6: ASCVD Risk Elevation Benefit Group

What 3 groups are treated as primary prevention of ASCVD and why?

1. LDL of 190+

2. diabetes

3. ascvd risk elevation

Because they have not had a clinical ASCVD event yet and we are trying to prevent it

What group is in the secondary prevention of ASCVD category?

clinical ASCVD

What are the 4 ASCVD risk score groups and what are their ranges?

1. low risk: 5% or less

2. borderline risk: 5 - 7.5%

3. intermediate risk: 7.5 - 20%

4. high risk: 20% or more

For which group is a statin not typically indicated?

low risk (5% or less)

What is the treatment pathway for both intermediate and borderline risk?

• check for risk enhancing factors (REFs)

• no? monitor

• yes? consider moderate intensity statin

What is the best way to remember the 8 REFs related to ASCVD risk elevation?

2 c’s, 3 p’s, and RML

What are the 2 C’s of REF?

1. Chronic inflammatory conditions

   • HIV, rheumatoid arthritis, psoriasis

2. CKD

   • eGFR less than 60 w/o dialysis or kidney transplant)

What are the 3 P’s of REF?

1. Premature family history of ASCVD

   • Male: 55 y/o or younger

   • Female: 65 y/o or younger

2. Primary hypercholesterolemia

   • LDL of 160-189

   • Non-HDL of 190-219

3. Premature menopause (40 y/o or younger) and pregnancy-associated conditions that increase ASCVD risk (pre-eclampsia)

What are the RML REFs?

1. Race/Ethnicity (south asian)

2. Metabolic syndrome

3. Lipid biomarkers

To be considered a metabolic syndrome, how many do you have to be diagnosed with?

3

What are the 5 metabolic syndrome diagnoses?

1. increased waist

2. TG > 150

3. elevated BP ( >130/80) or antihypertensive therapy

4. elevated BG (>100 fasting or on treatment)

5. HDL less than 40 in men or less than 50 in women

What are the 5 lipid/biomarkers?

1. persistent TG>175

2. hsCRP of 2 or more

3. lp(a) or 50 or more

4. apoB of 130 or more

5. ABI less than 0.9

What is the treatment pathway for both borderline and intermediate risk after initiating moderate intensity statin?

check for CAC score

What are the 3 groups for CAC scores?

1. 1-99

2. 100 or more

3. 1000 or more

If the CAC score is less than 300, which pathway do you follow?

CAC 1-99

If the CAC score is 300 or more, which pathway do you follow?

CAC 1000 or more

What are the goals for both borderline and intermediate risk following the CAC 1-99 pathway?

• ? intensity statin

• Goal: ? decrease in LDL

• LDL Threshold: ?

• Non-HDL: ?

THEN

• change to ?

• moderate

• 30% or more

• 100 or less

• 130 or less

THEN

• change to high intensity statin

What are the goals for both borderline and intermediate risk following the CAC 1000 or more pathway?

• ? intensity statin

• Goal: ? decrease in LDL

• LDL Threshold: ?

• Non-HDL: ?

THEN

• add ?

THEN

• add?

• high intensity statin

• 50% or more

• 70 or less

• 100 or less

THEN

• add ezetimibe

THEN

• add pcsk9i

What is the treatment pathway for high risk score?

• ? intensity statin

• Goal: ? decrease in LDL

• LDL Threshold: ?

• Non-HDL: ?

THEN

• add ?

• high intensity statin

• 50% or more

• 70 or less

• 100 or less

THEN

• add ezetimibe

For ASCVD risk elevation, if a high intensity statin is not tolerated, what can you do?

substitute for moderate intensity statin with ezetimibe

Monitoring Response: How often should you check lipid panel after initiation or dose adjustment? (FOR ALL BENEFIT GROUPS)

4-12 weeks

Monitoring Response: When should you recheck lipid panel after achieving goal? (FOR ALL GROUPS)

every 3-12 months

Equations: How do you calculate non-HDL?

Non-HDL = TC - HDL

Equations: What equation can be used to calculate LDL if not provided?

Friedwald Equation

LDL = TC - HDL - (TG/5)

Pertaining to ASCVD risk score, when are the only times non-statin therapy is added?

1. when CAC is 1000 or more (intermediate or borderline risk)

2. high risk