Hyperlipidemia
Screen appropriate patients for hyperlipidemia
In all patients whose cardiovascular risk is being evaluated, include the assessment of lipid status
When hyperlipidemia is present, take an appropriate history, and examine and test the patient for modifiable causes (e.g., alcohol abuse, thyroid disease)
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)
In treating hyperlipidemic patients, establish target lipid levels based on overall CV risk
In patients receiving medication for hyperlipidemia, periodically assess compliance with and side effects of treatment
Lipid Screening
Primary prevention (without CVD)
Consider screen men age 40-75y and women age 50-75y
Consider earlier screening if known traditional CVD risk factors including (eg. hypertension, family history of premature CVD, chronic kidney disease, diabetes, and smoking)
INESSS recommends screening only if ≥ 40yo and CVD risk factor
Repeat lipid screening q10y unless risk factors change
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
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
References:
2023 update PEER simplified lipid guideline. https://www.cfp.ca/content/69/10/675
2015 PEER simplified lipid guideline. http://www.cfp.ca/content/61/10/857.full
2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiol. 2016 Nov;32(11):1263-1282. doi: 10.1016/j.cjca.2016.07.510. Epub 2016 Jul 25. http://www.onlinecjc.ca/article/S0828-282X(16)30732-2/fulltext
Statins for the primary prevention of cardiovascular disease. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD004816. DOI: 10.1002/14651858.CD004816.pub5. http://onlinelibrary.wiley.com/wol1/doi/10.1002/14651858.CD004816.pub5/full
