25 - Hyperlipidemia Treatment

Question 1

What is a dyslipidemia?

Answer 1

Dyslipidemia: disorder of lipid and lipoprotein absorption and synthesis

Question 2

What are lipoproteins?

Answer 2

Lipoproteins = cholesterol transport mechanisms

Question 3

What is LDL-C and HDL-C? Triglycerides?

Answer 3

• LDL-C: Low Density Lipoprotein – Cholesterol
• HDL-C: High density Lipoprotein – Cholesterol
• Triglycerides: fatty acid

Question 4

There is a clear causal relationship between dyslipidemia and…

Answer 4

CAD - coronary artery disease

Question 5

There is a clear benefit in dyslipidemias by lowering…

Answer 5

Serum cholesterol (total LDL)

Question 6

What is the leading cause of death in the US?

Answer 6

Heart disease

Question 7

What is the general concept between the ACC/AHA guidelines for treating hyperlipidemias?

Answer 7

• There seems to be no evidence supporting a treatment plan which aims to lower cholesterol to a certain level
• Instead, treating with the appropriate intensity of statin therapy has been shown to reduce cardiovascular risk
• This means that you titrate the intensity of the therapy to the degree of risk the patient is at, don’t just aim to hit a certain cholesterol level

Question 8

What is a “primary strategy” in treating hyperlipidemia?

Answer 8

Preemptive treatment of high risk persons before any disease state has developed
- Primary is based on the risk level of the patient, so you are trying to push the first event back as far as possible, based on their risk level **

Question 9

What is a “secondary strategy” in treating hyperlipidemia?

Answer 9

Repeat treatment in known disease state

• Secondary means you’re too late – they already have the disease, you’re trying to prevent the next event or progression **
• Statins drug of choice; others might work (less robust evidence)

Question 10

What is a “pooled cohort risk assessment”?

Answer 10

“Pooled Cohort Risk Assessment Equations”

• Developed by the Risk Assessment Work Group to estimate 10-year risk*
• 10-year risk for (ASCVD): coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke
• Can use online calculator for equation

Question 11

What is the basic principle of dyslipidemia risk assessment?

Answer 11

Calculate 10 year risk, let treatment titration follow

Question 12

What are the factors that the risk assessment considers?

Answer 12

Risk influenced by age, gender, and other risk factors:
Hypertension
Smoking
Family history (premature CHD in first-degree relative)
* Diabetes not usually considered in screening guidelines for primary prevention (risk of CHD is known to be high)

Question 13

Describe a high risk patient

Answer 13

Patients at higher risk generally have several risk factors or a single severe risk factor (e.g. patient siblings with CHD in their 40s or very heavy smoking

Question 14

What are the major risk factors outside of high cholesterol?

Answer 14

• Cigarette smoking
• Hypertension (BP 140/90 mmHg or needing meds)
• If you don’t need meds, you decrease your risk - this is a goal
• Diabetes mellitus
• Family history of premature CAD
• CAD in male first degree relative

Question 15

When would it be reasonable to do a lipid screening?

Answer 15

• Adults ages 20 to 79, free from CVD with risk factors (smoking, HTN, diabetes, total cholesterol, HDL-C)
• Every 4 to 6 years to calculate 10-year CVD risk

Question 16

When would you possibly consider doing a lipid screening?

Answer 16

• Adults 20 – 59, free from CVD without other risks (10 year

Question 17

What do you need to remember about diabetes and ASCVD?

Answer 17

ASCVD = atherosclerotic cardiovascular disease

Diabetes is not a “risk factor” it IS the disease

Remember: Diabetes = known ASCVD!

Question 18

When you get a 7.5% or lower chance of an ASCVD in the next 5 years, what do you do?

Answer 18

Tell the patient to keep up the good work

Question 19

What is the drug of choice for dyslipidemia treatment?

Answer 19

HMG-CoA inhibitors (statins)

Question 20

What are the 4 major benefits of statins?

Answer 20

1 - Effective in secondary prevention of all individuals with clinical cardiovascular disease
2 - Effective in primary prevention for patients with isolated LDL-C
3 - Effective in primary prevention for patients with diabetes, 40-75 yo and LDL-C elevation
4 - Effective in primary prevention for patients with a 10-year CVD risk of greater than 7.5%, 40-75 yo and LDL-C elevation

Question 21

What is the primary prevention of LDL-lowering therapy?

Answer 21

Public health approach is mostly education - NON-DRUG

• Address lipid levels in asymptomatic (presumably disease-free) individuals
• Increase physical activity (aerobic)
• Weight control (BMI

Question 22

What is the secondary prevention of LDL-lowering therapy?

Answer 22

Non-drug

• Increase physical activity (aerobic)
• Weight control (if BMI>25)
• Dietary modification to reduce intake of saturated fat and cholesterol
• Control of other ASCVD risk factors

Drug of choice

• Statins *** (moderate or high intensity)
• Moderate intensity in 75+
• High intensity in

Question 23

What are the benefits of statin drug therapy?

Answer 23

• reduced total mortality & coronary mortality
• fewer major coronary events
• fewer coronary procedures
• reduced incidence of stroke

Question 24

What are side effects of statins?

Answer 24

= Myopathy

- Increased liver enzymes

Question 25

What are the contraindications of statins?

Answer 25

• Absolute: liver disease
• Relative: use with certain drugs
• Not-recommended: with class II-IV heart failure drugs or patients on hemodialysis