Lipids Part I - Patient Evaluation

What has changed as guidelines updated?

1. less focus on specific lipid goals

2. new risk estimation calculator

3. treatment recommendations focus on specific "benefit groups"

4. use of statins based on potency/intensity

5. 2022 guidelines place focus back on LDL goals

Coronary Heart Disease (CHD), clinical ASCVD major events, consist of?

1. acute coronary syndromes (MI, stable/unstable angina)

2. revascularization (stent placement via heart catheterization, coronary artery bypass grafting CABG)

3. stroke/TIA

4. peripheral arterial disease (symptomatic; previous revascularization or amputation, intermittent claudication)

What are the 4 statin benefit groups?

1. severe hypercholesterolemia (LDL > 190 mg/dL)

2. diabetes mellitus in adults 40-75 years with LDL < 190 mg/dL

3. no diabetes mellitus in adults 40-75 years with LDL < 190 mg/dL

4. secondary prevention

_____ prevention: patients at risk but who have not experienced their first CV event

primary

______ prevention: patients who already manifest vascular disease (aka clinical ASCVD)

secondary

What is the recommendation for those with severe hypercholesterolemia?

1. no risk assessment

2. high-intensity statin

3. LDL goal < 100 mg/dL

In primary prevention patients with severe hypercholesterolemia, if LDL remains > 100 mg/dL on max tolerated statin therapy, addition of ______ is reasonable.

Ezetimibe

In primary prevention severe hypercholesterolemia patients, if LDL remains > 100 mg/dL on max tolerated statin therapy + Ezetimibe & the patient has multiple risk factors, a ______ may be considered.

PCSK-9 Inhibitor

Primary prevention patients with severe hypercholesterolemia have LDL levels > _____ mg/dL.

190

What is the recommendation for primary prevention patients with diabetes (40-75 years with LDL < 190 mg/dL)?

1. start moderate intensity statin therapy without calculating 10-year ASCVD risk

2. in patients at higher risk (10 year risk score > 7.5%), especially those age 50-75 with multiple risk factors, start high intensity statin & reduce LDL by > 50%

What are diabetes-specific risk enhancers?

1. long duration (> 10 years for T2 or > 20 years for T1)

2. albuminuria > 30 mcg albumin/mg creatinine

3. eGFR < 60 mL/min/1.73m2

4. retinopathy

5. neuropathy

6. ankle brachial index < 0.9

Buildup of ______ is a sign of atherosclerosis or ischemic heart disease.

calcium

A coronary calcium (CAC) scan is a CT scan of your heart that detects & measures the amount of calcium in the walls of your _______?

coronary arteries

When may a CAC score be used to determine if statin therapy is warranted?

when there is clinical uncertainty regarding recommendation based off 10-year ASCVD risk score

What is the LDL goal for VERY high risk patients?

< 55 mg/dL

What is the LDL goal for high risk patients?

< 70 mg/dL

What do the guidelines classify as a major ASCVD event?

1. recent ACS (within the past 12 months)

2. history of MI (other than recent ACS)

3. history of ischemic stroke

4. symptomatic peripheral arterial disease

What do the guidelines classify as high-risk conditions?

1. age > 65

2. heterozygous familial hypercholesterolemia

3. history prior CABG or PCI outside of major ASCVD event

4. diabetes

5. hypertension

6. chronic kidney disease

7. current smoking

8. persistently elevated LDL-C (> 100 mg/dL despite max tolerated statin + Ezetimibe)

9. history of CHF

Primary Prevention LDL > 190 mg/dL?

1. high intensity statin

2. > 50% reduction in LDL

3. LDL < 100

Adults with diabetes 10-yr risk < 7.5%?

1. moderate intensity statin

2. 30-49% reduction in LDL

3. LDL < 100

Adults with diabetes 10-yr risk 7.5-20%?

1. high intensity statin

2. > 50% reduction in LDL

3. LDL < 100

Adults with diabetes 10-yr risk > 20%?

1. high intensity statin

2. > 50% reduction in LDL

3. LDL < 70

Secondary prevention high risk?

1. high intensity statin

2. > 50% reduction in LDL

3. LDL < 70

Secondary prevention very high risk?

1. high intensity statin

2. > 50% reduction in LDL

3. LDL < 55

If patients develop 2 consecutive LDL levels < ____ mg/Dl, clinical judgment should be used to determine whether deintensification of lipid lowering regimen is warranted.

25

Non-pharmacologic recommendations?

1. diet emphasizing intake of vegetables, fruits, legumes, whole grains & fish (i.e. DASH, USDA food pattern, AHA diet)

2. avoid processed meats, refined carbs, sweetened beverages

3. reduce sodium & cholesterol

4. engage in at least 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic per week

What statin benefit groups is a 10-year ASCVD risk score needed for?

1. diabetes

2. no diabetes