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

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

3. 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)

4. 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 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.

5. Risk Calculator ASCVD risk <5% = LOW RISK
ASCVD % = INTERMEDIATE
ASCVD >7.5% = HIGH RISK

6. 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 mg/dL
Group 4: 10 year ASCVD risk >7.5%
with LDL mg/dL

7. 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

8. 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

9. 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

10. 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 mg/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

11. 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

12. TEST yourself!

13. 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%

14. 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

15. 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.

16. 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

17. 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

18. 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)

19. 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.

20. 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

21. 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)

22. 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

23. Sources
Stone Nj, Robinson J, Lichtenstein Ah, Bairey Merz Cn, Lioyd-jones Dm, Blum Cb, Mcbride P, eckel Rh, Schwartz Js, Goldberg Ac, Shero St, Gordon D, Smith Sc Jr, Levy D, Watson K, Wilson Pw ACC/AHA Guideline On The Treatment Of Blood Cholesterol To Reduce Atherosclerotic Cardiovascular Risk In Adults: A Report Of The American College Of Cardiology/American Heart Association Task Force On Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. Pii: S
John F. Keaney, Jr., M.D., Gregory D. Curfman, M.D., And John A. Jarcho, M.D. A Pragmatic View Of The New Cholesterol Treatment Guidelines. N Engl J Med 2014; 370: