Cholesterol Management Guidelines
12 likes4,525 views
The document provides guidelines for cholesterol management and cardiovascular disease (CVD) risk assessment. It discusses guidelines for measuring cholesterol and lipid levels, calculating LDL and VLDL values, and assessing CVD risk. It recommends starting moderate- or high-intensity statin therapy for most adults aged 40-75 years with diabetes or LDL ≥70 mg/dL. For those without diabetes but with a CVD risk of 7.5% or higher, it recommends discussing statin therapy. The guidelines also provide recommendations for managing statin side effects, evaluating risk factors, and refining risk assessment using coronary artery calcium scoring. The main messages are to emphasize lifestyle changes, use high-intensity statins for high-risk patients, and consider patient risk
Cholesterol Management Guidelines
- 4. Friedewald formula Total cholesterol HDL + LDL + VLDL VLDL TGs (mg/dL) / 5 LDL TC - HDL – (TGs/5) **Not valid if TGs >400** Example: Total cholesterol: 230, TGs: 120, HDL: 25 • First calculate the VLDL: 120/5 = 24 • Then calculate LDL: 230 – (25+24) = 181 mg/dL
- 5. Causes of elevated LDL & TGs
- 6. Measurement of LDL • Adult >20 YO and not on any lipid lowering medications Measure lipid panel (fasting or non-fasting) to estimate ASCVD • If the non-fasting panel showed TGs >400 mg/dL Repeat a fasting panel. • If LDL <70 May measure direct LDL or modified LDL estimate. • If pt has a FHx of premature ASCVD or genetic HLD may start with a fasting panel.
- 9. ASCVD Risk Estimator Clinical ASCVD includes acute coronary syndromes, or a history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin.
- 10. Who is at a very high risk for future ASCVD?
- 11. Severe Hypercholesterolemia (LDL ≥190)
- 12. ASCVD risk management for diabetics
- 13. Which diabetic patient is at a very high risk to develop ASCVD?
- 14. Primary prevention of ASCVD
- 15. Statin use in general risk population (without ASCVD events, LDL >190mg/dl, or diabetes)
- 16. ASCVD risk enhancers These can be used to refine risk assessment in certain individuals at borderline or intermediate risk for ASCVD.
- 17. Statin therapy
- 20. Statin intolerant patients • Myalgia that resolve with discontinuation of statin treatment and occur with rechallenge • Myalgia have been demonstrated with rechallenge on at least 2 or 3 statins, including those with different metabolic pathways, and at least one statin at the lowest approved dose. • Incidence: Ranges from 1-10% • Risk factors: Impaired renal or hepatic function, ALT > 3X the upper limit of normal, age >75, Asian ancestry, or on drugs that affect statin metabolism. • Patients who develop myalgia on a statin should be tried on either a lower dose of the same statin or a different statin, or even dosing the statin once or twice weekly. >90 % will ultimately tolerate statin. • When a high intensity statin is indicated but not tolerated and a moderate intensity statin is used, further LDL lowering may be achieved with ezetimibe or a bile acid sequestrant.
- 21. Statin use in pre-menopausal women I C-LD Women of childbearing age who are treated with statin therapy and are sexually active should be counseled to use a reliable form of contraception. I C-LD Women of childbearing age with hypercholesterolemia who plan to become pregnant should stop the statin 1 to 2 months before pregnancy is attempted, or if they become pregnant while on a statin, should have the statin stopped as soon as the pregnancy is discovered.
- 22. Statin use in CKD patients • In patients with CKD (not treated with dialysis or transplant) with LDL >70 and ASCVD risk of ≥ 7.5% consider initiating moderate intensity statin ± ezetimibe. • In patients with CKD who require dialysis and currently on statin May continue statin. • In CKD patients who require dialysis DON’T start statin for primary prevention (Class III)
- 23. Statin use in chronic inflammatory disorders & HIV • Adults with these conditions and LDL >70 with ASCVD risk of ≥ 7.5% Consider starting moderate or high intensity statin (Class I). • Consider checking a fasting lipid profile before starting therapy and 4-12 weeks after that.
- 24. When to use statin in patients 20 -39 Years old? 1) Severe hypercholesterolemia e.g. LDL ≥190 2) Those with LDL 160-189 plus a family history of premature ASCVD (ASCVD event in men less than 55 and women less than 65)
- 25. Statin use in patients ≥ 75 years old • With clinical ASCVD may initiate moderate or high intensity statin after a thorough discussion and evaluation. • If patient tolerates high intensity statin May continue it.
