cholesterol Flashcards
is the leading cause of death of men and women
ASCVD (athloclerotic cardiovascular disease)
Risk of developing ASCVD is directly r/t
increases levels of blood cholesterol, in the form of LDL
Lower LDL, slow
slow progression of atherosclerosis, reduce risk for serious ASCVD
Very-low-density lipoproteins (VLDLs)
Triglycerides – levels above
500mg/dL – increase risk of pancreatitis.
Low-density lipoproteins (LDLs) (bad)
Cholesterol primary core lipid
Greatest contributor to coronary heart disease
For each 1% reduction in LDL
1% reduction in the risk for a major CV event.
High-density lipoproteins (HDLs) (good)
Cholesterol primary core lipid
Carry cholesterol from peripheral tissues back to the liver
HDL promotes
cholesterol removal – high HDL levels protect again ASCVD.
Risk Factors for ASCVD
Smoking High blood pressure Abnormal cholesterol Diabetes ASCVD risk status uncertain – a coronary artery calcium test (40 to 75 y.o.) Risk-enhancing factors (40 to 75 y.o.)
Primary hypercholesterolemia
(LDL-C, 160–189 mg/dL [4.1–4.8 mmol/L); non–HDL-C 190–219 mg/dL [4.9–5.6 mmol/L])*
Metabolic syndrome
(increased waist circumference, elevated triglycerides [>175 mg/dL], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 in women mg/dL] are factors; tally of 3 makes the diagnosis)
CKD
eGFR 15–59 mL/min/1.73 m2 with or without albuminuria; not treated with dialysis or kidney transplantation
Chronic inflammatory conditions
such as psoriasis, RA, or HIV/AIDS
History of premature menopause
before age 40 y) and history of pregnancy-associated conditions that increase later ASCVD risk such as preeclampsia
High-risk race/ethnicities
e.g., South Asian ancestry
Lipid/biomarkers
Associated with increased ASCVD risk
Persistently* elevated, primary hypertriglyceridemia (≥175 mg/dL);
If measured:
Elevated high-sensitivity C-reactive protein
(≥2.0 mg/L)
Elevated Lp(a):
A relative indication for its measurement is family history of premature ASCVD. An Lp(a) ≥50 mg/dL or ≥125 nmol/L constitutes a risk-enhancing factor especially at higher levels of Lp(a).
Elevated apoB
≥130 mg/dL: A relative indication for its measurement would be triglyceride ≥200 mg/dL. A level ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk-enhancing factor
ABI
<0.9
Adults > 20 y.o. without ASCVD/not on therapy – measure
LDL-C fasting or non-fasting plasma lipid profile (document)
If initial non-fasting lipid panel with triglycerides >
400mg/dL , repeat fasting lipid panel
3 Regimens Statins
High intensity, which typically lowers LDL-C by 50% or more
Moderate intensity, which lowers LDL-C by 30% to 49%
Low intensity, which lowers LDL-C by 30% or less
patients who have extreamly high (190 or higher) LDL are at risk
for lifetime risk of cardiac events
40 to 75 with diabetes
modtere to high risk. Remonded moderate intensity regimine
Lifestyle Modifications examples
Reduced caloric intake of saturated facts, dietary cholesterol
Eliminate trans fat
Average of 50 minutes of moderate to vigorous physical activity 3 to 4 times a week
Potential net clinical benefit of pharmacotherapy
Recommend statins as first-line therapy
Consider combination of statin and non-statin, if indicated
Discuss potential risk reduction from lipid-lowering therapy
Discuss potential for adverse effects or drug-drug interactions
ASCVD risk assessment
Assign to treatment group (use ASCVD Risk Estimator Plus)
Assess other patient characteristics – Risk-Enhancing Factors
Assess CAC, if risk decision is uncertain/additional information is needed
recommend what as first line therapy
statins
Major ASCVD Events
Recent ACS (within the past 12 mo)
History of MI (other than recent ACS event listed above)
History of ischemic stroke
Symptomatic peripheral arterial disease (history of claudication with ABI <0.85, or previous revascularization or amputation)
High-Risk Conditions
Age ≥65 y
Heterozygous familial hypercholesterolemia
History of prior coronary artery bypass surgery or percutaneous coronary intervention outside of the major ASCVD event(s)
Diabetes mellitus
Hypertension
CKD (eGFR 15-59 mL/min/1.73 m2)
Current smoking
Persistently elevated LDL-C (LDL-C ≥100 mg/dL [≥2.6 mmol/L]) despite maximally tolerated statin therapy and ezetimibe
History of congestive HF
Patient who might benefit form knowing their CAC score is zero
Patients reluctant to initiate statin therapy who wish to understand their risk and potential for benefit more precisely
Patients concerned about need to reinstitute statin therapy after discontinuation for statin-associated symptoms
Older patients (men, 55-80 y.o.; women, 60-80 y.o.) with low burden of risk factors who question whether they would benefit from statin therapy
