Diagnosis
HDL screening starts at age
Adults age 20 y.o. and older every 4-6 years
More frequent testing in patients with risk factors (diabetes, high ASCVD risk, etc..)
Patients 40-75 y.o. with an LDL of ≥70 mg/dL and this condition are started on a statin
Diabetes
High intensity statins and doses
Atorvastatin 40 and 80 mg
Rosuvastatin 20 and 40 mg
Statin without renal dose adjustments
Atorvastatin
OTC product that contains a chemical structure similar to lovastatin
Red yeast rice
Triglyceride cut off for Friedewald equation
>400 mg/dl
Formula that estimates LDL
LDL-C= TC - HDL - (TGs/5)
Patients with a history of clinical ___ are started on a statin
ASCVD
LDL-lowering of high, moderate, and low intensity statins
High= 50%
Moderate= 30-49%
Low= 30%
Statins are held when LFTs are...
3x ULN
Lipid panel component most greatly reduced by fibrates
Triglycerides
MOA: induction of lipoprotein lipolysis, induction of hepatic fatty acid uptake, increase in HDL production
What are the values of normal lipid panel
TC <200mg/dl
TG <150 mg/dl
HDL 40-60 mg/dl
LDL 60-130 mg/dl
Regardless of other conditions a statin is started in patients 40-75 years old with an ASCVD risk score of
≥7.5%
Statin with highest risk of myalgia
Atorvastatin and simvastatin- higher lipophilicity
Time to wait to repeat a lipid profile after starting or changing a statin
4-12 weeks
2nd line HLD treatment can lead to a 15-30% reduction in serum LDL but its use is precluded in patients with a fasting TG >300mg/dL
Bile acid sequestrants
increase in TG
Measures the amount of calcium buildup in the coronary arteries and indicates the potential presence of plaque and therefore the risk of heart disease
Coronary artery calcium "CAC" score
0: No calcium deposits, low risk of heart attack
1–10: Small amount of plaque, low risk of heart attack
11–100: Some plaque, mild heart disease, moderate risk of heart attack
101–400: Moderate amount of plaque, moderate to high risk of heart attack
Over 400: Large amount of plaque, high risk of heart attack
Regardless of other conditions, patients with this LDL are started on a statin
LDL ≥190 mg/dL
Statins to take in the evening
Simvastatin and lovastatin and fluvastatin
Maximize the effects of statins with shorter half-lives. Greatest drug concentrations would occur during peak endogenous cholesterol synthesis
Drugs that can cause secondary acquire HLD
Steroids, diuretics, beta-blockers
Zetia's place in therapy
-Clinical ASCVD and very high risk + LDL ≥ 55
-Clinical ASCVD not at very high risk or clinical ASCVD and baseline LDL ≥190 + LDL ≥70
-No clinical ASCVD with diabetes and/or 10-year ASCVD risk ≥20% + LDL ≥70
-No clinical ASCVD with baseline LDL ≥190 + LDL >100
According to ACC what is this patients LDL goal?
Patient GS is a 70yo male with PMH significant for T2DM, MI (2022), HTN, and gout presenting in clinic for a routine visit.
Current med list: Pravastatin 20mg once daily, ezetimibe 10mg once daily, Metforming 1000mg twice daily, insulin glargine 10U at bedtime, and allopurinol 100mg once daily
Lipid panel: TC= 180 mg/dL, TG= 180 mg/dL, HDL= 50 mg/dL, LDL= 94 mg/dL
<55 mg/dL
Major ACVD events: Recent ACS (within last 12 m), hx of MI, hx of ischemic stroke, symptomatic PAD
High-risk conditions: >65 y.o., heterozygous familial hypercholesterolemia, hx of prior CABG or PCI, diabetes, HTN, CKD (eGFR 15-59), current smoking, elevated LDL (>/= 100 despite max tolerated statin and ezetimibe, hx of congestive HF
What are some ASCVD risk factors in this patient?
AK is a 58 y.o. white male with a PMH of T2DM (~3 years ago), HTN (~5 years ago)
Current meds: Metformin 1000 mg BID and lisinopril 20 mg QD
Family history: father had a heart attack at 60 y.o.
Social history: 1-2 alcoholic drinks per weekend. Never smoked
Past labs:
LDL: 145 mg/dL
HDL: 35 mg/dL
Total cholesterol: 230 mg/dL
Triglycerides: 180 mg/dL
Blood pressure: 130/85 mmHg
Blood glucose: 130 mg/dL
Age, diabetes, HTN, cholesterol, current HTN treatment, race, family history
Statin with lowest risk of myalgia
Pravastatin- highly hydrophilic
other: rosuvastatin
Pneumonic for significant drug interactions with statins
G- PACMAN (*CYP3A4)
Grapefruit
Protease inhibitors
Azole antifungals
Cyclosporin, cobicistat
Macrolides (except azithromycin)
Amiodarone
Non-DHP CCBs
HLD agent is approved for secondary prevention of ASCVD and familial hypercholesterolemia with a MOA that prevents the production of PCSK9
Leqvio (inclisiran)
Dosing: initial 284 mg as a single injection, again at 3 months, then every 6 months