All right, everybody.
Grab your favorite fatty salty snack
and let's talk about hyperlipidemia.
So, first, let's consider screening
for lipid disorders and we’ll start with a case.
We have a 25-year-old man in for a
health maintenance examination.
He has a body mass index of 31 kg/m².
And otherwise, his exam is completely normal.
So, what should you recommend to him
regarding evaluating serum lipids.
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.
Let’s go over some of those guidelines.
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.
What are those risk factors?
How about obesity?
This patient has that.
So, check. He is in the pool.
Family or personal history of coronary heart disease.
Diabetes, of course.
So, those are all risk factors.
What else does USPSTF say?
Well, when you're 35 years old and male,
you should be routinely checked.
For women above 45 years of age,
they should be routinely checked
as well for serum lipids.
How often they should be checked is unclear.
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.
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.
But, yeah, the right interval for
screening is not evidence-based.
And so, it really comes up to you as a patient.
They also found that there
was insufficient evidence
to recommend for/against screening for lipids
among children and adolescents.
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.
I split the difference and I'll certainly target
overweight and obese children.
I’ll recommend them for screening lipids
as well as thinking about glucose
levels for those children as well.
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.
It's not based just on number values anymore.
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.
So, what I recommend –
and I actually like this approach.
Being a family physician and
a holistic practitioner myself,
it's not only the current recommendations.
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.
What are the components of this risk calculator?
Which you can download for free
and use it on – I use mine on my phone.
So, it's demographics, age, sex and race.
Then there are measurements of cholesterol.
So, you need a baseline cholesterol to
put that information into the calculator.
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.
It takes about a minute at most to put the information in
and get a 10-year predictive cardiovascular risk.
Linked to that is another site that tells you,
based on the information given,
here's what's recommended in terms of statin therapy.
Everybody who has some elevation of cholesterol
or cardiovascular risk factors that I mentioned earlier
should be thinking about low-fat diet and exercise.
It’s associated with about a 15% reduction in LDL with
lifestyle changes as well as an 18% reduction in triglycerides.
It also increases HDL by about 14% maximum.
So, lifestyle definitely has a role.
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.
They can be expected to reduce LDL cholesterol
by a maximum of about 50% with high-intensity statins.
Moderate intensity statins, which may include
those two drugs at a lower dose
or drugs like pravastatin
or simvastatin at the highest dose,
And then lower intensity statins can be expected
to reduce LDL by a maximum of about 20%.
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.
High intensity statins are employed,
anybody with a history of cardiovascular disease.
That’s prior stroke, prior revascularization procedure.
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.
So, they should absolutely
be on a high intensity statin
unless they have a severe contraindication.
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%.
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.
Moderate intensity statins
is for patients who can't
tolerate a high intensity statin.
That makes sense.
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.
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.
That’s how it breaks down.
A few notes on lipid management.
It’s no longer necessary to
routinely monitor transaminase levels.
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.
And patients can continue taking their statin all the way up till
when their liver enzymes rise to three times above the normal limit.
At that point, it’s time to make a change.
Also, it’s not as necessary to routinely monitor lipid levels.
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.
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.
Then you find out, lo and behold,
they only take it once a week.
I hear that regularly.
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.
Now, there are a new class of drugs
that have been out in the market for a couple years.
These proprotein convertase – and I can't pronounce it.
I call them the pesky nine inhibitors
for familial hypercholesterolemia.
Now, these drugs are now being promoted
beyond familial hypercholesterolemia.
They have been associated with a reduction in cardiovascular death and they are stronger in terms of LDL reduction.
We’re talking 70, up to 80% reduction,
severe falls in the total LDL cholesterol,
beyond what you can get with a statin alone.
And so, therefore, these
drugs will become promoted
for the prevention of cardiovascular
disease in a broader population,
but they are significantly more expensive.
It’s something to consider.
What about patients who can't tolerate a statin?
The most common reason patients can't tolerate statins is myalgia.
Remember that myalgias with statin tends
to affect the larger muscle groups.
It just feels like a dull ache.
It often happens after initiation
of treatment or increase in dose,
but it can emerge at any time during treatment.
And so, there's some simple rules, though.
You want these drugs, which really do make an impact
on cardiovascular disease, onboard as much as possible.
So, here's what I would recommend.
First, change the statin.
Just simply changing the statin to a different type.
So, they were on atorva, now they take rosuva.
They were on simva, now they take prava.
So, changing your statin works in about a third of the time.
Changing the class of statin,
moving from that high intensity to a
lower intensity statin can be helpful.
Then we’re talking about
lowering the dose of statin.
Now, you're making some compromises.
If they really need to be on high intensity,
not everybody can tolerate that,
but at least keep them on something.
Something is always better than nothing.
And at the end of day,
if it takes every other day dosing of the statin,
that’s still better than nothing.
That’s still better than – especially with a
history of cardiovascular disease.
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.