Pharmacotherapy of Hyperlipidemics Flashcards
1
Q
AHA-ACC Cholesterol Guidelines
A
- Based on whether management is for primary or secondary prevention
- Primary prevention gets ASCVD risk assessment to determine NEED for statin treatment
- Secondary prevention gets assessed to determine if they are very high risk and what the GOAL of statin therapy/additional therapy (if needed) is
2
Q
ASCVD Risk Assessment - >20 yo w/o ASCVD
A
- Assess traditional ASCVS risk factors every 4-6 years
* *Consider assessing 30-year or lifetime ASCVD risk based on ASCVD risk factors for adults 20-39 y.o.
3
Q
ASCVD Risk Assessment - 40-75 y.o. w/o ASCVD
A
- Assess traditional ASCVS risk factors every 4-6 years
- Assess 10-year ASCVD risk every 4-6 years
4
Q
ASCVS Risk Assessment
A
- Obtain lipoprotein profile (total chol., LDL, HDL, triglycerides)
- Race/ethnicity
- Weight, height
- Physical activity level
- Diet (food/alcohol)
Traditional Risk Factors
- Smoking status (within the last 7 days)
- Hypertension (>130/80)
- Low HDL-C (<40 mg/dl)
- Age and gender (>45 y.o. for men, >55 y.o. for women)
- Diabetes (hemoglobin A1c)
5
Q
Risk-Enhancing Factors
A
- Family history, 1st degree relative, of premature ASCVD (<55 y.o. for men, <65 for women)
- Primary hypercholesterolemia (LDL 160-189, non-HDL-C 190-219)
- Chronic kidney disease (eGFR 15-59)
- Chronic inflammatory conditions (psoriasis, HIV, rheumatoid arthritis)
- History of premature menopause and pregnancy-associated conditions that increase ASCVD (gestational DM and preeclampsia)
- High-risk race/ethnicity (South Asian)
- Metabolic Syndrome
6
Q
Metabolic Syndrome Risk Factors
A
Requires 3 of the following 5:
- Fasting glucose>100mg/dL
- HDL-C <40 mg/dL in males or <50 mg/dL in females
- TGs >= 150 mg/dL
- Waist circumference >40 inches in males or >34 inches in females
- SBP >= 130 mmHg or DBP >= 85 mmHg
- Receiving anti-hypertensive medicatiosn
7
Q
Lipid Biomarkers
A
- Persistently elevated TGs (>= 175 mg/dL)
- Elevatedhs-CRP >=2 mg/L
- Elevated Lp(a) >= 50 mg/dL
- Elevated apoB >= 130 mg/dL
8
Q
ABI
A
- Ankle-brachial Index
- ABI < 0.9 is a risk factor
- Ratio fo SBP measured at the ankle compared to it measured at brachial artery
- Typically used as indicator of peripheral arterial disease (PAD)
9
Q
Measuring LDL/Non-HDL Recommendations
A
- 20 y.o.+ and not on lipid-lowering therapy should have either fasting/non-fasting plasma lipid profile taken to estimate ASCVD risk, also document baseline LDL
- 20 y.o.+ who are found to have a TG >= 400 mg/dL, a repeat lipid profile in a fasting state should be done to assess fasting TG and LDL levels
- Assess fasting plasma lipid profile if they have a family history of premature ASCVD or genetic hyperlipidemia
10
Q
Healthy Lifestyle
A
- Guidelines endorse a healthy lifestyle for everyone
- Reduces ASCVD risk at all ages, can reduce development of risk factors and is the foundation of ASCVD risk reduction
- Lifestyle therapy is the primary intervention for metabolic syndrome
11
Q
Lifestyle Management
A
- Healthier dietary patterns
- Increasing healthy foods (veggies, fruits, whole grains, low-fat dairy, etc)
- Limit sweets, sugar-sweetened beverages, red meats
- Utilize plans such as DASH, USDA food pattern or AHA diet
- Reduce sodium intake (<2400 mg/day)
- Increased physical activity: 150 mins per week of moderate-intense exercise or 75 mins per week of vigorous-intensity exercise
- Healthy weight
- Stop smoking
12
Q
Secondary Prevention: ASCVD not high risk, Age =< 75 y.o.
