Dyslipidemia

Leslie Cho

POINTS TO REMEMBER

There is a strong, independent, continuous, and graded relation between total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) level and risk of coronary events.
Cholesterol screening:
- The NCEP Adult Treatment Panel III recommends that adults 20 years of age or older and without a history of coronary artery disease (CAD) or other atherosclerotic disease should have a fasting lipid panel [i.e., TC, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG)] every 5 years.
- The United States Preventive Services Task Force (USPSTF) recommends cholesterol screening starting at age 35 for men and 45 for women. You can screen patients starting at age 20 if they are at increased risk for coronary artery disease.
The five traditional risk factors for CAD are as follows:
- Age (male >45, female >55)
- Tobacco use
- Hypertension
- HDL level <40
- Family history of premature CAD (male <55 and female <65)
The treatment of hyperlipidemia requires two approaches: therapeutic lifestyle changes and medications.
NCEP Adult Treatment Panel III Treatment goals for LDL
- LDL <100:
  - CAD, atherosclerosis in noncoronary beds, diabetes, a calculated 10-year Framingham risk score > 20%
  - An LDL goal of <70 is a “reasonable therapeutic option”
- LDL <130:
  - Two or more traditional risk factors for CAD whose 10-year Framingham risk score falls between 10% and 20%
- LDL <160:
  - Zero or one risk factor with a 10-year Framingham risk score <10%
American College of Cardiology (ACC)/American Heart Association (AHA) Cholesterol Guideline 2013
- Focus Lipid Lowering Therapy to these 4 Groups
  - Group 1: Patients with clinical atherosclerotic cardiovascular disease (ASCVD)
  - Group 2: Patients age ≥ 21 years with LDL ≥ 190
  - Group 3: Patients with Diabetes, with age 40-75, LDL 70-189
  - Group 4: Patients aged 40-75, LDL 70-189 who are without ASCVD / DM but with coronary risk score of 10 yr ASCVD risk ≥ 7.5%
- Treatment – Focus has shifted from Target LDL levels to Dose intensity of a Statin Drug
  - Group 1: ASCVD: HIGH INTENSITY STATIN
  - Group 2: LDL > 190: HIGH INTENSITY STATIN
  - Group 3: Diabetic with LDL 70-189, Age 40-75
    - 10 year ASCVD risk < 7.5 %: MODERATE INTENSITY STATIN
    - 10 year ASCVD risk ≥ 7.5 : HIGH INTENSITY STATIN
  - Group 4: 10 year ASCVD risk ≥ 7.5 % (in absence of DM / ASCVD): Moderate – high intensity statin
- Statins
  - High Intensity Statins – atorvastatin 40mg-80mg, rosuvastatin 20mg-40mg
  - Moderate Intensity Statins – atorvastatin 10mg-20mg, rosuvastatin 5mg-10mg, simvastatin 20mg-40mg, pravastatin 40mg-80mg
- The Risk Calculator can be accessed on-line through AHA and ACC websites
- Statins are the lipid-modifying drugs of choice
- Lifestyle modifications are still recommended for all patients
The class of medications that have the strongest evidence of effectiveness are the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (“statins”).
Routine monitoring of liver function tests in patients on statins is no longer recommended. (A baseline measurement is recommended before starting therapy.)