cholesterol

Question 1

is the leading cause of death of men and women

Answer 1

ASCVD (athloclerotic cardiovascular disease)

Question 2

Risk of developing ASCVD is directly r/t

Answer 2

increases levels of blood cholesterol, in the form of LDL

Question 3

Lower LDL, slow

Answer 3

slow progression of atherosclerosis, reduce risk for serious ASCVD

Question 4

Very-low-density lipoproteins (VLDLs)

Triglycerides – levels above

Answer 4

500mg/dL – increase risk of pancreatitis.

Question 5

Low-density lipoproteins (LDLs) (bad)

Answer 5

Cholesterol primary core lipid

Greatest contributor to coronary heart disease

Question 6

For each 1% reduction in LDL

Answer 6

1% reduction in the risk for a major CV event.

Question 7

High-density lipoproteins (HDLs) (good)

Answer 7

Cholesterol primary core lipid

Carry cholesterol from peripheral tissues back to the liver

Question 8

HDL promotes

Answer 8

cholesterol removal – high HDL levels protect again ASCVD.

Question 9

Risk Factors for ASCVD

Answer 9

Smoking
High blood pressure
Abnormal cholesterol
Diabetes
ASCVD risk status uncertain – a coronary artery calcium test (40 to 75 y.o.)
Risk-enhancing factors (40 to 75 y.o.)

Question 10

Primary hypercholesterolemia

Answer 10

(LDL-C, 160–189 mg/dL [4.1–4.8 mmol/L); non–HDL-C 190–219 mg/dL [4.9–5.6 mmol/L])*

Question 11

Metabolic syndrome

Answer 11

(increased waist circumference, elevated triglycerides [>175 mg/dL], elevated blood pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 in women mg/dL] are factors; tally of 3 makes the diagnosis)

Question 12

CKD

Answer 12

eGFR 15–59 mL/min/1.73 m2 with or without albuminuria; not treated with dialysis or kidney transplantation

Question 13

Chronic inflammatory conditions

Answer 13

such as psoriasis, RA, or HIV/AIDS

Question 14

History of premature menopause

Answer 14

before age 40 y) and history of pregnancy-associated conditions that increase later ASCVD risk such as preeclampsia

Question 15

High-risk race/ethnicities

Answer 15

e.g., South Asian ancestry

Question 16

Lipid/biomarkers

Answer 16

Associated with increased ASCVD risk
Persistently* elevated, primary hypertriglyceridemia (≥175 mg/dL);
If measured:

Question 17

Elevated high-sensitivity C-reactive protein

Answer 17

(≥2.0 mg/L)

Question 18

Elevated Lp(a):

Answer 18

A relative indication for its measurement is family history of premature ASCVD. An Lp(a) ≥50 mg/dL or ≥125 nmol/L constitutes a risk-enhancing factor especially at higher levels of Lp(a).

Question 19

Elevated apoB

Answer 19

≥130 mg/dL: A relative indication for its measurement would be triglyceride ≥200 mg/dL. A level ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk-enhancing factor

Question 20

ABI

Answer 20

<0.9

Question 21

Adults > 20 y.o. without ASCVD/not on therapy – measure

Answer 21

LDL-C fasting or non-fasting plasma lipid profile (document)

Question 22

If initial non-fasting lipid panel with triglycerides >

Answer 22

400mg/dL , repeat fasting lipid panel

Question 23

3 Regimens Statins

Answer 23

High intensity, which typically lowers LDL-C by 50% or more
Moderate intensity, which lowers LDL-C by 30% to 49%
Low intensity, which lowers LDL-C by 30% or less

Question 24

patients who have extreamly high (190 or higher) LDL are at risk

Answer 24

for lifetime risk of cardiac events

Question 25

40 to 75 with diabetes

Answer 25

modtere to high risk. Remonded moderate intensity regimine

Question 26

Lifestyle Modifications examples

Answer 26

Reduced caloric intake of saturated facts, dietary cholesterol Eliminate trans fat Average of 50 minutes of moderate to vigorous physical activity 3 to 4 times a week

Question 27

Potential net clinical benefit of pharmacotherapy

Answer 27

Recommend statins as first-line therapy Consider combination of statin and non-statin, if indicated Discuss potential risk reduction from lipid-lowering therapy Discuss potential for adverse effects or drug-drug interactions

Question 28

ASCVD risk assessment

Answer 28

Assign to treatment group (use ASCVD Risk Estimator Plus) Assess other patient characteristics – Risk-Enhancing Factors Assess CAC, if risk decision is uncertain/additional information is needed

Question 29

recommend what as first line therapy

Answer 29

statins

Question 30

Major ASCVD Events

Answer 30

Recent ACS (within the past 12 mo) History of MI (other than recent ACS event listed above) History of ischemic stroke Symptomatic peripheral arterial disease (history of claudication with ABI <0.85, or previous revascularization or amputation)

Question 31

High-Risk Conditions

Answer 31

Age ≥65 y Heterozygous familial hypercholesterolemia History of prior coronary artery bypass surgery or percutaneous coronary intervention outside of the major ASCVD event(s) Diabetes mellitus Hypertension CKD (eGFR 15-59 mL/min/1.73 m2) Current smoking Persistently elevated LDL-C (LDL-C ≥100 mg/dL [≥2.6 mmol/L]) despite maximally tolerated statin therapy and ezetimibe History of congestive HF

