(6) Dyslipidemia Plan and Follow-up

Patient discussion topics: Shared decision making

• prioritize what the patient understands

• invite patient to ask questions, express values, preferences

• ascertains patient’s ability to adhere to lifestyle changes

• provide patient education materials

• develop smart goals

• collaborate with patient on follow-up plan

Heart Healthy diet for all

• eat a wide variety of fruits and vegetables

• chose whole grain products

  • barley, brown rice, buckwheat, oatmeal, popcorn, quinoa

• select lean protein choices

  • nuts, legumes, seafood, low-fat dairy, lean meat and poultry

• Pick foods that are made with non-tropical vegetable oils

  • canola, corn, olive, soybean, sunflower

• Minimize processed foods

• minimize added sugars

  • men no more than 35 g, women no more than 25 g

• decrease salt intake

• limit alcohol

foods to avoid

• baked goods

• foods fried in hydrogenated oils

Exercise

• patients should determine ability

• engage in 150 mins of moderate intensity aerobic activity

• engage in 75 mins of vigorous activity

• move more and sit less throughout the day: slow walking, cooking, light house work

• incorporate strength training, stretching and flexibility

considerations for treatment of dyslipidemia

• adherence to lifestyle modifications and evidence based, guideline directed therapy

• risk enhancing factors

• clinician-patient decisions about benefits, harms, and preferences

• percentage LDL-C reduction and absolute LDL or non-HDL levels achieved

• costs of therapy

• adverse effects

• persistent hypertriglyceridemia

Tips for the approach

• all patients should implement lifestyle modifications

• remember LDL goals are simple but risk determination may not be

  • < 100 mg/dl; <70 mg/dl; <55 mg/dl

• Non-HDL goal is 30 mg/dl higher than LDL goal

• statin intensity identifies dose

• to acheive goal of < 70 mg/dl a secondary agent is typically needed

• additional therapy is typicall added as ezetimibe, then PCSK9, then bempedoic acid but this varies depending on population

how to refer to the guidelines

2026 ACC/ AHA dyslipidemia guidelines

Primary Prevention

No Diabetes, NO genetics, No ASCVD

Primary prevention for Low risk (< 3%)

• lifestyle modifications

• use statin if LDL is 160-189 mg/dl

• Moderate intensity statin (if needed)

• Goal LDL reduction: >30%

• LDL goal < 100 mg/dl

• Non-HDL goal <130 mg/dl

• goal achived: monitor and continue

Primary prevention borderline risk (3-5%)

• lifestyle modifications

• statin use: yes; but if unsure consider CAC and if greater than 0 give statin

• Moderate intensity

• Goal LDL reduction: >30%

• LDL goal: <100 mg/dl

• Non-HDL goal:< 130 mg/dl

• Goal achieved: monitor and continue, repeat CAC in 3-7 years if statin isn’t used

Primary Prevention: Intermediate risk (5-10%)

• lifestyle modifications

• statin use: yes

• Moderate to high intensity

• Goal LDL reduction: 30-50%

• LDL goal: <100 mg/dl

• Non-HDL goal: <130 mg/dl

• Goal achieved: monitor and continue

Primary prevention: high risk (>10%)

• lifestyle modifications

• statin use: yes

• high intensity

• Goal LDL reduction: >50%

• LDL goal: <70 mg/dl

• Non-HDL goal: <100 mg/dl

• Goal achieved: Add ezetimibe if not at goal, then PCSK9 or bempedoic acid if needed

Severe Hypercholesterolemia: NO ASCVD, w/o RF, HeFH or subclinical atherosclerosis

• statin intensity: max tolerated

• LDL Goal: <100 mg/dl

• Non-HDL Goal: <130 mg/dl

• Goal Achieved: add ezetimibe, PCSK9 mAb or bempedoic acid

• Alternatives: Inclisiran as alt. for mAb

Severe Hypercholesterolemia: No ASCVD but WITH HeFH or RF or subclinical atherosclerosis

• statin intensity: max tolerated

• LDL Goal: <70 mg/dl

• Non-HDL Goal: <100 mg/dl

• Goal Achieved: add ezetimibe, PCSK9 mAb or bempedoic acid

• Alternatives: Inclisiran as alt. for mAb

Severe Hypercholesterolemia: with ASCVD

• statin intensity: max tolerated

• LDL Goal: <55 mg/dl, ApoB <55 mg/dl

• Non-HDL Goal: <85 mg/dl

• Goal Achieved: add ezetimibe, PCSK9 mAb or bempedoic acid

• Alternatives: Inclisiran as alt. for mAb

Severe Hypercholesterolemia: with HoFH

• statin intensity: max tolerated

• Additional medication: add PCSK9 mAb +/ or bempedoic acid and monitor response

• LDL at goal of <100 mg/dl

• No: add evinacumab and monitor

• Still not at goal? add lomitapide and monitor hepatic function

Diabetes and no ASCVD: 20-39 years old (diabetes risk enhancers present)