A
- High intensity statin, goal of lowering LDL by at least 50%
- If high intensity statin isn’t tolerated, use moderate intensity statin
- If on maximal statin therapy and LDL is still >= 70 mg/dL, adding Zetia may be reasonable
13
Q
Secondary Prevention: ASCVD not high risk, Age >75 y.o.
A
- Initiate moderate or high level intensity statin
- Continue high-intensity statin
14
Q
Secondary Prevention: high risk for ASCVD
A
- High intensity or maximal statin
- If on maximal statin an LDL is still above 70 mg/dL, adding Zetia may be reasonable
- If a PCSK9-I is considered, add Zetia to max statin first
- If on maximal LDL lowering therapy and LDL level is still too high ornon-HDL is >100 mg/dL, adding a PCSK9-I may be reasonable
15
Q
Very-High Risk of Future ASCVD Events
A
Previous Events
- Recent acute coronary syndrome within the past 12 months
- History of MI
- History of ischemic stroke
- Symptomatic peripheral arterial disease
Risky Conditions
- > 65y.o.
- Heterozygous familial hypercholesterolemia
- History of coronary artery bypass surgery or percutaneous coronary intervention
- Diabetes mellitus
- Hypertension
- Chronic kidney disease
- Currently smoking
- Persistently high LDL levels despite max statin therapy and Zetia
- History of congestive heart failure
**Need either 2 events or 1 event and 2+ conditions to be considered very high risk)
16
Q
High Intensity Statin Therapy
A
- Goal: daily dose to lower LDL by >50%
- Atorvastatin 80 mg
- Rosuvastatin 20 (40) mg
() - titration option
17
Q
Moderate-Intensity Statin Therapy
A
- Goal: lower LDL by 30-50%
- Atorvastatin 10 (20) mg
- Rosuvastatin (5) 10 mg
- Simvastatin 20-40 mg
- Pravastatin 40 (80) mg
- Lovastatin 40 mg
- **Fluvastatin XL 80 mg
- Fluvastatin 40 mg bid
- **Pitavastatin 2-4 mg
18
Q
Low-Intensity Statin Therapy
A
- **Simvastatin 10 mg
- Pravastatin 10-20mg
- Lovastatin 20 mg
- **Fluvastatin 20-40 mg
- **Pitavastatin 1 mg
19
Q
ASCVS not at Very High Risk
A
- Encourage healthy lifestyle
- High-intensity statin therapy or maximally tolerated therapy (goal to lower >50%)
- If high-intensity can’t be tolerated attempt moderate-intensity
- If on maximally tolerated statin therapy and LDL is still too high, add Zetia
- If patient is >75 y.o., initiate moderate or high intensity (continue high intensity if already on and tolerating)
20
Q
ASCVS at Very High Risk
A
- Encourage healthy lifestyle
- High-intensity statin therapy or maximally tolerated (goal to lower >50%)
- Add Zetia if necessary
- Zetia should be added BEFORE PCSK9-I
- If on maximal LDL lowering (Statin and Zetia) and LDL or non-HDL are still to high, adding a PCSK9-I is reasonable
21
Q
Primary Prevention: Patients with LDL > 190 mg/dL
A
- Patients 20-75 years of age with severe primary hypercholesterolemia - high intensity statin therapy or maximally tolerated statin therapy
- If <50% reduction of LDL or LDL remains higher than 100 mg/dL, add Zetia
- If <50% reduction of LDL occurs while on a statin + Zetia, BAS may be considered
- If LDL levels still remains high on statin + Zetia and the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor may be considering (long term safety is uncertain)
22
Q
Primary Prevention: Patients with Diabetes
A
- 40-75 y.o. with DM and high LDLs, start moderate-high statin therapy
- High risk ASCVD DM patients. especially those with multiple RFs or 50-75 y.o., use high-intensity statin therapies
- IF 10-year ASCVD risk >=20% and has <50% decrease in LDL on maximal statin, add Zetia
- If older than 75 y.o., start statin therapy after a discussion or continue therapy if already on it
