Statin therapy in the prevention of ASCVD

Question 1

Secondary prevention (establish ASCVD) recs

Answer 1

> 75 yrs - moderate int statin <75 yrs - high int statin

Question 2

What is established ASCVD

Answer 2

ACS, stable angina, arterial revascularization (CABG), stroke, TIA, PAD

Question 3

Primary prevention criteria for being on a statin:

Answer 3

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

Question 4

Do all DM2 pts need statin?

Answer 4

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.

Question 5

beware that statin and amiodarone can cause:

Answer 5

statin myopathy as amiodarone decreases statin metabolism (simvastatin, lovastain and atorvastatin) by CYP3A4 inhibition of liver

Question 6

Which statin is likely NOT to interact with amiodarone?

Answer 6

rosuvastatin as it’s not metabolized by the P450 system. IF not tolerated, can try less potent statins like pravastatin, fluvastain.

Question 7

What does coenzyme Q10 do?

Answer 7

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

Question 8

If patient is unable to tolerate any statin, what could you try?

Answer 8

Ezetimibe but it doesn’t significantly reduce the risk for coronary events.

Question 9

What does Gemfibrozil?

Answer 9

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

Question 10

differentials for statin myopathy / must rule out

Answer 10

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

Question 11

testing to evaluate for statin myopathy:

Answer 11

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.

Question 12

what do statins (HMG COa reductase inhibitors) do?

Answer 12

they lower LDL and VLDL and TG help to prevent cardiovascular events with a relative risk reduction of 20-30%

Question 13

statin may increase

Answer 13

risk of DM2 (new onset) or worsen glycemic control in older adults. new onset or worsening DM2 does not warrant discontinuation of statin

Question 14

what is the risk for hemorrhagic stroke with statin?

Answer 14

very low 0.05-0.1% over 5 years

Question 15

do statins cause hypothyroidism

Answer 15

no. can see statin induced myopathy that can be precipitated by TSH level

Question 16

risk for statins to induce myalgia? if pt does have myalgia what to do and when to restart statin?

Answer 16

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)

Question 17

what is mild hypertriglyceridemia

Answer 17

150-500 mg/dl

Question 18

what to do for people who have mild hypertriglyceridemia?

Answer 18

start on statin as 1st line. fish oils and fibrates don’t play a role in mild TGs

Question 19

what is severe hypertriglyceridemia

Answer 19

TG>1000 mg/dl increased risk for pancreatitis lower risk by giving fibrate therapy fish oil or niacin if fibrates are not tolerated.

Question 20

indications to start statin in prevention of ASCVD risk

Answer 20

Question 21

management of high triglycerides

Answer 21

Question 22

what does fish oil do?

Answer 22

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.

Question 23

PC SK9 inhibitors are:

Answer 23

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.

Question 24

PCSK-9 inhibitors are a recent

Answer 24

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.

Question 25

what to do for a 72 year old woman who has PAD and not on statin?

Answer 25

start a high intensity statin for her

all pts with clinical evidence of CAD <75 years old need a high intensity statin.

Question 26

Secondary causes of dyslipidemia

Answer 26

Question 27

prior to starting a statin what do you check?

Answer 27

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.

Question 28

what to order to assess adherence statin and how often to check?

Answer 28

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.

Question 29

what are therapeutic lifestyle changes for lower cholesterol?

Answer 29

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.