Hyperlipidemia - Primary Prevention

Groups who may not benefit from lipid-lowering therapy for primary prevention

• Age 0-19 (unless familial hypercholesterolemia)

• Age 20-39 (unless family history of premature ASCVD or LDL-C > 160 mg/dL)

• Patients over 75 (unless risk discussion warrants treatment)

groups who benefit from lipid-lowering therapy for primary prevention

• All patients with LDL-C > 190 mg/dL

• Patients 40-75 years WITH DIABETES

• Patients 40-75 years with LDL-C > 70 - < 190 mg/dL WITHOUT DIABETES (dependent ASCVD-risk)

How to choose between ezetimibe and PCSK-9 inhibitors

• Choose ezetimibe if patient needs <25% additional LDL-C lowering (after lipid panel)

  • Cost and lack of injection as well

• Choose PCSK-9 inhibitor if patient needs > 25% additional LDL-C lowering (after lipid panel)

  • Patient preference

How to choose between bempedoic acid and inclisiran

• Choose bempedoic acid if patient needs <17% additional LDL-C lowering

  • Lack of inject <3

• Choose inclisiran if patient needs > 17% additional LDL-C lowering

  • Desire for twice yearly dosing regimen

What cannot be taken with inclisiran?

PCKS-9 inhibitors

Can adults 40-59 with 10% or greater 10-year CVD risk begin aspirin as primary prevention?

Yes, but the evidence indicated that the net benefit of aspirin use in this group is small

Can adults 60 years and older take aspirin as primary prevention?

No, it is recommended against initiating low-dose aspirin use for the primary prevention of CVD

Do you need to do an ASCVD risk score for patients with LDL-C > 190 mg/dL?

No need- these patients are at very high risk of ASCVD events due to their lifetime exposure to markedly elevated LDL-C levels

Therapy goals for patients with LDL-C > 190 mg/dL?

Lower LDL by > 50%

Get LDL-C < 100 mg/dL

Get Non-HDL-C < 130 mg/dL

Medication steps for patients with LDL-C > 190 mg/dL?

• First-line Medication = High-Intensity statin

• Second-line Medication = consider ezetimibe and/or PCSK-9 inhibitor

• Third-Line Medication = may consider bempedoic acid or inclisiran

Are patients 40-75 with diabetes and a 10-year ASCVD risk score >7.5% OR diabetes-specific risk enhancers high risk?

Yes! These patients are at risk of ASCVD events, and additional assessments need to be done to determine just how high their risk is. (The 10-year ASCVD risk score > 7.5% or diabetes-specific risk enhancers make these patients HIGH RISK CATEGORY)

Therapy goals for high-risk diabetes patients between 40-75 with a 10-year ASCVD score of < 20%?

Lower LDL by > 50%

Get LDL-C to < 100 mg/dL

Get Non-HDL-C to < 130 mg/dL

Therapy goals for high-risk diabetes patients between 40-75 with a 10-year ASCVD score of > 20%?

Lower LDL by >50%

Get LDL-C to < 70 mg/dL

Get Non-HDL-C < 100 mg/dL

Treatment options for high-risk diabetic patients 40-75?

First-line medication = high intensity statin

second-line medication = ezetimibe

Therapy goals for patients 40-75 with diabetes that are NOT high risk?

Lower LDL by > 30-49%

Get LDL-C to < 100 mg/dL

Get Non-HDL-C to < 130 mg/dL

Treatment options for patients 40-75 with diabetes that are NOT high risk?

first-line medication = moderate-intensity statin

second-line medication = high-intensity statin

third-line medication = add ezetimibe

Treatment options for patients 40-75 with LDL-C > 70 to < 190 mg/dL and an ASCVD risk score of <5% (low risk)

• First discuss risk/risk factors with the patient, emphasize lifestyle to reduce ASCVD risk!

• Then if risk-enhancing factors present, can consider a moderate-intensity statin for the patient

Treatment options for patients 40-75 with LDL-C > 70 to < 190 mg/dL and an ASCVD risk score of 5% - 20% (borderline and intermediate risk)?

First line = if risk enhancers present, put patient on moderate intensity statin

second line medication = high-intensity statin

Therapy goals for patients 40-75 with LDL-C > 70 to < 190 mg/dL and an ASCVD risk score of 5% - 20% (borderline and intermediate risk)?

Lower LDL by > 30-49%

Get LDL-C to < 100 mg/dL

Get Non-HDL-C < 130 mg/dL

Treatment options for patients 40-75 with LDL-C > 70 to < 190 mg/dL and an ASCVD risk score of > 25%?

first-line medication = high intensity statin

second-line medication = ezetimibe

Therapy goals for patients 40-75 with LDL-C > 70 to < 190 mg/dL and an ASCVD risk score of > 25%?

Lower LDL > 50%

Get LDL-C < 70 mg/dL

Get Non-HDL-C < 100 mg/dL

Treatment for adults with LDL > 190 mg/dL and unable to tolerate statins

first-line medication = ezetimibe or PCSK-9 inhibitor

second-line medication = bempedoic acid or inclisiran

Adults 40-75 with diabetes and unable to tolerate statins?

first-line medication = ezetimibe

second-line medication = bile acid sequestrant

third-line medication = bempedoic acid

Adults 40-75 with LDL-C > 70 to < 190 mg/dL and unable to tolerate statins?

first-line medication = ezetimibe

second-line medication = bile acid sequestrant

third-line medication = bempedoic acid