Evidence & Guidelines of Dyslipidemia

Question 1

What is the primary mechanism for how statins improve hyperlipidemia?

Answer 1

Lower LDL

Question 2

What positive effect does lowering LDL have on health? (2)

Answer 2

1) Helps prevent the development of CAD

2) Helps prevent first occurrence of coronary event

Question 3

What is the definition of PRIMARY PREVENTION r/t dyslipidemia?

Answer 3

No interventions or medical event has occurred

Question 4

What medical condition automatically warrants initiation of statin therapy

Answer 4

Diabetes

Question 5

If a patient has a baseline LDL >190, what intensity of statin should be prescribed and what is the goal of that treatment?

Answer 5

High Intensity

Class I= 50% reduction in LDL from baseline

Question 6

If a patient has DM and is age 40-75, what intensity of statin should be prescribed and what is the goal of that treatment?

Answer 6

Medium Intensity
Class I=30-50% reduction in LDL from baseline

*consider risk assessment to consider high-intensity statin therapy

Question 7

What are the ASCVD risk percentage ranges? (4)

Answer 7

<5% is low risk
5-<7.5% is borderline risk
>7.5-<20% is intermediate risk
>20% high risk

Question 8

What is the appropriate intervention for a patient at ‘borderline risk’ of ASCVD?

Answer 8

Discuss risk /r/t moderate-intensity STATIN therapy, Class IIB)

*5-<7.5%

Question 9

What is the appropriate intervention of a patient at intermediate or high risk of ASCVD?

Answer 9

STATIN Therapy, Class I

*>7.5-<20% is intermediate risk
>20% high risk

Question 10

What is the appropriate intervention for a patient with familial hypercholesterolemia (HeFH)?

Answer 10

Statin therapy, regardless of age to prevent early age MIs (in 20s)

Question 11

When should STATIN therapy be initiated? (14)

Answer 11

If over 7.5% risk AND, at least one of the following:
Over 65 years
HeFH
Hx of CABG or PCI apart from ASCVD
DM
CKD w/eGFR 15-59 ML/min
Smoker
LDL>100 despite max tolerated statin and ezetimibe
Hx of CHF
Hx of preeclampsia 
Hx of premature menpause
Chronic inflammatory disease (RA, HIV)
South Asian Ancestry
Persistent TG >175 (related to shifting in LDL to small dense particals)

Question 12

When should High-Intensity, PRIMARY PREVENTION Statin therapy be initiated?

Answer 12

ASCVD risk >20%

Question 13

What is the LDL lowering goal of High-Intensity, PRIMARY PREVENTION Statin therapy?

Answer 13

50%

Question 14

What are the drugs/dosages used in high-intensity, PRIMARY PREVENTION Statin therapy? (2)

Answer 14

Atorvastatin 10-20 mg

Rosuvastatin 20-40mg

Question 15

When should Medium-Intensity, PRIMARY PREVENTION Statin therapy be initiated?

Answer 15

ASCVD RISK >7.5-<20%

Question 16

What is the LDL lowering goal of Medium-Intensity PRIMARY PREVENTION Statin therapy?

Answer 16

30-49%

Question 17

What are the drugs/dosages used in Medium intensity, PRIMARY PREVETNEION Statin therapy? (3)

Answer 17

Atorvastatin 10-20 mg
Rosuvastatin 5-10mg
Simvastatin 20-40mg

Question 18

Which statin is contraindicated for use in those of Asian ethnicity?
What is the risk?

Answer 18

Rosuvastatin

Johnston Syndrome

Question 19

When should low-intensity PRIMARY PREVENTION Statin Therapy be initiated?

Answer 19

ASCVD <5%

Question 20

What is the LDL lowering goal of low-intensity PRIMARY PREVENTION Statin Therapy?

Answer 20

<30%

Question 21

What drug/dosage is indicated for low-intensity PRIMARY PREVENTION Statin therapy?

Answer 21

Simvastatin 10mg

Question 22

What is the definition of Secondary Prevention r/t dyslipidemia?

