Hyperlipidemia: Lecture 2

Question 1

Steps to Assessing Patients

Answer 1

Step 1: Do they have ASCVD?

Yes (Secondary prevention)
Very high risk? Age if not

No (Primary prevention)
Age? LDL? DM?

Question 2

Most common forms of ASCVD

Answer 2

MI
ACS
Stable/unstbale angina
CVA (Stroke)
CABG post MI
PTCA +/- stent post MI

Question 3

ASCVD Risk Enhancing Factors

Answer 3

Family History of premature ASCVD
Primary hypercholesterolemia
CKD (15-59)
 TG > 175
C-reactive protein >2

Question 4

Patient considered high risk if…

Answer 4

1. history of multiple major ASCVD events

2. 1 major ASCVD event with multiple high risk conditions

Question 5

High risk conditions

Answer 5

Age
H/O CABG or PCI no MI
DM
HTN
CKD
current smoking
persistent LDL >100 despite max statin
CHF

Question 6

How long should you be fasting before getting blood drawn?

Answer 6

Ideally 12hrs

Question 7

If TG levels are above >400mg/dL, then LDL numbers….

Answer 7

might not be accurate

Question 8

CTT Meta-Analysis

Answer 8

statin proportional benefit independent of baseline lipids

Question 9

Heart protection study

Answer 9

Lipid Lowering benefits patients regardless of baseline LDL

Question 10

CARDS

Answer 10

Confirmation of Lipid lowering benefit in DM patients

Question 11

REVERSAL

Answer 11

Intensive Lipid lowering slows atherosclerosis progression > moderate Lipid lowering

Question 12

Treating to new Targets

Answer 12

Benefit of intensive vs moderate Lipid lowering

Question 13

IMPROVE-IT

Answer 13

Statin + Ezetimibe better than statin alone in ACS pts

Question 14

GLASGOV

Answer 14

PCSK9i reduced size of atherosclerotic plaques

Question 15

FOURIER

Answer 15

PCSK9i reduce ASCVD events and death better than statins alone

Question 16

Meta-Analysis

Answer 16

Reducing LDL as low as 21 mg/dl = lower ASCVD events

Question 17

2018 ACC/AHA guideline overal premise

Answer 17

the more we lower LDL, the more we lower ASCVD risk

Goal: Lower LDL by >50% and or < 100mg/dL

Question 18

Patient: ASCVD not at very high risk, under age 75 =

Answer 18

high intensity statin

IF not tolerated, use moderate intensity
If on max therapy and LDL > 70, can add ezetimibe

Question 19

Patient: ASCVD not at very high risk, over age 75

Answer 19

Start moderate or high intensity statin

Continue high intensity statin

Question 20

Patient: Very high risk ASCVD

Answer 20

High intensity or maximal statin +

1. If on max statin and LDL >70, can add ezetimibe
2. If PCSK9i considered, try ezetimibe first
   2a. If LDL >70, PCSK9i considered but less cost effective

Question 21

Primary Prevention: Risk score: <5% (40-75yr old and LDL >70)

Answer 21

Low Risk

Emphasize lifestyle to reduce risk factors

Question 22

Primary Prevention Risk score: 5%-7.5% (40-75yr old and LDL >70)

Answer 22

Borderline Risk

If have risk enhancers, discuss moderate intensity statin but try TLC first for ~ 3 months

Question 23

Primary Prevention Risk score: 7.5%-20% (40-75yr old and LDL >70)

Answer 23

Intermediate risk

If estimate/score favor statin then initiate moderate intensity to reduce LDL

Question 24

Primary Prevention Risk score: > 20% (40-75yr old and LDL >70)

Answer 24

High risk

Initiate statin to reduce LDL >50%

Question 25

Primary prevention: LDL >190

Answer 25

start high intensity statin

Question 26

Primary prevention: DM and 45-75yr

Answer 26

start moderate intensity statin or high intensity depending on risk assessment

Question 27

ASCVD examples

Answer 27

MI
ACS
Unstable/Stable Angina
CVA
CABG
PTCA +/- Stent

Question 28

ASCVD equivalents

Answer 28

DM
CKD Stage 3/4
HeFH
PAD
CEA
ASCVD 10yr risk >20%