRC’s success.

The results highlight the CRRC’s effectiveness as an integrated practice unit and the value of a multidisciplinary approach.⁵² By fostering collaboration among healthcare professionals (HCPs) – including cardiologists, medical officers, nurses, dietitians and physiotherapists – tailored care is delivered to optimise treatment protocols and enhance patient outcomes. Data-driven decision-making ensures continuous evaluation for optimal cardiovascular risk management.

Expanding the range of risk factors addressed in the CRRC programme, along with the involvement of family medicine specialists and pharmacists, will improve overall population health. This ecosystem will facilitate the escalation and de-escalation of patient cases, providing comprehensive cardiovascular care beyond the hospital setting.

Recognising the potential of CRRC, IJN has been invited to share the success of CRRC by local government bodies and regional cardiology partners, including those in the Philippines and Indonesia. Evidence suggests that interprofessional collaboration is effective in the management of patients at cardiovascular risk, having demonstrated benefits in improving patient-centred outcomes, such as achieving target LDL-C levels, reducing blood pressure, lowering HbA1c levels and reducing the number of hospitalisations.⁵³ By engaging in continuous intercountry learning and collaboration, regional partners can leverage shared knowledge and best practices to establish and optimise their CRRCs. This collaborative approach fosters innovation, improves patient care and ensures the implementation of effective strategies tailored to specific regional needs.

In addition, the Ministry of Health (MOH) Family Medicine Specialists Services expressed interest in collaborating with the IJN to establish CRRCs across Malaysia. A signing of a memorandum of understanding is scheduled, which will encompass training programmes for setting up CRRCs, starting with three to five satellite clinics. The collaborative efforts between IJN and MOH will focus on identifying site-specific gaps and customising tailored solutions.

Comparative Insights from Global Lipid Clinic Models

Table 3 provides a side-by-side comparison of lipid clinic implementations in Denmark, the US and Malaysia, highlighting differences in patient populations, intervention strategies, care structures and outcomes. This comparative summary offers insights into how lipid clinics function within different health system models, and underscores the potential adaptability and impact of such clinics globally.

Future Directions: Enablers to Implementing Lipid Clinics

Funding and Reimbursement

The successful implementation and long-term sustainability of lipid clinics are highly dependent on dedicated financial resources. While lipid clinics offer long-term cost savings by reducing cardiovascular events, hospital readmissions and disease progression, they require substantial initial investment in infrastructure, human resources, diagnostic capabilities and care coordination systems.^9,45,50 It is essential that funding mechanisms, whether from government allocations, private partnerships or public health grants, be structured to support both initial setup and long-term operational needs. In the Malaysian context, policymakers can act as key enablers by integrating lipid clinics into Malaysia’s national non-communicable disease strategies and CVD prevention frameworks. Strategic resource allocation based on disease burden data, especially for high-risk populations, can guide equitable deployment.

Public–private partnerships also present a promising avenue to mobilise funding and operational resources. Collaborations with industry, insurance providers and private healthcare networks can support innovation and service expansion, especially in urban centres or underserved regions.

Moreover, integration of lipid clinic services into existing insurance and reimbursement models is critical to improve affordability and access. A study has reported that accurate patient selection by a regional lipid clinic led to high approval rates from medication insurance providers.⁵⁴ This underscores the potential for lipid clinics to increase reimbursement approval rates for cardiac rehabilitation programmes in Malaysia. Demonstrating the ability of CRRCs to enhance cardiovascular outcomes through effective LDL-C management could further support this potential. Expanding insurance coverage for services offered by lipid clinics could motivate more patients to seek care, thereby improving accessibility and overall cardiovascular health outcomes.

In addition, pilot CRRCs should incorporate cost-effectiveness analyses to quantify potential savings in cardiovascular outcomes. These data can strengthen advocacy for national scale-up and justify inclusion in health financing schemes.