• Statin intensity: moderate

• Goal LDL reduction: >30%

• LDL goal: <100 mg/dl

• Non-HDL goal: <130 mg/dl

• Goal acheived: monitor and continue

Diabetes and no ASCVD: 30-39 years old (10 y prevent score 3-10%)

• Statin intensity: moderate

• Goal LDL reduction: >30%

• LDL goal: <100 mg/dl

• Non-HDL goal: <130 mg/dl

• Goal acheived: monitor and continue

Diabetes and No ASCVD: 40-75 (10 y prevent score < 10%)

• Statin intensity: moderate

• Goal LDL reduction: >30%

• LDL goal: <100 mg/dl

• Non-HDL goal: <130 mg/dl

• Goal acheived: monitor and continue

• A

Diabetes and No ASCVD: 40-75 years (10 y PREVENT score > 10% or multiple ASCVD risk factors)

• Statin intensity: high

• Goal LDL reduction: > 50%

• LDL goal: <70 mg/dl

• Non-HDL goal: <100 mg/dl

• Goal acheived: If LDL < 100 mg/dl and TG is 150-500 then add IPE

Diabetes and no ASCVD: 75+

• risk enhancers: engage in benefit risk discussion

• Statin intensity: moderate

• Goal LDL reduction: >30%

• LDL goal: <100 mg/dl

• Non-HDL goal: <130 mg/dl

• Goal acheived: monitor and continue

Dyslipidemia risk enhancers: diabetes

• long duration of diabetes

  • >10 years for T2DM

  • >20 years for T1DM

• Albuminuria

  • >30 ug of albumin/ mg of creatinine

• eGFR

  • < 60

• Retinopathy

• Neuropathy

• ABI < 0.9

Dyslipidemia risk enhancers: Genetic

• premature ASCVD in parent/sibling

  • < 55 in men

  • < 65 in women

• Ancestry: south asian or filipino

• LDL > 160-189 persistently

• Non-HDL > 190-219

Dyslipidemia risk enhancers: Other

• chronic inflammation, lupus, RA, advanced psoriasis, inflammatory arthritis

• CKM syndrome

• reproductive risk

• Lp(A) > 50 mg/dl

• hsCRP > 2 mg/dl

• TG> 175 nonfasting

When to use a moderate statin in secondary prevention

those older than 75 with clinical ASCVD and evaluation for adverse effects, drug interactions, and preference

When to use a low to moderate statin in secondary prevention

• when high intensity statin is contraindicated

• patient has statin associated side effects but needs LDL reduction of 30-40%

When to use a high statin in secondary prevention

to achieve 50% or greater reduction in LDL

M > 40/ W >45 with subclinical atherosclerosis but no ASCVD: CAC: 1-99 au (< 75th percentile for age, race, sex)

• statin intensity: moderate

• goal LDL % reduction: 30-49%

• LDL goal: < 100 mg/dl

• non-HDL goal: < 130 mg/dl

• Goal achieved: monitor and continue

M > 40/ W >45 with subclinical atherosclerosis but no ASCVD: CAC: 100-299 au

• qualifier: > 75th percentile for age, sex, race

• statin intensity: High

• goal LDL % reduction: > 50%

• LDL goal: <70

• non-HDL goal: <100

• Goal achieved: monitor and continue

M > 40/ W >45 with subclinical atherosclerosis but no ASCVD: CAC: 300-999

• qualifier: severe

• statin intensity: high

• goal LDL % reduction: >50%

• LDL goal: < 70 mg/dl, apob < 70 mg/dl

• non-HDL goal: <100 mg/dl

• Goal achieved: monitor and continue

M > 40/ W >45 with subclinical atherosclerosis but no ASCVD: CAC >1000

• qualifier: extensive

• statin intensity: high

• goal LDL % reduction: >50%

• LDL goal: <55 mg/dl, ApoB <55 mg/dl

• non-HDL goal: <85 mg/dl

M > 40/ W >45 with subclinical atherosclerosis but no ASCVD: incidental (mild CAC)

• statin intensity: moderate

• goal LDL % reduction: >30%

• LDL goal: <100 mg/dl

• non-HDL goal: <130 mg/dl

• Goal achieved: monitor and continue

M > 40/ W >45 with subclinical atherosclerosis but no ASCVD: incidental (2)