Answer 22

An event has occurred (MI, etc), and now trying to prevent others.

Question 23

What conditions/events are present for defining Secondary Prevention r/t dyslipidemia? (5)

Answer 23

1) ASCVD, recent or multiple ACS events (STEMI/NSTEMI/unstable angina) within last 12 months
2) Hx of MI (other than recent ACS events above)
3) Hx of ischemic stroke
4) Symptomatic PD
5) Previous revascularization or amputation

Question 24

What is the LDL lowering goal in Secondary Prevention of dyslipidemia?

Answer 24

<70%

But baseline labs not needed (need one of you to explain to me how this works) :)

Question 25

In SECONDARY PREVENTION therapy for dyslipidemia, what drug can be added if the patient is already on the max dose of therapy without adequate effect?

Answer 25

Ezetimibe

Question 26

In SECONDARY PREVENTION therapy for dyslipidemia, what drug can be added to max statin dose and Exetimibe if no adequate effect?

Answer 26

PCSK9-I

Question 27

What are the disadvantages of PCSK9-I therapy? (3)

Answer 27

Very expensive Must get pre-authorization for use Only given parenterally

Question 28

What are treatment considerations if TG is >1000? (5)

Answer 28

1) Treat underlying problems (DM, meds, hypothyroidism, obesity, CKD, nephrotic syndrome) 2) Low-fat diet 3) Avoid refined carbs 4) Avoid Etoh 5) Consume O3FA and +/- fibrate (to decrease the risk of pancreatitis)

Question 29

What should happen in statin therapy if the patient becomes pregnant?

Answer 29

STOP statins immediately--cholesterol is needed to make hormones

Question 30

What should happen if a patient on statin therapy is planning to get pregnant?

Answer 30

Stop statin 1-2 months prior to trying to become pregnant

Question 31

What should statin therapy treatment plan be for someone who is not pregnant but who is sexually active?

Answer 31

Use RELIABLE birth control while on Statin

Question 32

What are dyslipidemia treatment considerations if pt has CKD and is on hemodialysis?

Answer 32

If not on a statin, don't initiate | If already on station prior, continue statin

Question 33

What are dyslipidemia treatment considerations in patients with HIV or chronic inflammatory disease?

Answer 33

Reassess lipid and risk after the disease is under control.

Question 34

A 40mg/dL decrease in LDL correlates to what percentage of decreased risk of major vascular events?

Answer 34

25%

Question 35

When treating high LDL, is the focus on staying within specific ranges or percentage of LDL reduction?

Answer 35

Percentage of reduction.

Question 36

What groups of people are the highest risk for developing clinically relevant ASCVD? (3)

Answer 36

Ldl -c> 190 Diabetics age 40-75 Those with a 10 year risk of >75% and who are 40-75 years old

Question 37

What statins are HIGH INTESITY Statins? (2)

Answer 37

Atorvastatin (Lipitor), 40-80 mg | Rosuvastatin (Crestor), 20-40mg

Question 38

What statins are MEDIUM INTENSITY Statins? (6)

Answer 38

``` Atorvastatin (Lipitor), 10-20 mg Rosuvastatin (Crestor), 5-10mg Simvastatin, 20-40mg Pravastatin, 40-80 mg Fluvastatin XL, 80mg Pitavastatin, 2-4 mg ```

Question 39

Non-traditional risk factors for dyslipidemia (4)

Answer 39

Family history Increased CRP levels High Coronary Calcium Score Ankle Brachial Index (peripheral arterial disease)

Question 40

What are baseline monitoring recommendations for the treatment of dyslipidemia? (4)

Answer 40

Baseline Lipid Profile Baseline LFTs Baseline Hbg A1C Baseline Thyroid Function test

Question 41

What follow-up monitoring is recommended during the treatment of dyslipidemia?

Answer 41

Lipid profiles every 4-12 weeks after starting statins and then every 3-12 months to assess response adherence

Question 42

Once statins are initiated, at what point can the dosage be reduced?

Answer 42

Dosages can be reduced when LDL-C < 40 on 2 consecutive occasions