Lipids

Tyler Schubert

Background 

  • 1º prevention: patients at increased risk without prior vascular event 
  • 2º prevention: patients with established ASCVD (stroke, TIA, CAD, ACS, arterial revascularization, PAD)

Screening and evaluation 

  • AHA/ACC: screen with lipid panel starting age 19 at least every 5 years, and more often in those with ASCVD risk factors. Measure Lp(a) at least once in all adults. 
  • Use the PREVENT-ASCVD calculator to estimate 10-year ASCVD risk 
  • Consider secondary causes of HLD: hypothyroidism, DM, EtOH use, smoking, liver disease, nephrotic syndrome, CKD, medications (e.g. thiazide, glucocorticoids)

Risk stratification in primary prevention 

  • Low risk (0-3%): lifestyle modifications, including: 
    • 5-10% weight loss, exercise, smoking/EtOH cessation 
    • Diet: minimize trans/saturated fats (15-20 mg/dL ↓ in LDL-C, ~50% ↓risk of CAD). Limit sodium (<2300 mg/day) and sugar-sweetened foods and beverages. Emphasize vegetables, fruits, legumes, lean proteins, whole grains, nuts. 
  • Borderline risk (3-<5%): consider statin if risk-enhancing factors present. If starting, moderateintensity statin to reduce LDL 30-49% 
    • Risk-enhancers: family history premature ASCVD, LDL-C >160 mg/dL,DM, CKD, chronic inflammation, TG >175 mg/dL, Lp(a) >50 mg/dL (or >125 nmol/L) 
  • Intermediate risk (5-<10%): at least moderate-intensity statin to reduce LDL 30-49% (Reasonable to target goal LDL < 100 and non-HDL-C < 130) 
  • High risk (> 10%): high-intensity statin to reduce LDL > 50% (Reasonable to target goal LDL < 70 and non-HDL-C < 100). If not at goal consider adding ezetimibe 
  • Coronary artery calcium: consider if risk decision is uncertain in pts at intermediate risk and select patients at borderline risk without prior ASCVD (lipid-lowering therapy recommended for CAC > 0 and especially CAC > 100 or 75th %tile

Statin Therapy 

  • Check AST/ALT prior to initiation but does not routinely need to be monitored thereafter 
  • Repeat lipid panel 4-12 weeks after initiation, and then every 6-12 months 
  • AHA Algorithm: Primary Prevention in Adults 30-79 Without ASCVD 
  • AHA Algorithm:

Statin Potency

Statin Properties
High-Intensity
(≥50% ↓LDL-C)

Atorvastatin 40-80 mg

Rosuvastatin 20-40 mg
  • Safest in CKD: atorva, fluva (no renal dose adj.required)
  • Safest in cirrhosis: prava
  • Lowest rate of myopathy: prava, fluva, pitava
  • Lower overall s.e.: prava, rosuva (both hydrophilic)
  • Biggest Change in LDL: rosuvastatin > atorvastatin > simvastatin
Moderate-Intensity
(30-49% ↓LDL-C)

Atorvastatin 10-20mg

Rosuvastatin 5-10mg

Simvastatin 20-40mg

Pravastatin 40-80mg

Lovastatin 40-80mg

Fluvastatin XL 80mg

Fluvastatin 40mg BID

Pitavastatin 1-4mg
Low-Intensity
(<30% ↓LDL-C)

Simvastatin 10mg

Pravastatin 10-20mg

Lovastatin 20 mg

Fluvastatin 20-40mg
*Dosing with RCT-proven LDL-lowering benefit is bolded

Statin side effects

  • Spectrum of statin associated muscle symptoms (SAMS) include myalgias, myopathy, rhabdomyolysis, autoimmune myopathy 
  • Consider drawing CK, LFTs, BMP, TSH, and vitamin D 
  • Hold until symptoms resolve, then rechallenge with lower dose or alternative statin. Consider every other day rosuvastatin. Ezetimibe, bempedoic acid, and PCSK9 inhibitors are other alternatives. 
  • Statin intolerance = Unacceptable muscle symptoms that resolve with discontinuation and recur with rechallenge on at least 2 (preferably 3) statins, including one at the lowest approved dose 
  • "ACC Statin Intolerance Calculator” for etiology

Additional information 

  • Secondary Prevention: in those with clinical ASCVD, first stratify as “very high-risk" or not 
    • “Very high-risk ASCVD”: high-intensity statin for > 50% LDL reduction and goal LDL < 55 and non-HDL-C < 85 > ezetimibe and/or PCSK9 
    • Not very high-risk: high intensity statin for > 50% LDL reduction and goal LDL < 70 and non-HDL-C < 100
  • Fasted lipid panel not needed unless TG >400 mg/dL; if so, repeat with fasting 
  • PCSK9 inhibitor requires referral to Lipid Clinic 
  • In diabetics age 40-75 without clinical ASCVD, start at least moderate-intensity statin to achieve 30-49% LDL reduction and LDL < 100

Hypertriglyceridemia 

  • Moderate 175-499 mg/dL; Moderate-severe 500-999 mg/dL; Severe >1000 mg/dL 
  • Address lifestyle factors and stop TG-raising medications (thiazides, some beta-blockers, estrogens, antipsychotics, some anti-retrovirals) 
  • For patients with established ASCVD (or diabetes with >1 risk factors) on maximally-tolerated statin and TGs 150-499mg/dL: intensify LDL-lowering therapy if not at goal; add iconaspent ethyl if LDL at goal 
  • For triglycerides >500: maximize statin/LLT add fibrate and prescription omega-3-fatty acid 
  • Fibrates: fenofibrate 120 mg daily (avoid in CKD), gemfibrozil 600 mg BID (avoid with statins due to myopathy risk)

VA-specific guidelines 

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

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