Statin therapy in the prevention of ASCVD Flashcards
Secondary prevention (establish ASCVD) recs
> 75 yrs - moderate int statin <75 yrs - high int statin
What is established ASCVD
ACS, stable angina, arterial revascularization (CABG), stroke, TIA, PAD
Primary prevention criteria for being on a statin:
LDL>190 (needs high int statin)
DM2 >40 yrs (need to risk stratify by ASCVD risk– >20% vs 10 yr risk <20% moderate intensity statin
Estimated 10 yr ASCVD risk >7.5% -10% - needs moderate to high intensity statin
Do all DM2 pts need statin?
If they >40 yrs, need a statin and use ASCVD risk to determine if high or moderate (>20% is high) If <40 yrs, look at risk enhancers or calcium scoring and consider low dose statin.
beware that statin and amiodarone can cause:
statin myopathy as amiodarone decreases statin metabolism (simvastatin, lovastain and atorvastatin) by CYP3A4 inhibition of liver
Which statin is likely NOT to interact with amiodarone?
rosuvastatin as it’s not metabolized by the P450 system. IF not tolerated, can try less potent statins like pravastatin, fluvastain.
What does coenzyme Q10 do?
Never the answer on test.
Instead, you should pick the answer that changes intensity of statin from high intensity to moderate intensity
some small studies show limited evidence it may reduced incidence of muscle toxicity
If patient is unable to tolerate any statin, what could you try?
Ezetimibe but it doesn’t significantly reduce the risk for coronary events.
What does Gemfibrozil?
lowers TG and raises HDL but not as effective as statins in lowering LDL. Also may inhibit amiodarone clearance in a patient who is taking amio
differentials for statin myopathy / must rule out
alcohol induced myopathy
connective tissue disease SLE or RA
electrolyte disturbances hypokalemia hypo/hyperthyroidism,
Cushing’s Addison’s
acromegaly
fibromyalgia
peripheral neuropathy
polymyositis/dermatomyositis
vitamin D deficiency
testing to evaluate for statin myopathy:
vitamin D, TSH and serum CK levels
and other testing depends upon symptoms and lab findings.
stop statin and check these labs. correct labs if abnormal.
can be mild muscle aches to fulminant rhabdomyolysis.
if CK elevated, then switch pt to a more hydrophilic statin like pravastatin or switch to a non statin drug like PCSK9 inhibitor.
pts without CK elevation, trial lower dose or a different statin without CK elevation.
what do statins (HMG COa reductase inhibitors) do?
they lower LDL and VLDL and TG help to prevent cardiovascular events with a relative risk reduction of 20-30%
statin may increase
risk of DM2 (new onset) or worsen glycemic control in older adults. new onset or worsening DM2 does not warrant discontinuation of statin
what is the risk for hemorrhagic stroke with statin?
very low 0.05-0.1% over 5 years
do statins cause hypothyroidism
no. can see statin induced myopathy that can be precipitated by TSH level
risk for statins to induce myalgia? if pt does have myalgia what to do and when to restart statin?
2-10% risk but only a 0.1% risk for rhabdomyolysis muscle symptoms are likely from pre-existing liver and renal disease or hypothyroidism. They should discontinue medication until symptoms improve then pick a statin with less muscle toxicity (pravastatin and rosuvastatin)
what is mild hypertriglyceridemia
150-500 mg/dl
what to do for people who have mild hypertriglyceridemia?
start on statin as 1st line. fish oils and fibrates don’t play a role in mild TGs
what is severe hypertriglyceridemia
TG>1000 mg/dl increased risk for pancreatitis lower risk by giving fibrate therapy fish oil or niacin if fibrates are not tolerated.
indications to start statin in prevention of ASCVD risk
management of high triglycerides
what does fish oil do?
2g/day can lower TG in dose dependent manner.
But if has elevated TG need to lose weight, increase exercise regimen and avoid concentrated sugars.
PC SK9 inhibitors are:
new class of medications that may be an effective alternative to statins but are expensive and subcutaneously administered.
Evolocumab and alirocumab.
Give when pt has CAD and has high LDL>70
can be used for familial hypercholesterolemia or established CAD with LDL above goal despite maximal statin therapy.
PCSK-9 inhibitors are a recent
addition to what can be used to prevent CAD in pts with familial hypercholesterolemia or established CAD and LDL above the goal despite maximally tolerated statin therapy.
if high intensity statin is already on and continues to have LDL>70 can give PCSK-9 inhibitor.
Approved PCSK9 inhibitors are: evolocumab and alirocumab
give every 2-4 weeks as a subcutaneous injection
very expensive in cost but insurance will approve it in a case by case basis.
what to do for a 72 year old woman who has PAD and not on statin?
start a high intensity statin for her
all pts with clinical evidence of CAD <75 years old need a high intensity statin.
Secondary causes of dyslipidemia
prior to starting a statin what do you check?
need to check lipid panel
and LFTs
follow up LIPID panel in 4-12 weeks after initiation of therapy to assess adherence and response. Further evaluation of LFTs after starting is not necessary unless symptoms appear.
Dont get LFTs and muscle enzyme studies during the absence of symptoms.
what to order to assess adherence statin and how often to check?
follow up LIPID panel in 4-12 weeks after initiation of statin to assess adherence and response. Further evaluation of LFTs after starting is not necessary unless symptoms appear.
Dont get LFTs and muscle enzyme studies during the absence of symptoms.
what are therapeutic lifestyle changes for lower cholesterol?
dietary changes - consumption of fruits, vegetables, fiber, monounsaturated fats, and minimizes intake of saturated and transfats, simple carbohydrates, and red meats.
regular exercise
weight loss
smoking cessation
replacing saturated fats iwt hpolyunsaturated fats been shown to reduce LDL cholesterol levels and cardiovascular mortality.
