Lipid management guidelines

1. Cholesterol Management
Guidelines
Kerolus Shehata, MD

2. Lipoprotein Metabolism

3. Lipid lowering medications

4. Friedewald formula
Total cholesterol HDL + LDL + VLDL
VLDL TGs (mg/dL) / 5
LDL TC - HDL – (TGs/5)
**Not valid if TGs >400**
Example:
Total cholesterol: 230, TGs: 120, HDL: 25
• First calculate the VLDL: 120/5 = 24
• Then calculate LDL: 230 – (25+24) = 181 mg/dL

5. Causes of elevated LDL & TGs

6. Measurement of LDL
• Adult >20 YO and not on any lipid lowering medications  Measure lipid
panel (fasting or non-fasting) to estimate ASCVD
• If the non-fasting panel showed TGs >400 mg/dL  Repeat a fasting
panel.
• If LDL <70  May measure direct LDL or modified LDL estimate.
• If pt has a FHx of premature ASCVD or genetic HLD  may start with a
fasting panel.

7. Secondary ASCVD prevention

9. ASCVD Risk Estimator
Clinical ASCVD includes acute
coronary syndromes, or a history
of myocardial infarction, stable or
unstable angina, coronary or
other arterial revascularization,
stroke, transient ischemic attack,
or peripheral arterial disease
presumed to be of atherosclerotic
origin.

10. Who is at a very high risk for future ASCVD?

11. Severe Hypercholesterolemia (LDL ≥190)

12. ASCVD risk management for diabetics

13. Which diabetic patient is at a
very high risk to develop ASCVD?

14. Primary prevention of ASCVD

15. Statin use in
general risk
population
(without ASCVD events, LDL
>190mg/dl, or diabetes)

16. ASCVD risk enhancers
These can be used to refine risk assessment in certain
individuals at borderline or intermediate risk for ASCVD.

17. Statin therapy

18. Non-Statin therapy

19. Lifestyle and Lipids

20. Statin intolerant patients
• Myalgia that resolve with discontinuation of statin treatment and occur
with rechallenge
• Myalgia have been demonstrated with rechallenge on at least 2 or 3
statins, including those with different metabolic pathways, and at least
one statin at the lowest approved dose.
• Incidence: Ranges from 1-10%
• Risk factors: Impaired renal or hepatic function, ALT > 3X the upper limit of
normal, age >75, Asian ancestry, or on drugs that affect statin metabolism.
• Patients who develop myalgia on a statin should be tried on either a lower
dose of the same statin or a different statin, or even dosing the statin once
or twice weekly. >90 % will ultimately tolerate statin.
• When a high intensity statin is indicated but not tolerated and a moderate
intensity statin is used, further LDL lowering may be achieved with
ezetimibe or a bile acid sequestrant.

21. Statin use in pre-menopausal women
I C-LD
Women of childbearing age who are treated with statin therapy and
are sexually active should be counseled to use a reliable form of
contraception.
I C-LD
Women of childbearing age with hypercholesterolemia who plan to
become pregnant should stop the statin 1 to 2 months before
pregnancy is attempted, or if they become pregnant while on a
statin, should have the statin stopped as soon as the pregnancy is
discovered.

22. Statin use in CKD patients
• In patients with CKD (not treated with dialysis
or transplant) with LDL >70 and ASCVD risk of
≥ 7.5%  consider initiating moderate
intensity statin ± ezetimibe.
• In patients with CKD who require dialysis and
currently on statin May continue statin.
• In CKD patients who require dialysis  DON’T
start statin for primary prevention (Class III)

23. Statin use in chronic inflammatory
disorders & HIV
• Adults with these conditions and LDL >70 with
ASCVD risk of ≥ 7.5%  Consider starting
moderate or high intensity statin (Class I).
• Consider checking a fasting lipid profile before
starting therapy and 4-12 weeks after that.

24. When to use statin in patients 20 -39 Years old?
1) Severe hypercholesterolemia e.g. LDL ≥190
2) Those with LDL 160-189 plus a family history
of premature ASCVD (ASCVD event in men
less than 55 and women less than 65)

25. Statin use in patients ≥ 75 years old
• With clinical ASCVD  may initiate moderate
or high intensity statin after a thorough
discussion and evaluation.
• If patient tolerates high intensity statin 
May continue it.

