Hyperlipidemia

  1. Screen appropriate patients for hyperlipidemia

  2. In all patients whose cardiovascular risk is being evaluated, include the assessment of lipid status

  3. When hyperlipidemia is present, take an appropriate history, and examine and test the patient for modifiable causes (e.g., alcohol abuse, thyroid disease)

  4. Ensure that patients diagnosed with hyperlipidemia receive appropriate lifestyle and dietary advice. Periodically reassess compliance with this advice (especially in patients at overall low or moderate CV risk)

  5. In treating hyperlipidemic patients, establish target lipid levels based on overall CV risk

  6. In patients receiving medication for hyperlipidemia, periodically assess compliance with and side effects of treatment

Lipid Screening

  • Primary prevention (without CVD)

    • Men and Women ≥ 40yo

      • Consider earlier screening if CVD risk factors (see image to the right)

      • INESSS recommends only screening if ≥ 40yo and CVD risk factor

  • Repeat lipid screening q5y until 75yo (or q1y if ≥5% risk)

    • Can recalculate global CVD risk earlier if new risk factor

  • Nonfasting lipid levels can be used to calculate global CVD risk

    • Fasting if TG>4.5

Risk assessments

  • Framingham (2x risk if first degree relative F<65yo or M<55yo)

    • Sex, Age, Total Chol, HDL, Smoker, sBP (or if treated)

  • QRISK2 if CKD

  • Risk estimation should NOT be routinely done if

    • Pre-existing CVD (automatically high risk)

    • <40yo or >75yo as not studied

      • Can discuss testing >75yo if life expectancy and overal health status are good

        • No studies have shown a mortality benefit in >75yo

    • Lipid therapy

  • Consider baseline tests

    • eGFR

    • A1c or fasting glucose

    • TSH r/o hypothyroidism (both as a cause of hyperlipidemia and risk factor to myopathy)

Treatment

  • Lifestyle interventions

    • Smoking cessation

    • Mediterranean diet, avoid trans fats and decrease saturated fats

      • Dietician

    • Exercise (150 mins of moderate-vigorous intensity exercise)

  • Statin-indicated conditions (including secondary prevention) consider high-intensity statin (NNT 20-25)

    • Atherosclerosis (eg. ACS) , AAA, DM, CKD, LDL>5 (see image to the right)

    • Can consider ezetimibe as add-on once statin maximized (6% RRR on CVD, no benefit on mortality)

  • Primary-prevention, if 10y CVD risk

    • 10-19%, discuss moderate-intensity statin

      • Consider statin if

        • LDL≥ 3.5 mmol/L

        • Men≥50yo, Women≥60yo with ≥1 CV risk factor

      • Can consider Coronary Artery Calcium (CAC) scan or Lp(a) to further guide decision on starting statin

    • ≥20%, consider high-intensity statin (25% RRR on CVD, 14% RRR on mortality, NNT 35)

      • If ≥20% or CVD, can offer ASA if bleeding risk low (12.5% RRR on CVD)

  • Consider lower intensity statin if elderly or CKD

    • Uncertain benefit of statins in elderly

  • If unable to tolerate, offer lower-intensity or drug holiday

  • Can consider ASA in primary prevention

Statins

  • Rosuvastatin 2.5mg, 5-10mg, 20-40mg PO daily (Cheapest)

    • Alternatives: Atorvastatin, Simvastatin, Lovastatin, Avoid Pravastatin in >65yo risk of cancer

  • If myalgias: Stop statin, follow CK until normal, consider restarting at lower dose / different statin / referral

  • Consider baseline CK, ALT but generally NOT needed to be followed

    • CK or ALT levels only if symptomatic or high risk of adverse events

  • Cholesterol target for reducing CVD NOT required (statins have been shown to reduce risk regardless of LDL)

    • Monitoring lipid levels during therapy NOT required

    • Note: CCS guidelines still recommend LDL targets despite no conclusive data for using targets

      • LDL-C <2 mmol/L or >50% reduction

      • Alternative target variables are apoB < 0.8 g/L or non-HDL-C < 2.6 mmol/L

  • Consider add-on therapy if very high risk (ezetimibe, PCSK9i)

References:

Reducing CVD Risk Patient Handout.pdf