Please enable JavaScript.
Coggle requires JavaScript to display documents.
Dyslipidemia, Statin selection by clinical scenario, Which statement best…
Dyslipidemia
Epidemiology
In 2021-2023, 11.3% of US adults had high total cholesterol (>/= 240 mg/dL)
Major modifiable driver of ASCVD
Often coexists with HTN, diabetes, obesity, CKD, and tobacco use.
Risk Factors
Modifiable: diet high in saturated/trans fats, physical inactivity, tobacco use, obesity, diabetes
Nonmodifiable: age and family history of high cholesterol
ASCVD risk-enhancing conditions: premature family history of ASCVD, metabolic syndrome, CKD, persistently elevated triglycerides, elevated Lp(a), and elevated apoB
Pathophysiology
An imbalance of LDL, HDL & triglycerides can lead to dyslipidemia: abnormal levels of lipids (fats) in the blood, which can increase the risk of cardiovascular diseases.
A combination of genetic and environmental factors contribute to a person's risk of developing dyslipidemia
Primary dyslipidemia (irreversible): caused by genetic mutations that affect the metabolism of lipids
Secondary dyslipidemia (reversible): caused by lifestyle factors or other medical conditions that alter the levels of lipids in the blood.
Lipids (LDL, HDL & triglycerides) are absorbed from the intestines and carried throughout the body via lipoproteins for energy, steroid production, or bile acid formation.
Dyslipidemia can cause inflammation, oxidative stress, cardiovascular diseases, and other metabolic dysfunctions
Dyslipidemia can then increase the risk of cardiovascular diseases (coronary artery disease, peripheral artery disease, stroke, and heart failure) by promoting atherosclerosis and its complications.
Dyslipidemia can also affect heart function and the blood vessels by altering nitric oxide availability (key regulator of vascular tone, blood pressure, and platelet aggregation)
Dyslipidemia can also affect the structure and function of the cardiac muscle, leading to cardiac hypertrophy, fibrosis, and arrhythmias
Treatment
Statin Therapy
High intensity: Atorvastatin 40–80 mg; Rosuvastatin 20–40 mg
Moderate intensity: Atorvastatin 10–20 mg; Rosuvastatin 5–10 mg; Simvastatin 20–40 mg; Pravastatin 40–80 mg
Low intensity: Simvastatin 10 mg; Pravastatin 10–20 mg; Lovastatin 20 mg
Non-statin Pharmacologic Therapy
Fibrates: Fenofibrate, gemfibrozil; lower triglycerides.
Ezetimibe (Zetia): Reduces intestinal cholesterol absorption
PCSK9 inhibitors: Alirocumab (Praluent), Evolocumab (Repatha); lowers LDL
Inclisiran: PCSK9-targeting therapy that lowers LDL
Lifestyle Modifications
Diet
Exercise
Smoking cessation
Physical Exam
BP, heart rate & rhythm, BMI, cardiovascular and peripheral vascular exams (pulses, edema, etc.), auscultate for bruits, assess signs of secondary causes, look for xanthomas
Patient Education
Heart healthy diet: reduce intake of trans and saturated fats, opt for lean proteins, increase intake of fiber through fresh fruits and vegetables
Smoking cessation
Statin education: best taken at night, common side effects, common interactions (grapefruit, etc.), medication monitoring (lipids every 3-6 months, LFTs)
Strive for at least 150 minutes of moderate-intensity aerobic exercise per week
Explain ASCVD risk and impact on risk through lifestyle changes and medication
Diagnostics
Lipid panel, A1c/glucose, TSH, CMP, eGFR (as indicated), Lp(a) once in adulthood, consider apoB selectively
History
Patients with severe or untreated dyslipidemia may develop s/s related to the complications of dyslipidemia
Xanthomas
Lipemia retinalis
Lower limb ischemia
Arcus senilis
Angina
TIAs & CVAs
Patients are asymptomatic & dyslipidemia progresses silently
Integration of IT
EHR : Track lipid panel results, medications, risk factors and trends over time
ASCVD risk calculators: Use electronic clinical decision support tools to estimate cardiovascular risk and help guide lipid lowering therapy
CVD Risk Estimator Plus : calculates 10 and 30 year cardiovascular risk, uses cholesterol and other patient specific risk factors, helps guide lipid lowering therapy and lifestyle interventions, allows results to be exported for clinical use.
https://tools.acc.org/cvd-risk-estimator-plus/#!/calculate/estimate/
Clinical Decision Support: EHR alerts can identify abnormal lipid results, medication interactions and patients due for a follow up
Patient Portals: Share lab results, medication instructions, educational resources and communicate with patients between visits
Telehealth : follow up on medication adherence, lifestyle changes, side effects, and lipid management goals remotely.
Electronic prescribing : review medication history/interactions and prescribe or adjust lipid lowering therapy electronically.
Remote monitoring / wearables : activity trackers and health apps can help patients monitor physical activity, weight, diet and lifestyle goals
Psychological, Cultural, Genetics, and Environmental Influences
Psychological Influences: Stress, health beliefs, readiness to make lifestyle changes (AHA)
Cultural Influences: cultural food, dietary patterns, saturated fats, sodium intake, and added sugars.
Black Population: dyslipididemia may present differently, black adults have higher HDL and lower triglycerides compared to Non-Hispanic, White, & Mexican adults (AHA)
-South Asia: current AHA guidelines identify south Asian ancestry as an ASCVD risk
-Asian American: AHA data shows higher LDL among asian Indian, Filipino, Japanese, and Vietnamese.
Genetics: Family History of high cholesterol or premature ASCVD, familial hypercholesterolemia, inherited abnormalities affecting LDL, and elevated lipoprotein.
Environmental: Limited access to nutritious foods, food insecurity, socioeconomic status, tobacco exposure, limited access to healthcare.
Care planning: Ensure patient has access to education materials in their primary language. Ensure care plan is patient-centered (utilize shared decision-making, medications are affordable, follow-up care is accessible, etc.)
Referral & Collaboration
Pharmacist : Collaborate for adherence concerns, interactions and medication intolerance
Genetic Counselor : Collaborate when familial hypercholesterolemia (FH) is suspected or confirmed for family screening.
Lipid Specialist / Cardiology should be referred if family history, severe/complex dyslipidemia, statin intolerance, or LDL-C above goal despite therapy. Also if there is a very high risk ASCVD or severe hypertriglyceridemia >1,000 mg/dL.
Registered Dietitian : Collaborate when pt needs nutrition/weight counseling
Patient, Family, & Community Roles
Family: Support healthy lifestyle changes; assess family history and screen relatives if FH is suspected.
Community: Access to healthy foods, exercise resources, smoking cessation programs, healthcare, and cholesterol screening.
Patient: Heart healthy diet, exercise, weight management, medication adherence, tobacco avoidance, routine lipid monitoring.
Statin selection by clinical scenario
LDL > 190 mg/dl → start maximally tolerated statin therapy
Age 40-75 + diagnosis of diabetes → start moderate intensity statin for a LDL goal <100
Diabetes + multiple ASCVD risks → start high intensity statin for a LDL goal of <70
ASCVD: high risk → maximally tolerated statin: add nonstatin therapy as needed LDL goal <55
ASCVD: not high risk → start high intensity statin LDL goal <70
Persistent TG elevation → lifestyle modifications + statin
TG >1000 mg/dl → treatment to reduce pancreatitis risk + lifestyle / statin management
monitor for muscle symptoms and medication interactions; assess adherence and response with repeat lipid testing.
Which statement best explains how dyslipidemia increases cardiovascular disease risk and how it is managed?