26. Statin safety and side effects
• Need to have a discussion with your patient before starting statins regarding
potential side effects e.g. SAMS (Statin-associated muscle symptoms).
• SAMS include: Myalgia (normal CK), myositis, rhabdomyolysis and
autoimmune myopathy (HMG Coenzyme A Reductase AB)
• Mild or moderate SAMS  Reassess and Rechallenge.
• Severe SAMS on rechallenge  May start Non-statin therapy
• Even in patients with increased risk for DM  Continue statin (Class I)
• Severe SAMS  Measure CK and LFTs
• Transaminases elevation > 3x upper normal limit is infrequent
• Patient with chronic stable liver disease who has high ASCVD risk  get a
baseline LFTs and OK to start statin with close follow up (Class I).
• Coenzyme Q10 is NOT recommended for routine use or in treatment of SAMS.
• Don’t routinely check CK or transaminases in every patient on Statins.

27. Management of SAMS

28. Management of Hypertriglyceridemia
• Adult with moderate hyperTGs (177-499)Address obesity and metabolic
syndrome. Treat the secondary factors (DM, CKD, Nephrotic syndrome, chronic
liver disease, hypothyroidism and medications that increase TGs
• Adult with moderate or severe hyperTGs with ASCVD risk of ≥ 7.5% consider
initiating statin therapy.
• Adult with fasting TGs ≥1000 Consider adding Fibrate therapy and omega-3 FAs

29. Coronary Artery Calcium (CAC) score
• Use to refine risk in individuals with borderline to intermediate risk.
• Use in patients with intermediate ASCVD risk, but reluctant to start a statin.
• Patients ≥55 Years of age who have a CAC of Zero may consider withholding a
statin and reassessing in 5-10 years, however statin should be initiated if CAC is
more than zero.
CAC score Action
Zero Treatment with statin therapy may be withheld
or delayed, except in cigarette smokers, those
with diabetes mellitus, and those with a strong
family history of premature ASCVD
1 – 99 Favors statin therapy, especially in those ≥55
years of age.
> 100 Statin therapy is indicated

30. Miscellaneous
• Individuals from South Asia have increased ASCVD risk.
• ASCVD risk is higher among individuals from Puerto Rico than those from Mexico.
• Native American/Alaskan populations have high rates of risk factors for ASCVD.
• In Asians, Start low dose (5 mg) of rosuvastatin versus 10 mg in whites.
• Baseline serum CK values are higher in blacks than in whites.
• In adults of East Asian descent, other statins should be used preferentially over
simvastatin.
• Resistance exercise training will reduce LDL.
• Fenofibrate (not gemfibrozil) can be combined with statins if indicated.
• Goal LDL in patients with severe hypercholesterolemia (LDL-C>19) is greater than
50% reduction in LDL and resultant LDL<100mg/dl.
• Bile acid sequestrants are contraindicated when serum triglycerides >300mg/dl.
• All patients with diabetes who are 40 and older should be treated with a statin.
• PCSK9 inhibitors have no role in lipid management in patients with DM (unless
have established ASCVD or LDL>190mg/dL).
• Use high intensity statin if ASCVD risk >20%.

31. Take Home Messages - I
• In all individuals, emphasize a heart-healthy lifestyle across the life course.
• CAC scores can be used in patients up to age 80
• In patients with clinical ASCVD, reduce LDL with high-intensity statins or
maximally tolerated statin therapy.
• In very high-risk ASCVD, use a LDL threshold of 70 to consider the addition
of non-statins to statin therapy.
• In patients with LDL ≥ 190, start high intensity statins without calculating 10-
year ASCVD risk.
• In patients 40 to 75 years of age with DM and LDL>70 mg/dl, start
moderate-intensity statin (High intensity if with multiple risk factors) without
calculating 10-year ASCVD risk.
• In patient 40 to 75 years of age evaluated for primary ASCVD prevention,
have a clinician–patient risk discussion before starting statin therapy.

32. Take Home Messages - II
• In patients 40 to 75 years of age without DM, but with LDL≥70 and ASCVD
risk of ≥7.5%, start a moderate-intensity statin if patient agrees.
• In patients 40 to 75 years of age without DM, but with ASCVD risk of 7.5%
to 19.9% (intermediate risk), risk-enhancing factors favor initiation of
statins.
• In patients 40 to 75 years of age without DM, but with LDL ≥70, at a 10-
year ASCVD risk of 7.5% to 19.9% (intermediate risk), if a decision about
statin therapy is uncertain, consider measuring CAC
• Assess adherence and percentage response to LDL lowering medications
and lifestyle changes with repeat lipid panel in 1-3 months after statin
initiation or dose adjustment, repeated every 3 to 12 months as needed.
• In patients who smoke, a CAC score of zero does not exclude coronary artery
disease. The CAC score is also limited in those with diabetes and those with
a family history of early CAD.

33. Summary

34. Thank You