Clinical Guidelines

The existence of clear, evidence-based clinical practice guidelines is a strong enabler of consistent and high-quality care in lipid clinics.⁵⁰ Beyond standardising diagnostic and treatment pathways, these guidelines should be designed to support proactive, long-term cardiovascular risk management. A key future direction is the incorporation of comprehensive cardiovascular risk stratification into clinical workflows. This includes the evaluation of risk-enhancing factors (e.g. chronic kidney disease, inflammatory conditions, premature menopause, family history of premature ASCVD and elevated lipoprotein[a]) to better identify patients who may benefit from early intervention, even in the presence of borderline LDL-C levels.

Additionally, distinguishing between 10-year ASCVD risk and lifetime cardiovascular risk should be standard practice in lipid clinics. While 10-year risk guides decisions in older adults with established risk profiles, lifetime risk assessment is more relevant for younger patients or those without overt disease, enabling clinicians to initiate lifestyle or pharmacological interventions early before irreversible vascular damage occurs. Embedding these stratification tools in daily clinical operations will enhance patient-specific risk communication and treatment planning.

To operationalise these guidelines, digital integration into electronic health records (EHRs) should be prioritised. For instance, EHRs in MOH clinics could incorporate automated prompts that calculate both 10-year and lifetime risk using validated scoring systems (e.g. pooled cohort equations), dynamically adjusting treatment recommendations based on real-time patient data. This would promote consistent, guideline-concordant care and facilitate early escalation when LDL-C targets are not met.

By evolving beyond static algorithms to a digitally enabled, risk-personalised approach, Malaysia’s lipid clinics can serve as scalable models for precision cardiovascular prevention. These tools would also support data capture for registry development, long-term outcomes tracking and national benchmarking.

Clinical Leadership and Collaboration

Effective implementation of lipid clinics requires robust clinical leadership. Such leadership is pivotal for ensuring the delivery of high-quality patient care, as it establishes a clear vision and direction, fosters a positive clinical work environment, and secures organisational support.⁵⁵ Appointing a dedicated ‘champion’ of CRRCs (i.e. a clinician leader who actively advocates for lipid clinics at both institutional and national levels) is essential. This champion can engage with policymakers, present real-world data and influence resource allocation within Malaysia’s healthcare system.

Furthermore, fostering collaboration among HCPs is crucial for exchanging treatment data and promoting knowledge sharing among lipid clinics, thereby optimising treatment protocols and strategies.⁵⁶ Assembling a strategic task force comprising clinicians, administrators, policymakers and public health experts can facilitate the development of a national road map for lipid clinic implementation. This task force would be well-positioned to pilot region-specific strategies, assess operational feasibility and coordinate advocacy efforts to integrate lipid clinics into broader non-communicable disease prevention frameworks.

Moreover, partnerships with pharmaceutical companies can help accelerate implementation by addressing educational and training gaps. These collaborations may include the development of online learning modules, continuous medical education on emerging lipid-lowering therapies, and implementation audits to ensure the rational and cost-effective use of high-cost medications. Collectively, these initiatives will empower clinicians with up-to-date knowledge, as well as equip healthcare systems with tools to monitor prescribing patterns and treatment outcomes effectively. Additionally, establishing regional lipid clinic networks or centres of excellence would allow sharing of best practices, benchmarking outcomes and conducting collaborative research. This networked approach could also support resource-limited areas through teleconsultation support.

Technological Advances

Adopting the latest technological advances is crucial for the growth and effectiveness of lipid clinics. Telehealth services, in particular, streamline the coordination of care by eliminating the logistical challenges of scheduling, travel and other barriers to accessing specialised care.⁵⁷ Evidence indicated that telehealth can reduce hospital readmissions, generate savings for both patients and providers, and improve the overall quality of patient care.⁵⁸ Additionally, the use of computerised systems, such as EHRs, plays a role in elevating the quality of care. EHRs can contribute to better organisation and accessibility of patients’ medical data.⁵⁹ Another important aspect is the use of data analytics to evaluate clinic performance, identify trends in adherence and treatment response, and flag patients at risk of non-compliance or treatment failure. By integrating technological solutions, lipid clinics can enhance their service delivery, making care more efficient and patient-focused.

