Outpatient / Cardiology
Hyperlipidemia
#Hyperlipidemia
Current LDL: ***
At Goal?: ***
ASCVD Risk: ***
Indications for Statin
-- ASCVD (h/o CAD, stroke/TIA, ACS, PAD, h/o revascularization) - high-intensity
-- LDL >190 (followed by ) - high-intensity
-- Diabetes (age 40-75) - moderate-intensity
-- Age 40-75 based on ASCVD risk
- <5% risk - lifestyle changes only
- 5.0-7.5% risk - mod-intesity statin
- 7.5-19.5% risk - statin goal 30% reduction in LDL
- >20% risk - statin goal 50% reduction in LDL
Plan:
-- Statin: ***
- High intensity - atorva 40-80mg; rosuva 20-40mg
- Moderate intensity - atorva 10-20, rosuva 5-10, simva 20-40, prava 40-80
- Low intensity - simva 10, prava 10-20
- Rosuva and atorva are most potent, atorva safe in CKD, prava safe in cirrhosis, prava best to avoid myopathy, prava and rosuva least side effects overall
-- Add Ezetimibe or PCSK9 if LDL still >100 after statin or statin intolerance
-- Lifestyle: weight loss, exercise, smoking cessation, limit EtOH, low saturatedand trans fat diet
-- Workup: f/u LFTs before starting statin; consider sending A1c, U/A, BMP
-- Monitoring: Assess LDL q3-12 months ***
-- Refer: if c/f FHx or considering initiation of PCSK9i (LDL >90 even with statin and ezetimibe and high risk factors)
Template Coming Soon!
Patient Guidance and Information
New Diagnosis - Lifestyle Changes
Our labwork suggests you have elevated ***. We call this hyperlipidemia ***.
Other ways to lower cholesterol include lifestyle changes such as following a low saturated and trans fat diet, weight loss, exercise, smoking cessation, and limiting alcohol intake.
You can learn more about such lifestyle changes here.
New Diagnosis - Treatment
Our labwork suggests you have elevated ***. We call this hyperlipidemia ***.
Based on this, and your history of ***, we would like to start you on a medication called ***. The benefits of taking this medicine include reducing the risk of having a heart attack or stroke over the next decades of your life.
Please take ***mg, ***.
Some side effects of *** can include *** muscle pains called myalgias or elevated liver enzymes. Before you are treated, we’d like to send lab work to assess your liver function. Please let us know if you experience any severe muscle pains once you start the medication.
Once you start treatment, we will plan to follow up with a repeat lipid testing in *** weeks to assess its efficacy and decide on dosing or the need for other medicines.
If You Remember Nothing Else
Addressing hyperlipidemia is about playing the long game and reducing life-time risk of having a cardiovascular event, namely macrovascular ACS/MI. The ASCVD risk is largely driven by age and thus many patients will end up on statins in their 50's and beyond. You should risk stratify to determine which statin to use and precribe additional medications if the patient is not at goal despite lifestlye changes and statin use.
Clinical Pearls
- Screen adults 20-39 q4-6 years, 40-75 q3-12 months and assess 10-year ASCVD risk
- Repeat the screen when patient is fasting if the triglycerides are >440
- Hyperlipidemia can be elevated total cholesterol, LDL, or triglycerides; dyslipidemia can mean high LDL or low HDL
- Hypercholesterolemia prevalence in U.S is ~50% - more commonly acquired
- Most common inherited causes are Type II hyperlipoproteinemia (defective LDL receptors) or Type IV hyperlipoproteinemia (overproduction of VLDL) - both are Autosomal Dominant and lead to premature atherosclerosis
- Secondary causes of HLD are hypothyroidism, diabetes, nephrotic syndrome, CKD, meds (thiazides, antipsychotics, steroids), alcohol use, and liver disease
- Statins - can lower LDL 20-60%; decreases CV events (NNT 91) - check AST/ALT before starting
- Statin is a HMG-CoA reductase inhibitor and can cause LFT elevations, myalgias, and in rare cases rhabdomyolysis
- Statin myalgia/myopathy is more likely to be muscle aches in bilateral proximal muscles with onset within weeks of initiation; CK should be normal
- If statin intolerance - hold until symptoms resolve, trial lower dose or alternative (pravastatin lower risk), go to every other day dosing with aotrva or rosuva, or trial ezetimibe
- Ezetimibe - when statin-intolerant OR LDL <50% reduction with statin - lowers LDL 23%, decreased CV events (NNT 50)
- Ezetimibe decreased intestinal cholesterol absorption
- PCSK9 Inhibitors - degradation of LDL-R on hepatocyte surface - high risk pts with CVD and LDL >70 even with statin and ezetimibe OR FHx - lowers LDL 38-72% - decreases CV events (NNT ~67), $$$
- Omega 3 Fatty Acids - vascepa (EPA) - hypertTG, CVD prevention - when added to statin decreased CV events (NNT 2); Vascepa is icosapent ethyl, a highly purified eicosapentaenoic acid (EPA) ethyl ester
- Xanthomas are nodular deposits of lipids in the skin and tendons; xanthelasma (around eyes) - also can be in tendons, palms of hands, back
- Nephrotic syndrome leads to hyperlipidemia due to loss of protein in urine, and decrease in oncotic pressure leads the liver to increase the production of lipoproteins; liver damage that disrupts the enterohepatic circulation and fat metabolism leads to elevated cholesterol levels
Trials and Literature
- HOPE-3 Trial - statin for primary prevention in those of intermediate risk without cardiovascular disease - ARR 1.1% in CV events (NNT 91)
- IMPROVE-IT Trial - ezetimibe + statin ARR 2% in CV events (NNT 50)
- FOURIER Trial - evolocumab + statin ARR 1.5% in CV events (NNT 67)
- ODYSSEY Trial - alirocumab + statin ARR 1.6% in CV events
- REDUCE-IT Trial - vascepa (EPA) + statin ARR 4.8% in CV events (NNT 21)
Other Resources
- ASCVD Risk Calculator - 10-year risk of cardiovascular event
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