Question 32

Patient who might benefit form knowing their CAC score is zero

Answer 32

Patients reluctant to initiate statin therapy who wish to understand their risk and potential for benefit more precisely Patients concerned about need to reinstitute statin therapy after discontinuation for statin-associated symptoms Older patients (men, 55-80 y.o.; women, 60-80 y.o.) with low burden of risk factors who question whether they would benefit from statin therapy Middle-aged adults (40-55 y.0.) with PCE-calculated 10-year risk of ASCVD 5% to <8.5% with factors that increase their ASCVD risk, although they are in the borderline risk group

Question 33

Monitoring

Answer 33

Middle-aged adults (40-55 y.0.) with PCE-calculated 10-year risk of ASCVD 5% to <8.5% with factors that increase their ASCVD risk, although they are in the borderline risk group

Question 34

Average 40 minutes of

Answer 34

Average 40 minutes of

Question 35

Lipid disorders r/t obesity – intensify

Answer 35

lifestyle therapy, moderate caloric restriction and regular aerobic physical activity

Question 36

In children and adolescents with obesity or other metabolic risk factors, it is reasonable

Answer 36

to measure a fasting lipid profile to detect lipid disorders as components of the metabolic syndrome

Question 37

to measure a fasting lipid profile to detect lipid disorders as components of the metabolic syndrome

Answer 37

fasting or non-fasting lipoprotein profile as early as age 2 years to detect FH or rare forms of hypercholesterolemia.

Question 38

In children and adolescents without cardiovascular risk factors or family history of early CVD, it may be reasonable to measure a

Answer 38

fasting lipid profile or non-fasting non HDL-C once between the ages of 9 and 11 years, and again between the ages of 17 and 21 years, to detect moderate to severe lipid abnormalities.

Question 39

In children and adolescents found to have moderate or severe hypercholesterolemia, it is reasonable to carry out

Answer 39

reverse-cascade screening of family members, which includes cholesterol testing for first-, second-, and when possible, third-degree biological relatives, for detection of familial forms of hypercholesterolemia

Question 40

In children and adolescents 10 years of age or older with an LDL-C level persistently 190 mg/dL (≥4.9 mmol/L) or higher or 160 mg/dL (4.1 mmol/L) or higher with a clinical presentation consistent with FH and who do not respond adequately with 3 to 6 months of lifestyle therapy, it is reasonable to initiate

Answer 40

statin therapy

Question 41

In adults 75 years of age or older with an LDL-C level of 70 to 189 mg/dL, initiating

Answer 41

a moderate-intensity statin may be reasonable.

Question 42

In adults 75 years of age or older, it may be reasonable to stop

Answer 42

statin therapy when functional decline (physical or cognitive), multimorbidity, frailty, or reduced life-expectancy limits the potential benefits of statin therapy.

Question 43

In adults 76 to 80 years of age with an LDL-C level of 70 to 189 mg/dL, it may be reasonable to measure

Answer 43

CAC to reclassify those with a CAC score of zero to avoid statin therapy

Question 44

Consider conditions specific to women, such as

Answer 44

premature menopause (age <40 years) and history of pregnancy-associated disorders (hypertension, preeclampsia, gestational diabetes mellitus, small-for-gestational-age infants, preterm deliveries), when discussing lifestyle intervention and the potential for benefit of statin therapy.

Question 45

Women of childbearing age who are treated with

Answer 45

statin therapy and are sexually active should be counseled to use a reliable form of contraception.

Question 46

statin therapy and are sexually active should be counseled to use a reliable form of contraception.

Answer 46

hypercholesterolemia who plan to become pregnant should stop the statin 1 to 2 months before pregnancy is attempted, or if they become pregnant while on a statin, should have the statin stopped as soon as the pregnancy is discovered.

Question 47

. In all individuals, emphasize a

Answer 47

heart-health lifestyle across the life course.

Question 48

In patients with clinical ASCVDF, reduce

Answer 48

low-density lipoprotein cholesterol (LDL-C with high intensity statin therapy or maximally tolerated statin therapy.

Question 49

In very high-risk ASCVD, use a

Answer 49

LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy.

Question 50

In patients with severe primary hypercholesterolemia (LDL-C level ≥ 190 mg/dL[≥4.9 mmol/L]) without calculating 10-year ASCVD risk, begin

Answer 50

high-intensity statin therapy without calculating 10-year ASCVD risk.

Question 51

In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start

Answer 51

moderate-intensity statin therapy without calculating 10-year ASCVD risk

Question 52

In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician

Answer 52

patient risk discussion before starting statin therapy.

Question 53

In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a

Answer 53

In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a

Question 54

In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a

Answer 54

initiation of statin therapy (see No. 7)

Question 55

In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL- 189 mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain,

Answer 55

consider measuring CAC.

Question 56

. Assess adherence and percentage response to LDL- C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after

Answer 56

statin initiation or dose adjustment, repeated every 3 to 12 months as needed.