One practical example of digital integration is the IJN Care app, which empowers patients by enabling appointment scheduling, medication home delivery, access to personalised patient education modules and secure viewing of their EHRs. Such tools not only enhance convenience but also promote patient engagement and adherence to long-term lipid-lowering therapy.

Education

Education and capability-building form the foundation for sustainable and effective lipid clinic implementation.⁵⁰ Structured training programmes for HCPs, including doctors, pharmacists, nurses and dietitians, are essential to ensure consistent, evidence-based care across diverse practice settings. These programmes should focus on core competencies, such as cardiovascular risk stratification (including use of risk-enhancer criteria, and distinguishing between 10-year and lifetime risk), guideline-driven lipid management and multidisciplinary care coordination.

To scale efforts nationwide, a digitally enabled education strategy can be adopted. Digital platforms offer flexibility and scalability for delivering interactive learning modules, allowing HCPs from both public and private sectors to engage in continuous professional development. For example, an integrated online learning platform may include modules on lipid guideline updates, shared decision-making strategies and monitoring of high-cost therapies, supplemented with case-based discussions and competency assessments.

Moreover, embedding educational efforts within an international framework (e.g. the standards established by the European Association of Preventive Cardiology) can support benchmarking, accreditation and ongoing quality improvement across lipid clinics. These standards also facilitate alignment with global best practices, fostering consistency and credibility in care delivery.

Future Directions: Barriers to Overcome

Economic and Resource Challenges

Financial hurdles can stifle the growth of lipid clinics. Setting up a lipid clinic requires an initial investment in training staff and acquiring necessary equipment. The initial capital required to establish a lipid clinic, including investment in diagnostic equipment, digital infrastructure and staff training, can be prohibitive for smaller healthcare facilities, particularly in rural or semi-urban areas. Without targeted funding or incentive structures, the expansion of lipid clinics remains constrained, limiting their potential to reduce the burden of atherosclerotic cardiovascular disease. Ongoing operational costs can be burdensome. In a resource-constrained environment, lipid clinics may be deprioritised compared with other urgent care services.

Moreover, inadequate reimbursement models limit the viability of lipid clinics, especially in the private sector or mixed-care settings. Coverage gaps for essential components, such as lipid-lowering medications, genetic screening or repeat testing, create additional patient burden and deter follow-up. To overcome this, health economic data demonstrating cost savings from reduced cardiovascular events should be used to support budget negotiations and policy advocacy. Public–private partnerships and international grants could also serve as alternative funding avenues during the pilot phase.

Workforce and Capacity Limitations

The successful establishment of lipid clinics hinges on the availability of a multidisciplinary clinical team, typically comprising doctors, medical officers, pharmacists, nurses, dietitians and physiotherapists. However, a major barrier in the Malaysian context is the shortage of trained HCPs, particularly in specialised roles, such as dietitians and physiotherapists. This shortfall significantly affects the clinic’s ability to deliver holistic care and limits the scalability of the lipid clinic model.

Compounding the workforce shortage is a gap in formal education and awareness. Many clinicians, including general practitioners and junior medical officers, may not have received structured training in lipidology, cardiovascular prevention or risk stratification. Without targeted capacity-building initiatives, even well-resourced clinics may struggle to deliver consistent, evidence-based care aligned with international standards.

This limitation is not unique to Malaysia. For instance, a US study indicated that the inability of lipid clinics to accommodate all referred patients presents a major barrier to their long-term sustainability.⁵ This limited capacity can result in some patients receiving care from a single regional lipid expert instead of the intended multidisciplinary team.⁵ This situation, in turn, can lead to frustration for both patients and healthcare providers who were expecting a comprehensive evaluation by a diverse team of specialists.⁵

To mitigate these challenges, task-sharing with trained allied HCPs (e.g. nurses or pharmacists) can extend care delivery without overburdening lipid specialists. Additionally, integrating structured, multidisciplinary training programmes into national upskilling strategies will be key to addressing the human resource bottleneck. Incentivising healthcare workers to pursue specialisation in lipid management and prevention, along with strategic deployment of existing staff, can enhance the reach and sustainability of lipid clinics across Malaysia.

