Hyperlipidemia: Diagnosis and Management

00:01 All right, everybody.

00:02 Grab your favorite fatty salty snack and let's talk about hyperlipidemia.

00:08 All right.

00:08 So, first, let's consider screening for lipid disorders and we’ll start with a case.

00:13 We have a 25-year-old man in for a health maintenance examination.

00:17 He has a body mass index of 31 kg/m².

00:21 That’s obesity.

00:22 And otherwise, his exam is completely normal.

00:26 So, what should you recommend to him regarding evaluating serum lipids.

00:30 No exam until he is at least 35 years old? No exam until he’s at least 50 years old? Evaluation now with a basic lipid panel? Or do you want to evaluate now with a lipid panel including lipoprotein(a) and apolipoprotein-B? What do you think? Current guidelines from our US Preventive Services Task Force would say evaluate now with a basic lipid panel.

00:53 Let’s go over some of those guidelines.

00:55 So, recommended is that men between 20 and 35 years of age and women 20 to 45 years of age get screened with a basic lipid panel if there is increased risk of coronary heart disease, if there's any risk factor present.

01:09 What are those risk factors? How about obesity? This patient has that.

01:12 So, check. He is in the pool.

01:15 Smoking.

01:16 Family or personal history of coronary heart disease.

01:19 Diabetes, of course.

01:20 And hypertension.

01:22 So, those are all risk factors.

01:24 What else does USPSTF say? Well, when you're 35 years old and male, you should be routinely checked.

01:32 For women above 45 years of age, they should be routinely checked as well for serum lipids.

01:38 How often they should be checked is unclear.

01:40 And that's kind of nice because in my clinical practice I have patients who are borderline who I want to check on an annual basis.

01:47 I have patients who clearly have low cholesterol levels thanks to their lifestyle and their genes and, therefore, I don't need to screen them very often at all, maybe every five years or so.

01:59 But, yeah, the right interval for screening is not evidence-based.

02:04 And so, it really comes up to you as a patient.

02:08 They also found that there was insufficient evidence to recommend for/against screening for lipids among children and adolescents.

02:16 Now, that's interesting, but it contrasts with recommendation from the American Academy of Pediatrics, which says, all children should be screened around the age of 9 and 10.

02:27 I split the difference and I'll certainly target overweight and obese children.

02:32 I’ll recommend them for screening lipids as well as thinking about glucose levels for those children as well.

02:39 So, what do you do with the results? Well, currently, the American Heart Association has gone to a more holistic approach to the evaluation of lipids.

02:48 It's not based just on number values anymore.

02:50 In fact, it incorporates multiple facets of a person's sociodemographic and disease profile to create a score, a 10-year risk for cardiovascular disease.

03:01 So, what I recommend – and I actually like this approach.

03:04 Being a family physician and a holistic practitioner myself, it's not only the current recommendations.

03:10 I think it actually is a little bit more evidence-based and it allows me to really more aggressively treat patients with lipids and, therefore, prevent more heart attacks and strokes.

03:22 What are the components of this risk calculator? Which you can download for free and use it on – I use mine on my phone.

03:29 So, it's demographics, age, sex and race.

03:32 Then there are measurements of cholesterol.

03:34 So, you need a baseline cholesterol to put that information into the calculator.

03:38 You have to state whether the patient has hypertension, whether it’s treated, if they have diabetes, their smoking status and the systolic blood pressure.

03:45 It takes about a minute at most to put the information in and get a 10-year predictive cardiovascular risk.

03:53 Linked to that is another site that tells you, based on the information given, here's what's recommended in terms of statin therapy.

04:05 Everybody who has some elevation of cholesterol or cardiovascular risk factors that I mentioned earlier should be thinking about low-fat diet and exercise.

04:16 It’s associated with about a 15% reduction in LDL with lifestyle changes as well as an 18% reduction in triglycerides.

04:26 It also increases HDL by about 14% maximum.

04:30 So, lifestyle definitely has a role.

04:34 And in terms of statin therapy, if you want to broadly compare high-intensity statins – and that’s something along the lines of atorvastatin, rosuvastatin at a higher dose.

04:44 They can be expected to reduce LDL cholesterol by a maximum of about 50% with high-intensity statins.

04:51 Moderate intensity statins, which may include those two drugs at a lower dose or drugs like pravastatin or simvastatin at the highest dose, 30% reduction.

05:01 And then lower intensity statins can be expected to reduce LDL by a maximum of about 20%.