Middle-aged adults (40-55 y.0.) with PCE-calculated 10-year risk of ASCVD 5% to <8.5% with factors that increase their ASCVD risk, although they are in the borderline risk group
Monitoring
Middle-aged adults (40-55 y.0.) with PCE-calculated 10-year risk of ASCVD 5% to <8.5% with factors that increase their ASCVD risk, although they are in the borderline risk group
Average 40 minutes of
Average 40 minutes of
Lipid disorders r/t obesity – intensify
lifestyle therapy, moderate caloric restriction and regular aerobic physical activity
In children and adolescents with obesity or other metabolic risk factors, it is reasonable
to measure a fasting lipid profile to detect lipid disorders as components of the metabolic syndrome
to measure a fasting lipid profile to detect lipid disorders as components of the metabolic syndrome
fasting or non-fasting lipoprotein profile as early as age 2 years to detect FH or rare forms of hypercholesterolemia.
In children and adolescents without cardiovascular risk factors or family history of early CVD, it may be reasonable to measure a
fasting lipid profile or non-fasting non HDL-C once between the ages of 9 and 11 years, and again between the ages of 17 and 21 years, to detect moderate to severe lipid abnormalities.
In children and adolescents found to have moderate or severe hypercholesterolemia, it is reasonable to carry out
reverse-cascade screening of family members, which includes cholesterol testing for first-, second-, and when possible, third-degree biological relatives, for detection of familial forms of hypercholesterolemia
In children and adolescents 10 years of age or older with an LDL-C level persistently 190 mg/dL (≥4.9 mmol/L) or higher or 160 mg/dL (4.1 mmol/L) or higher with a clinical presentation consistent with FH and who do not respond adequately with 3 to 6 months of lifestyle therapy, it is reasonable to initiate
statin therapy
In adults 75 years of age or older with an LDL-C level of 70 to 189 mg/dL, initiating
a moderate-intensity statin may be reasonable.
In adults 75 years of age or older, it may be reasonable to stop
statin therapy when functional decline (physical or cognitive), multimorbidity, frailty, or reduced life-expectancy limits the potential benefits of statin therapy.
In adults 76 to 80 years of age with an LDL-C level of 70 to 189 mg/dL, it may be reasonable to measure
CAC to reclassify those with a CAC score of zero to avoid statin therapy
Consider conditions specific to women, such as
premature menopause (age <40 years) and history of pregnancy-associated disorders (hypertension, preeclampsia, gestational diabetes mellitus, small-for-gestational-age infants, preterm deliveries), when discussing lifestyle intervention and the potential for benefit of statin therapy.
Women of childbearing age who are treated with
statin therapy and are sexually active should be counseled to use a reliable form of contraception.
statin therapy and are sexually active should be counseled to use a reliable form of contraception.
hypercholesterolemia who plan to become pregnant should stop the statin 1 to 2 months before pregnancy is attempted, or if they become pregnant while on a statin, should have the statin stopped as soon as the pregnancy is discovered.
. In all individuals, emphasize a
heart-health lifestyle across the life course.
In patients with clinical ASCVDF, reduce
low-density lipoprotein cholesterol (LDL-C with high intensity statin therapy or maximally tolerated statin therapy.
In very high-risk ASCVD, use a
LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy.
In patients with severe primary hypercholesterolemia (LDL-C level ≥ 190 mg/dL[≥4.9 mmol/L]) without calculating 10-year ASCVD risk, begin
high-intensity statin therapy without calculating 10-year ASCVD risk.
In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start
moderate-intensity statin therapy without calculating 10-year ASCVD risk
In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician
patient risk discussion before starting statin therapy.
In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a
In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a
In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a
initiation of statin therapy (see No. 7)
In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL- 189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain,
consider measuring CAC.
. Assess adherence and percentage response to LDL- C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after
statin initiation or dose adjustment, repeated every 3 to 12 months as needed.