Referral Pathway

The absence of a clear and effective referral pathway is another primary barrier to establishing lipid clinics. Without a streamlined system for healthcare providers to refer patients with lipid disorders, access to necessary services can be compromised. This can delay early intervention and holistic management of lipid-related conditions. Moreover, the lack of a designated referral pathway might leave patients and providers unaware of lipid clinics in their vicinity, further restricting access to specialised care. In Malaysia, it is crucial for stakeholders, including IJN, MOH and primary care physicians, to collaborate in creating a dedicated referral pathway that is easily accessible for patients with difficult-to-treat lipid conditions or high cardiovascular risk. Educational campaigns targeting healthcare providers should highlight when and how to refer, and what to expect from lipid clinic involvement, thereby demystifying the process and encouraging referrals.

Provider and Patient Reluctance

Gaining widespread support for lipid clinics requires buy-in from the healthcare providers, as their resistance poses a considerable challenge to establishing them. First, some healthcare providers who refer patients may not perceive these clinics as saving them time in managing cholesterol.¹³ Additionally, referrals often lack clear instructions, failing to specify the need for the multidisciplinary approach offered by lipid clinics.⁵ To address this, lipid clinics should implement referral feedback loops, including summary reports and follow-up recommendations to referring providers. Highlighting positive patient outcomes and adherence improvements may also help build confidence.

Patient reluctance to engage with these services, often due to a perception of being in good health, creates another obstacle to delivering comprehensive lipid management solutions.^60,61 To overcome this, clear education on the silent nature and long-term risks of dyslipidaemia is key. Personalised risk assessments, such as cardiovascular risk scores, can make the need for intervention more tangible.

Recommendations

Policy and Advocacy

To foster the establishment of lipid clinics and facilitate their growth, it is essential to advocate for supportive policies and promote necessary policy changes. This includes advocating for policies that recognise the importance of lipid clinics in addressing lipid-related health concerns and improving patient outcomes. Policymakers should be encouraged to allocate resources and funding to support the establishment and sustainability of lipid clinics. Advocating for policy changes that enhance reimbursement mechanisms can facilitate easier access to lipid clinic services for patients and healthcare providers. By actively engaging in policy advocacy efforts, stakeholders can create an enabling environment that promotes the establishment and expansion of lipid clinics, ultimately improving the quality of care for individuals with lipid disorders.

Research Needs

The foundation of a lipid clinic must prioritise research and remain informed about advances in technology and treatment methods. Identifying research gaps, such as the efficacy of new lipid-lowering drugs or the impact of lifestyle interventions on lipid profiles, can inform evidence-based practice and enhance patient care. Keeping abreast of emerging technologies, such as genetic testing for lipid disorders or advanced lipid imaging techniques, can facilitate more accurate diagnosis and personalised treatment plans for patients. By integrating research-driven approaches and leveraging innovative technologies, lipid clinics can optimise their services and provide comprehensive care to individuals with lipid-related health concerns.

Education and Feedback

Patient and provider education plays a pivotal role in increasing awareness and acceptance of lipid clinics, with patients being recognised as key stakeholders in their success. By maintaining ongoing communication and making patient experience a measurable success factor, clinics can integrate continuous feedback to improve care. Educational programmes empower patients to manage their lipid disorders, while provider education fosters collaboration in optimising treatment. This ongoing exchange ensures clinics can adapt to patient needs, enhancing both satisfaction and outcomes in cardiovascular risk reduction.

Conclusion

Lipid clinics represent a pivotal advancement in the management of dyslipidaemia, offering potential benefits in reducing CVD risk. By providing specialised care, they improve patient outcomes, enhance treatment adherence and contribute to achieving LDL-C targets. Despite challenges, such as economic constraints, workforce limitations and the need for effective referral pathways, lipid clinics demonstrate significant potential for widespread implementation. Recommendations for their success include securing funding, developing clear clinical guidelines, fostering leadership and collaboration, and embracing technological advancements. Ultimately, a concerted effort from healthcare providers, policymakers and patients is crucial to overcoming barriers and harnessing the full benefits of lipid clinics, aligning with global efforts to mitigate the burden of CVD.