05:09 So, where are these drugs applied? High-intensity – and this is where I think – if you’re going to get questions on these guidelines, this is where they’re going to come from.

05:16 High intensity statins are employed, anybody with a history of cardiovascular disease.

05:22 That’s prior stroke, prior revascularization procedure.

05:26 That is truly where statins do their best work and the best evidence is in – not in primary prevention of cardiovascular disease, secondary prevention – preventing that next episode from happening.

05:37 So, they should absolutely be on a high intensity statin unless they have a severe contraindication.

05:42 Those with really high LDL levels, which may indicate some type of familial hypercholesterolemia, and then those patients who fit in this broad category, they have diabetes, they have a moderate LDL increase at least, and they've got a increased ten-year cardiovascular risk above 7.5%.

06:01 I can tell you from lots of patients who fit these criteria that most patients with diabetes will qualify for high-intensity statins based on those criteria right there.

06:11 Moderate intensity statins is for patients who can't tolerate a high intensity statin.

06:16 That makes sense.

06:17 And also those diabetes patients, the rare ones, who tend to be a lot younger because you don't see that many heart attacks in 32-year-olds, those are the ones who may just take a moderate intensity statin versus a high-intensity.

06:30 And low intensity statin, those are patients who kind of fit on the borderline with some mild increase in their ten-year cardiovascular risk, but they don't have diabetes and they don't have prior cardiovascular disease.

06:45 That’s how it breaks down.

06:48 A few notes on lipid management.

06:50 It’s no longer necessary to routinely monitor transaminase levels.

06:54 If patients develop symptoms, feeling fatigue and certainly feeling myalgias, it’s a good idea to check transaminase levels when they’re on statin therapy, but routine evaluation is no longer necessary.

07:09 And patients can continue taking their statin all the way up till when their liver enzymes rise to three times above the normal limit.

07:19 At that point, it’s time to make a change.

07:22 Also, it’s not as necessary to routinely monitor lipid levels.

07:26 If you have a patient who is on the highest dose rosuvastatin or atorvastatin, there's not much else you can do if their LDL doesn't fall into the old goals.

07:35 However, for patient adherence, it can be useful to check lipid levels, and just ask, are you taking your statin because I see despite intensive therapy, your LDL is 140, that doesn't compute for most patients.

07:47 Then you find out, lo and behold, they only take it once a week.

07:50 I hear that regularly.

07:52 And, of course, reassess that cardiovascular risk every four to six years because they may change from needing a low or moderate intensity up to a higher intensity statin.

08:03 Now, there are a new class of drugs that have been out in the market for a couple years.

08:07 These proprotein convertase – and I can't pronounce it.

08:11 I call them the pesky nine inhibitors for familial hypercholesterolemia.

08:16 Now, these drugs are now being promoted beyond familial hypercholesterolemia.

08:21 They have been associated with a reduction in cardiovascular death and they are stronger in terms of LDL reduction.

08:27 We’re talking 70, up to 80% reduction, severe falls in the total LDL cholesterol, beyond what you can get with a statin alone.

08:39 And so, therefore, these drugs will become promoted for the prevention of cardiovascular disease in a broader population, but they are significantly more expensive.

08:49 It’s something to consider.

08:52 What about patients who can't tolerate a statin? The most common reason patients can't tolerate statins is myalgia.

08:58 Remember that myalgias with statin tends to affect the larger muscle groups.

09:02 It just feels like a dull ache.

09:04 It often happens after initiation of treatment or increase in dose, but it can emerge at any time during treatment.

09:12 And so, there's some simple rules, though.

09:15 You want these drugs, which really do make an impact on cardiovascular disease, onboard as much as possible.

09:22 So, here's what I would recommend.

09:23 First, change the statin.

09:25 Just simply changing the statin to a different type.

09:27 So, they were on atorva, now they take rosuva.

09:30 They were on simva, now they take prava.

09:33 So, changing your statin works in about a third of the time.

09:37 Changing the class of statin, moving from that high intensity to a lower intensity statin can be helpful.

09:43 Then we’re talking about lowering the dose of statin.

09:46 Now, you're making some compromises.

09:48 If they really need to be on high intensity, not everybody can tolerate that, but at least keep them on something.

09:53 Something is always better than nothing.

09:55 And at the end of day, if it takes every other day dosing of the statin, that’s still better than nothing.

10:01 That’s still better than – especially with a history of cardiovascular disease.

10:07 And in those patients who really can't tolerate a statin in any way, shape or form, who have a history of cardiovascular events, that's where I think those pesky nine inhibitors can make a difference.