Mini-Lecture Michelle Di Fiore Revised 4/2017 Lipid Management Mini-Lecture Michelle Di Fiore Revised 4/2017

Objectives Review current guidelines on lipid management Recommendations on who to test Current statin treatment recommendations Current statin safety recommendations

2013 ACC/AHA Guidelines Previous ATP III (Adult Treatment Panel III) looked at LDL goals in combination with patient’s risk. Current ACC/AHA does not focus on pure lab values, but on overall atherosclerotic cardiovascular risk disease The goal was To guide clinicians in treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults, currently the leading cause of death and disability in America The RCTs identified, demonstrated consistent reduction in ASCVD events from statins therapy in secondary and primary prevention populations (with the exception of those with NYHA class II-IV heart failure or receiving maintenance hemodialysis)

Who to test? USPSTF recommends screening: Men: >35yo Women: >45yo at increased increased risk Increased risk is defined as having: diabetes, CHD, family history of CHD in males <50yo and in females <60yo, smokers, HTN, obesity All patients aged 40-79 years old should have their 10year risk for ASCVD using Pooled Cohort Equation Of note, European Federation of Clinical Chemistry and Laboratory Medicine recommended in April 2016 non-fasting measurements in most patients.

Risk Calculator ASCVD risk <5% = LOW RISK ASCVD 5- 7.5% = INTERMEDIATE ASCVD >7.5% = HIGH RISK http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

Who needs treatment? Group1: Clinical ASCVD Group2: LDL >190 ACS, history of MI, angina, stroke, TIA, PAD Group2: LDL >190 Rule out secondary causes Group 3: All Diabetics without clinical ASCVD 40-75yo with LDL 70-189mg/dL Group 4: 10 year ASCVD risk >7.5% with LDL 70-189mg/dL

Management: Step 1: healthy lifestyle modifications prior to and in any pharmacologic therapy Avoid tobacco Regular exercise: 40mins 3-4x a week Aerobic exercise reduces LDL by 3-6mg/dL Healthy diet: DASH diet Lowers LDL by 10mg/dL ACC/AHA does not list a length of time lifestyle modifications should be trialed

Management STEP 2: Start statin Select appropriate dose for patient Keep potential side effects and drug interactions in mind If high/moderate intensity not tolerate, use max dose tolerated

Statin Safety Recommendations Considerations when starting a statin: Impaired renal or hepatic function History of statin intolerance or muscle disorder Age >75 years old ALT > 3x upper limit of normal History of hemorrhagic stroke Asian ancestry

Management Intensity of Statin: Established ASCVD Age > 75 moderate intensity statin Age <75 high intensity statin LDL cholesterol >190mg/dL High intensity statin Diabetes 40-75yo w/LDL 70-189mg/dL and no ASCVD ASCVD 10 year risk >7.5% high intensity statin ASCVD 10 year risk < 7.5% moderate intensity statin No ASCVD or DM, but 10 year ASCVD > 7.5% Moderate to high intensity statin Adults >76 yo w/o history of ASCVD Insufficient evidence to recommend for/against statins

Monitoring while on Statin Prior to initiating therapy: Fasting lipid panel ALT During Statin Treatment: Only get ALT or CK if patient develops symptoms of liver or muscle disease Repeat lipid panel 1-3 months after statin treatment, then every 3-12 months thereafter If no improvement, increase dose If LDL <40mg/dL, on 2 occasions, decrease dose

TEST yourself!

Question 1 41 yo M evaluated in PCP appointment. He is healthy with no symptoms, is sedentary and obese. PMH and FHx non-contributory. He does not smoke, drink, or use illicit drugs. He takes no meds. On exam, BP 132/82, HR 80, and BMI 32. Labs show total cholesterol 251, LDL 172, HDL 35, TG 220, HbA1c 5%. Estimated 10 year risk for ASCVD is 3.4%

Question 1 Which of the following is the most appropriate management of this patient’s hyperlipidemia? A: Ezetimibe B: High-intensity rosuvastatin C: Moderate intensity rosuvastatin D. Niacin E: Therapeutic Lifestyle modification

Question 1 Which of the following is the most appropriate management of this patient’s hyperlipidemia? A: Ezetimibe B: High-intensity rosuvastatin C: Moderate intensity rosuvastatin D. Niacin E: Therapeutic Lifestyle modification This patient has hyperlipidemia but without clinical atherosclerotic cardiovascular disease, DM, LDL >190 or elevated 10 year risk for ASCVD. Therapeutic lifestyle changes is the primary intervention for prevention of ASCVD.

Question 2 80 yo M was hospitalized for a 5 day history of acute leg ischemia treated with angioplasty and stenting. Now asymptomatic. PMH significant for CKD stage III and HTN on diltiazem, lisinopril, ASA and plavix. Exam is normal. Labs: AST 20, Total cholesterol 170, LDL 97, HDL 44, Cr. 1.8, TG 147 and GFR 35

Question 2 Which of the following is the most appropriate therapy for secondary prevention of cardiovascular disease in this patient? A: High intensity rosuvastatin B: Moderate intensity rousvastatin C: Niacin D: No additional Treatment

Question 2 Which of the following is the most appropriate therapy for secondary prevention of cardiovascular disease in this patient? A: High intensity rosuvastatin B: Moderate intensity rousvastatin C: Niacin D: No additional Treatment Patient has clinical ASCVD and therefore needs treatment. Usually you would start a high intensity statin, however he has risk factors for statin-associated adverse effects because of his age >75yo, CKD, and medication interaction (diltiazem)

Question 3 48 yo M evaluated during follow up appointment. 3 months ago, he had a STEMI and underwent PCI with bare metal stent of Left circumflex artery. He was started on high intensity rosuvastatin at the time. LFT’s normal and Cr level was normal. He is now asymptomatic, no chest pain or muscle pain.His meds are aspirin, metoprolol, lisinopril, rosuvastatin, and plavix. Exam and vitals normal. No muscle or abdominal tenderness.

Question 3 Which of the following is the most appropriate laboratory study to obtain at this visit? A: Alanine aminotransferase level B: Creatine Kinase Level C: Fasting Lipid Panel D. High sensitivity C-reactive protein level

Question 3 Which of the following is the most appropriate laboratory study to obtain at this visit? A: Alanine aminotransferase level B: Creatine Kinase Level C: Fasting Lipid Panel D. High sensitivity C-reactive protein level Repeat fasting lipid panel should be obtained 1-3 months after initiation of statin therapy to determine medication adherence and effectiveness of treatment (50% or more LDL reduction from the pre-treatment baseline)

Conclusions: Test: men >35yo and women >45yo at increased risk Who to treat: Clinical ASCVD, LDL >190, All Diabetics w/o clinical ASCVD, 10 year ASCVD risk >7.5% Management: Lifestyle modification, and statin therapy. Intensity depends on age, and which group you are treating Labs: Get FLP and ALT prior to treatment, and repeat FLP 1-3 months after you start, 3-12 months thereafter Only get ALT or CK if patient has symptoms Consider: lower dose of statin if renal impairment, older age, transaminitis, hemorrhagic stroke, or Asian background

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