- 26. Statin safety and side effects • Need to have a discussion with your patient before starting statins regarding potential side effects e.g. SAMS (Statin-associated muscle symptoms). • SAMS include: Myalgia (normal CK), myositis, rhabdomyolysis and autoimmune myopathy (HMG Coenzyme A Reductase AB) • Mild or moderate SAMS Reassess and Rechallenge. • Severe SAMS on rechallenge May start Non-statin therapy • Even in patients with increased risk for DM Continue statin (Class I) • Severe SAMS Measure CK and LFTs • Transaminases elevation > 3x upper normal limit is infrequent • Patient with chronic stable liver disease who has high ASCVD risk get a baseline LFTs and OK to start statin with close follow up (Class I). • Coenzyme Q10 is NOT recommended for routine use or in treatment of SAMS. • Don’t routinely check CK or transaminases in every patient on Statins.
- 28. Management of Hypertriglyceridemia • Adult with moderate hyperTGs (177-499)Address obesity and metabolic syndrome. Treat the secondary factors (DM, CKD, Nephrotic syndrome, chronic liver disease, hypothyroidism and medications that increase TGs • Adult with moderate or severe hyperTGs with ASCVD risk of ≥ 7.5% consider initiating statin therapy. • Adult with fasting TGs ≥1000 Consider adding Fibrate therapy and omega-3 FAs
- 29. Coronary Artery Calcium (CAC) score • Use to refine risk in individuals with borderline to intermediate risk. • Use in patients with intermediate ASCVD risk, but reluctant to start a statin. • Patients ≥55 Years of age who have a CAC of Zero may consider withholding a statin and reassessing in 5-10 years, however statin should be initiated if CAC is more than zero. CAC score Action Zero Treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD 1 – 99 Favors statin therapy, especially in those ≥55 years of age. > 100 Statin therapy is indicated
- 30. Miscellaneous • Individuals from South Asia have increased ASCVD risk. • ASCVD risk is higher among individuals from Puerto Rico than those from Mexico. • Native American/Alaskan populations have high rates of risk factors for ASCVD. • In Asians, Start low dose (5 mg) of rosuvastatin versus 10 mg in whites. • Baseline serum CK values are higher in blacks than in whites. • In adults of East Asian descent, other statins should be used preferentially over simvastatin. • Resistance exercise training will reduce LDL. • Fenofibrate (not gemfibrozil) can be combined with statins if indicated. • Goal LDL in patients with severe hypercholesterolemia (LDL-C>19) is greater than 50% reduction in LDL and resultant LDL<100mg/dl. • Bile acid sequestrants are contraindicated when serum triglycerides >300mg/dl. • All patients with diabetes who are 40 and older should be treated with a statin. • PCSK9 inhibitors have no role in lipid management in patients with DM (unless have established ASCVD or LDL>190mg/dL). • Use high intensity statin if ASCVD risk >20%.
- 31. Take Home Messages - I • In all individuals, emphasize a heart-healthy lifestyle across the life course. • CAC scores can be used in patients up to age 80 • In patients with clinical ASCVD, reduce LDL with high-intensity statins or maximally tolerated statin therapy. • In very high-risk ASCVD, use a LDL threshold of 70 to consider the addition of non-statins to statin therapy. • In patients with LDL ≥ 190, start high intensity statins without calculating 10- year ASCVD risk. • In patients 40 to 75 years of age with DM and LDL>70 mg/dl, start moderate-intensity statin (High intensity if with multiple risk factors) without calculating 10-year ASCVD risk. • In patient 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician–patient risk discussion before starting statin therapy.
- 32. Take Home Messages - II • In patients 40 to 75 years of age without DM, but with LDL≥70 and ASCVD risk of ≥7.5%, start a moderate-intensity statin if patient agrees. • In patients 40 to 75 years of age without DM, but with ASCVD risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statins. • In patients 40 to 75 years of age without DM, but with LDL ≥70, at a 10- year ASCVD risk of 7.5% to 19.9% (intermediate risk), if a decision about statin therapy is uncertain, consider measuring CAC • Assess adherence and percentage response to LDL lowering medications and lifestyle changes with repeat lipid panel in 1-3 months after statin initiation or dose adjustment, repeated every 3 to 12 months as needed. • In patients who smoke, a CAC score of zero does not exclude coronary artery disease. The CAC score is also limited in those with diabetes and those with a family history of early CAD.
- 33. Summary
- 34. Thank You