Hyperlipidemia

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 overall 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)

  • If additional cardiovascular risk reduction is desired beyond max statin therapy, can consider ezetimibe (6% RRR on CVD, no benefit on mortality) or PCSK9 inhibitor as add-on

    • Only consider icosapent add-on after ezetimibe or PCSK9-inhibitors because of potential adverse effects (atrial fibrillation, bleeding)

• Primary-prevention, if 10y CVD risk

  • <10%, consider retesting lipids q10y with risk estimation

  • 10-19%, discuss moderate-intensity 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