Hyperlipidemia: Lecture 2 Flashcards
Steps to Assessing Patients
Step 1: Do they have ASCVD?
Yes (Secondary prevention)
Very high risk? Age if not
No (Primary prevention)
Age? LDL? DM?
Most common forms of ASCVD
MI ACS Stable/unstbale angina CVA (Stroke) CABG post MI PTCA +/- stent post MI
ASCVD Risk Enhancing Factors
Family History of premature ASCVD Primary hypercholesterolemia CKD (15-59) TG > 175 C-reactive protein >2
Patient considered high risk if…
- history of multiple major ASCVD events
2. 1 major ASCVD event with multiple high risk conditions
High risk conditions
Age H/O CABG or PCI no MI DM HTN CKD current smoking persistent LDL >100 despite max statin CHF
How long should you be fasting before getting blood drawn?
Ideally 12hrs
If TG levels are above >400mg/dL, then LDL numbers….
might not be accurate
CTT Meta-Analysis
statin proportional benefit independent of baseline lipids
Heart protection study
Lipid Lowering benefits patients regardless of baseline LDL
CARDS
Confirmation of Lipid lowering benefit in DM patients
REVERSAL
Intensive Lipid lowering slows atherosclerosis progression > moderate Lipid lowering
Treating to new Targets
Benefit of intensive vs moderate Lipid lowering
IMPROVE-IT
Statin + Ezetimibe better than statin alone in ACS pts
GLASGOV
PCSK9i reduced size of atherosclerotic plaques
FOURIER
PCSK9i reduce ASCVD events and death better than statins alone
Meta-Analysis
Reducing LDL as low as 21 mg/dl = lower ASCVD events
2018 ACC/AHA guideline overal premise
the more we lower LDL, the more we lower ASCVD risk
Goal: Lower LDL by >50% and or < 100mg/dL
Patient: ASCVD not at very high risk, under age 75 =
high intensity statin
IF not tolerated, use moderate intensity
If on max therapy and LDL > 70, can add ezetimibe
Patient: ASCVD not at very high risk, over age 75
Start moderate or high intensity statin
Continue high intensity statin
Patient: Very high risk ASCVD
High intensity or maximal statin +
- If on max statin and LDL >70, can add ezetimibe
- If PCSK9i considered, try ezetimibe first
2a. If LDL >70, PCSK9i considered but less cost effective
Primary Prevention: Risk score: <5% (40-75yr old and LDL >70)
Low Risk
Emphasize lifestyle to reduce risk factors
Primary Prevention Risk score: 5%-7.5% (40-75yr old and LDL >70)
Borderline Risk
If have risk enhancers, discuss moderate intensity statin but try TLC first for ~ 3 months
Primary Prevention Risk score: 7.5%-20% (40-75yr old and LDL >70)
Intermediate risk
If estimate/score favor statin then initiate moderate intensity to reduce LDL
Primary Prevention Risk score: > 20% (40-75yr old and LDL >70)
High risk
Initiate statin to reduce LDL >50%
Primary prevention: LDL >190
start high intensity statin
Primary prevention: DM and 45-75yr
start moderate intensity statin or high intensity depending on risk assessment
ASCVD examples
MI ACS Unstable/Stable Angina CVA CABG PTCA +/- Stent
ASCVD equivalents
DM CKD Stage 3/4 HeFH PAD CEA ASCVD 10yr risk >20%