• qualifier: moderate to severe

• statin intensity: moderate to high

• goal LDL % reduction: > 50%

• LDL goal: <70 mg/dl

• non-HDL goal: <100 mg/dl

Statins and Muscle toxicity

• myalgia: muscle ache or weakness

• myositis: muscle symptoms with increase CK (CK>ULN)

• Rhabdomyolysis: muscle symptoms with CK levels > 10x upper limit of normal and with creatinine elevation (dark urine, urinary myoglobin) and renal injury

Statin Associated muscle symptom risk

• age > 65

• low body mass index

• female

• obesity

• hypothyroidism

• diabetes

• chronic liver disease

• chronic kidney disease

• alcohol consumption

• vigorous exercise

• high dose statin therapy

• disease associated with muscle weakness

How can statin associated muscle symptoms be prevented

• identify potential predisposing symptoms

• consider history of med intolerance

• screen for drug interactions

how should statin associated muscle symptoms be handled

• thoroughly assess the symptoms

• consider non-statin causes and predisposing factors

  • thyroid panel

  • hepatic panel

  • electrolyte panel

  • renal panel

  • vitamin D

• If the patient has renal injury or is identified with elevations in CK then send to ER for admission and ICU treatment

Strategy for statin associated side effects

• discontinue statin and wait for symptom resolution (about 2 weeks)

• reassess patient

• Rechallenge patient to achieve maximal LDL with a modified dose regimen, an alternate statin, or combination with a nonstatin therapy

  • try low dose of alternative statin

  • if low dose is tolerated then increase slowly

  • consider bempedoic acid, ezetimibe, PCSK9 mAb

• If issues occur with second statin then discontinue and seek alternative

30-75 with secondary ASCVD at very high risk

• Statin intensity: high intensity or maximally tolerated

• LDL % reduction goal: >50%

• LDL goal: <55 mg/dl; optional ApoB goal <55 mg/dl

• Non-HDL goal: <85 mg/dl

• Goal not achieved: add ezetimibe or PSCK9 mAb

  • if not able add Inclisiran

  • if still not at goal add bempedoic acid

Adults with Hypertriglyceridemia and ASCVD

• secondary causes: identify and manage

• Lifestyle modification: optimize diet, physical activity, alcohol intake, manage weight

• Lipid lowering therapy: maximize statin and other LDL lowering therapies to meet LDL goals

• Persistent fasting hypertrigylceridemia: >150-499

• Continued lipid elevation: LDL < 100 mg/dl and non HDL<130 on max tolerated statin

• Additional meds: intensify LDL lowering therapy and add icosapent ethyl

Adults with hypertriglyceridemia and NO ASCVD or diabetes

• secondary cause: identify and manage

• lifestyle modifications: optimize diet, physical activity, alcohol intake, manage weight

• Persistent fasting hypertrigylceridemia: >150-499

• Assess risk: calculate 10 year risk score

• Next steps: discuss risk and benefit with lifestyle and maximize LDL lowering therapy

Adults with hypertriglyceridemia with TG > 500 mg/dl

• secondary cause: identify and manage

• lifestyle modifications: optimize diet, physical activity, alcohol intake, manage weight

• lipid lowering therapy: maximize statin

• Persistent fasting hyperglycemia: >150-499

• Assess risk: have risk benefit discussion, maximize statin and other lipid lowering therapies, optional apoB levels

• Add therapy: intensify LDL lowering therapy

  • add fibric acid derivatives or prescription omega 3 fatty acids to lower TG level and risk of pancreatitis

Adults with hypertriglyceridemia with TG > 1000 mg/dl

• secondary cause: identify and manage

• lifestyle modifications: optimize diet, physical activity, alcohol intake, manage weight

• referral: lipid specialist

• Add therapy: intensify LDL lowering therapy

  • add fibric acid derivatives or prescription omega 3 fatty acids to lower TG level and risk of pancreatitis

• therapy escalation: add olezarsen to lower triglycerides and risk of pancreatitis

Other patient categories

• use primary prevention adults ages 40-75 years old regardless of LDL level in

  • those with diabetes

  • CKD stage 3 or 4

  • those with HIV on stable antiretroviral therapy

• After age 75 consider in conjunction with lifestyle to decrease ASCVD risk with consideration of life expectancy

Laboratory follow up

• draw lipid profile

  • 4-12 weels after initiation or dose adjustment

  • every 6-12 months after to determine adherance

• determine therapy response

  • consider ASCVD risk

  • % reduction in LDL from baseline

  • achievement of LDL and non HDL goals

  • medication used

  • patient adherance