48. Hyperlipidemia

Question 1

Describe : Lipid Screening

Answer 1

Primary prevention (without CVD)
* Consider screen men age 40-75y and women age 50-75y
* Consider earlier screening if known traditional CVD risk factors including (eg. hypertension, family history of premature CVD, chronic kidney disease, diabetes, and smoking)
* INESSS recommends screening only if ≥ 40yo and CVD risk factor

Repeat lipid screening q10y unless risk factors change
* Can recalculate global CVD risk earlier if new risk factor

Nonfasting lipid levels can be used to calculate global CVD risk
* Fasting if TG>4.5

Question 2

Describe risk assessments for hyperlipidemia (2)

Answer 2

• Framingham (2x risk if first degree relative F<65yo or M<55yo) : Sex, Age, Total Chol, HDL, Smoker, sBP (or if treated)
• QRISK2 if CKD

Question 3

Risk estimation should NOT be routinely done if what ? (3)

Answer 3

• Pre-existing CVD (automatically high risk)
• <40yo or >75yo as not studied.
• Lipid therapy

Question 4

Describe testing and benefit if > 75 yo ? (2)

Answer 4

• Can discuss testing >75yo if life expectancy and overall health status are good
• No studies have shown a mortality benefit in >75yo

Question 5

Name baseline tests : hyperlipidemia (3)

Answer 5

• eGFR
• A1c or fasting glucose
• TSH r/o hypothyroidism (both as a cause of hyperlipidemia and risk factor to myopathy)

Question 6

Name Lifestyle interventions for hyperlipidemia (3)

Answer 6

• Smoking cessation
• Mediterranean diet, avoid trans fats and decrease saturated fats -> Dietician
• Exercise (150 mins of moderate-vigorous intensity exercise)

Question 7

When to consider high-intensity statin ? (5)

Answer 7

Statin-indicated conditions (including secondary prevention)
* Atherosclerosis (eg. ACS)
* AAA
* DM
* CKD
* LDL>5

Question 8

If additional cardiovascular risk reduction is desired beyond max statin therapy, can consider what? (2)

Answer 8

• ezetimibe (6% RRR on CVD, no benefit on mortality)
• or PCSK9 inhibitor as add-on (évolocumab (Repatha))

Question 9

What other add-on can you consider after ezetimibe/PCSK9-inhibitors ?

Answer 9

icosapent add-on after ezetimibe or PCSK9-inhibitors because of potential adverse effects (atrial fibrillation, bleeding)

Question 10

Describe statin tx in regards to 10y CVD risk (Primary-prevention) (3)

Answer 10

• <10%, consider retesting lipids q10y with risk estimation
• 10-19%, discuss moderate-intensity statin
• ≥20%, consider high-intensity statin.

Question 11

When to consider ASA in hyperlipidemia ?

Answer 11

If ≥20% or CVD, can offer ASA if bleeding risk low

Question 12

Consider ___ if elderly or CKD

Answer 12

lower intensity statin

Question 13

If unable to tolerate statin, offer what? (2)

Answer 13

lower-intensity or drug holiday

Question 14

Name Statins

Answer 14

• Rosuvastatin 2.5mg, 5-10mg, 20-40mg PO daily (Cheapest)
• Alternatives: Atorvastatin, Simvastatin, Lovastatin, Avoid Pravastatin in >65yo risk of cancer

Question 15

Name common side effect statin

Answer 15

myalgias

Question 16

Ife myalgias with statin, what to do ? (3)

Answer 16

• Stop statin
• Follow CK until normal
• Consider restarting at lower dose / different statin / referral

Question 17

When to do labs with statin ?

Answer 17

• Consider baseline CK, ALT but generally NOT needed to be followed
• CK or ALT levels only if symptomatic or high risk of adverse events

Question 18

Describe cholesterol targe with statin (5)

Answer 18

• Cholesterol target for reducing CVD NOT required (statins have been shown to reduce risk regardless of LDL)
• Monitoring lipid levels during therapy NOT required
• Note: CCS guidelines still recommend LDL targets despite no conclusive data for using targets
• LDL-C <2 mmol/L or >50% reduction
• Alternative target variables are apoB < 0.8 g/L or non-HDL-C < 2.6 mmol/L