Cardiovascular Risk Reduction: Lipids

Question 1

True or false: there is no evidence to support treating to a specific LDL or HDL target.

Answer 1

true

Question 2

What are the four statin benefit groups? (people who benefit from statins)

Answer 2

1. people with clinical CV disease
2. People with LDL over 190
3. People 40-75 yo with diabetes (even with normal LDL and no CV disease)
4. People who have an estimated 10 yr CV disease risk over 7.5% (even without clinical CV disease or diabetes)

Question 3

High intensity statin therapy will reduce LDL on average by what percent?

Answer 3

greater or equal to 50%

Question 4

Moderate intensity statin therapy will reduce LDL by what?

Answer 4

30-50%

Question 5

Low intensity statin therapy will reduce LDL by what?

Answer 5

less than 30%

Question 6

What are the two high-intensity statin regimens?

Answer 6

Atorvastatin 40-80 mg

Rosuvastatin 20-40mg

Question 7

What are some secondary causes of hyperipidemia?

Answer 7

diet (and alcohol)

drugs: diuretics, cyclosporine, steroids, amiodarone, estrogens, beta blockers, thiazides

biliary obstruction, nephrotic syndrome, chronic renal failure

hypothyroidism, pregnancy

Question 8

What are the factors that go into calculating the CV risk status?

Answer 8

age, gender, blood pressure, diabetes, hypertension (treated or not) and smoking

Question 9

In patients with diabetes, what intensity of statin therapy should you use?

Answer 9

moderate is recommended, but you should consider high-intensity if their CV disease risk is over 7.5%

Question 10

In benefit group 4 (CV risk over 7.5% but no diabetes and normal ldl), what intensity of statin therapy should you use?

Answer 10

moderate or high

Question 11

How often should you estimate someone’s CV risk if they’re not on a statin?

Answer 11

every 4-6 years

Question 12

What are some patient characteristics that would make you think a patient may not be able to tolerate a high-intensity statin?

Answer 12

1. medical comorbidities like liver and renal disease
2. baseline ALT > 3x normal
3. Age over 75
4. on interacting drugs
5. hx hemorrhagic stroke (IDK why)
6. Asian ancestry (I assume it’s a metabolism thing)

Question 13

What is the most complicated problem of statin safety?

Answer 13

myopathy (ranges from myalgia to rhabdomyolysis and renal failure)

Question 14

Because of the risk of myopathy, should you routinely check a baseline CK?

Answer 14

no, but consider if they’re at risk for muscle disease (family hx of statin intolerance or muscle disease)

Question 15

So when should you measure a CK then?

Answer 15

if they have symptoms develop (pain, stiffness, cramping, fatigue)

Question 16

If the symptoms are mild to moderate, what other causes should you consider?

Answer 16

hypothyroid
PMR
steroid myopathy
Vit D deficiency
primary muscle disease

Question 17

True or false: if someone has a statin intolerance, you should never use the same statin again.

Answer 17

false - after symptoms resolve, you should rechallenge with the original or lower dose of the same statin to establish causality

then is symptoms recur, you should change to a different statin at a low dose

Question 18

You should get a baseline ALT before starting a statin, but do you need to routinely check it?

Answer 18

nope - not recommended unless the patient has symptoms suggesting hepatotoxicity (fatigue, loss of appetite, abdominal pain, dark urine, jaundice)

Question 19

True or false: statin use has been associated with a modest excess risk of new-onset diabetes in RCTs and meta-analyses.

Answer 19

true

but it’s confined to those with other risk factors

ultimately the small risk of DM outweight the potential ASCVD risk reduction

Question 20

True or false: there is evidence for memory impairment/confusion with statin use.

Answer 20

false - no proven link

Question 21

What are the three pharmacologic categories you can use in patients who can’t take a statin or didn’t respond adequately to a statin?

Answer 21

ezetimibe
bile acid sequestrants
PCSK-9 inhibitors

Question 22

How does ezetimibe work?

Answer 22

it modifies cholesterol absorption in small intestine

Question 23

Bile acid sequestrants can have an added benefit in what patient population?

Answer 23

diabetics

coleselavan has been shown to lower A1c by 0.5%

Question 24

What are the limiting factors for bile acid sequestrants

Answer 24

GI side effects and pill burden

Question 25

How do the PCSK-9 inhibitors work?

Answer 25

they’re monoclonal antibodies against PCSK-9, which increases LDL receptors/clearance

Question 26

What is the main drawback for the PCSK-9 inhibitors?

Answer 26

cost (13K/yr)