- 20-39 y.o. with DM risk enhancers, initiate moderate intensity statin
23
Q
Diabetes-Specific Risk Enhancers
A
- Long duration (over 10 years for type 2, over 20 years for type 1)
- Albuminuria >= 30mcg of albumin/mg creatinine
- eGFR < 60 mL/min/1.73 m^2
- Retinopathy
- Neuropathy
- ABI< 0.9
24
Q
Primary Prevention: 40-75 y.o., no DM, LDL 70-189 mg/dL (Based on ASCVD Risk Assessment)
A
- Risk <5% (Low Risk) - Emphasize lifestyle changes to reduce risk factors
- Risk 5-7.5% (Borderline Risk) - If risk enhancers present, discuss moderate intensity statin, CAC may help with decision process
- 7.5-20% (Intermediate Risk) - if risk estimate and enhancers favor statins then prescribe moderate intensity statin (if uncertain, consider measuring CAC)
- > 20% (High Risk) - initiate statin to reduce LDL >= 50%
25
Q
CAC Scores
A
- Coronary Artery Calcium Score
- If zero, withhold statin therapy and reassess in 5-10 years as long as higher risk conditions are absent
- If 1-99, start statin therapy for >=55 y.o.
- If >100 or >= 75th percentile, initiate statin therapy
26
Q
CAC
A
- Computed tomography of chest
- Measures amount of calcified plaque in coronary arteries
- Zero - low risk
- 1-99 - mild plaque development
- > 100 - moderate amount of plaque
27
Q
Monitoring
A
- Assess adherence and percentage response to LDL lowering medications and lifestyle changes with repeat lipid measurement 4-12 weeks after statin initiation or dose adjustment
- Repeat every 3-12 months as needed
- Define responses to lifestyle and statin therapy by percentage reductions in LDL levels compared with baseline
28
Q
Primary Prevention: 20-39 y.o.
A
- 10-year ASCVD risk not available using PCE
- Can use to estimate Lifetime risk
- Consider statin therapy if family history of premature ASCVD and LDL >= 160 mg/dL
29
Q
Primary Prevention: >= 75 y.o.
A
- If LDL levels between 70-189 mg/dL, initiating a moderate-intensity statin may be reasonable
- May be able to stop statin therapy when functional decline, multimorbidity, frality, or reduced life-expectancy limits the potential benefits of statin therapy
- In 76-70 y.o. with LDL 70-189 mg/dL, may be reasonable to measure CAC to reclassify those with a CAC score of zero to avoid statin therapy
30
Q
Primary Prevention: Pediatrics
A
- Children/adolescents with lipid disorders related to obesity, recommend to intensify lifestyle therapy
- In children >10 y.o. with persistent LDL >190 or >160 with possible FH, not responding to 3-6 mo. of lifestyle therapy, reasonable to start statin therapy
- IF family history of premature CVD or primary dyslipidemia, reasonable to measure fasting lipid profile as early as 2 y.o. to detect FH or primary dyslipidemias
- In children w/o CV risk factors of family history of ASCVD, may be reasonable to measure lipid rpofile between 9-11 y.o. and again at 17-21 y.o.
31
Q
Recommendations for Hypertriglyceridemia, > 20 y.o.
A
-Those with moderate hypertriglyceridemia should have lifestyle factors addressed, secondary factors assessed, and consider medications that increase TGs
32
Q
Recommendations for Mod-Sev Hypertriglyceridemia, 40-75 y.o.
A
- ASCVD risk >= 7.5%, reevaluate ASCVD risk after lifestyle and secondary factors are addressed
- Consider persistently high TG levels as a factor favoring the initiation or intensification of statin therapy
33
Q
Recommendations for Severe Hypertriglyceridemia, 40-75 y.o.
A
-ASCVD >= 7.5%, reasonable to address reversible causes of high TGs and initiate statin therapy
