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Lipids

Brittany Saldivar

Background

  • 1º Prevention: pts at increased risk who have not yet had a vascular event

  • 2º Prevention: pts with pre-existing occlusive vascular disease or ASCVD (e.g., stroke, TIA, CAD + angina, ACS, coronary or arterial revascularization, PAD)

  • Screening: USPSTF 2016 Guidelines: q5years for adults 40-75yrs

    • ACC/AHA 2019 Guideline: adults 20-39 q 4-6yrs; <21yrs if strong fam hx; 40-75 “routinely” assess CV risk and calculate 10 yr ASCVD risk (lipid pnl q3-12 months)

    • Dot phrase: .ASCVD2013

Evaluation

  • Fasting vs Non-Fasting Lipid Panel

    • Triglycerides are most impacted by non-fasting testing which can artificially lower LDL-C depending on how the laboratory measures/calculates LDL. Consider fasting lipid panels when triglyceride levels are high

  • Consider 2º causes of HLD in initial workup: hypothyroidism, DM, EtOH use, smoking, liver disease, nephrotic syndrome, CKD, meds (e.g., thiazide, glucocorticoids)

Management

  • Lifestyle changes:

    • Heart Healthy Diet: ↓ trans/saturated fats, choose skim milk, low-fat dairy products

    • Emphasizes fruits, vegetables, whole grains, poultry, fish, nuts and olive oil, while limiting red and processed meats, sodium and sugar-sweetened foods and beverages

    • Promote a healthy weight, regular exercise, smoking cessation, limit EtOH

    Statin Therapy

    • Initiate as outlined in the following algorithms

    • Check AST/ALT prior to initiation

    • Note that PCE used to estimate ASCVD risk is best validated for non-Hispanic whites and blacks. Consider use of additional risk prediction tools/factors in other patient populations

ascvd primary prevention

Figure from 2019 ACC/AHA Guideline on Primary Prevention of Cardiovascular Disease

ascvd primary prevention

Figure from 2018 ACC/AHA Guideline on Management of Blood Cholesterol

High Intensity
(Decr LDL-C by > 50%)		 Moderate Intensity
(Decr LDL-C by 30% - 49%)		 Low Intensity
(Decr LDL-C by <30%)

Atorvastatin (40mg) 80mg

Rosuvastatin 20mg (40mg)

Atorvastatin 10mg (20mg)

Rosuvastatin (5mg) 10mg

Simvastatin 20 - 40mg

 Simvastatin 10mg

Pravastatin 40mg (80mg)

Lovastatin 40mg (80mg)

Fluvastatin XL 80mg

Fluvastatin 40mg BID

Pitavastatin 1-4mg

Pravastatin 10-20mg

Lovastatin 20 mg

Fluvastatin 20-40mg
*Bold denotes dosing with RCT proven LDL lowering benefit

Statin Options

Statin Side effects:

  • Spectrum of statin associated muscle symptoms (SAMS) include myalgias, myopathy, rhabdomyolysis, autoimmune myopathy

    • Myalgias: bilateral involving large muscle groups, onset within weeks of initiation of therapy and should resolve within weeks of cessation; CK should be normal

  • Consider evaluation with CK, BMP, TSH, and vitamin D

  • ACC has a “Statin Intolerance Calculator” to help assess etiology of symptoms

Additional Information

  • If patient is not tolerating a statin, consider:

    • Holding statin until symptoms resolve and trialing lower dose or alternative statin (Pravastatin and Fluvastatin may have lower risks of myopathy)

    • Every other day dosing with atorvastatin and rosuvastatin (longer half-lives)

  • If repeated failed attempts, consider alternative agents: Ezetimibe, PCSK9 inhibitor

  • PCSK9 inhibitor requires referral to Lipid Clinic

Hypertriglyceridemia:

  • Moderate: TG 175-499 mg/dL; Moderate-severe 500 - 999; Severe: TG > 1000

  • Focus on addressing lifestyle factors and stopping medication that increase TG’s (HCTZ, some BB’s, estrogens, some ART, antipsychotics)

  • Consider medical therapy when TG> 500mg/dL (increased risk of pancreatitis):

    • Omega-3-fatty acids (icosapent ethyl) 4gm daily or Vascepa 4gm daily

    • Fibrates: Fenofibrate 120 mg daily (avoid in CKD), Gemfibrozil 600mg bid (increased risk of myopathy with concomitant statin)

VA-Specific Guidelines

  • https://www.healthquality.va.gov/guidelines/cd/lipids/index.asp

  • Lowest LDL goal recognized for VA Criteria for Use is 100

  • Preferred statins: Atorvastatin, Simvastatin, Lovastatin

  • Statins that require PADR: Pravastatin, Rosuvastatin (2nd line high intensity statin)

    • Must have documented intolerances or drug-drug interaction to all preferred statins

  • Other agents that require PADR:

    • Ezetimibe

      • Pt has tried and failed or not tolerated all statins (allergy, AE, etc.)

      • Pt not meeting goal on max dose of statin PLUS bile acid sequestrants or niacin

    • Fenofibrate

      • Pt has tried all formulary alternatives or has contraindication to use of formulary alternatives (statin, niacin, gemfibrozil, cholestyramine, fish oil)

      • If TG > 500 mg/dL, fenofibrate should be approved

Last update: 2022-06-29 05:57:33