Dyslipidemia and Primary Prevention Therapeutics I jfarrar7@uthsc.edu

Tips for success: For case based questions, it can save time to read the question first, and then read through the case. Read case information carefully! SCROLL DOWN Use process of elimination. If you do not immediately know which answer is correct, try to determine reasons why the other possible answers might be incorrect. Study thoughtfully. This class is more than straight memorization.

Diabetes Type I or 2 and age 40-75 yo Use this case to answer the following 4 questions: AG is a 45 yo male recently diagnosed with hyperlipidemia. He has a pmh of t2dm, tia three years ago, and htn for which he takes amlodipine. his fh includes his mother experiencing an mi at age 64. he denies cigarette or regular alcohol use. His 10-yr ASCVD risk score is 7.4%. His most recent lipid panel included the following: TC 210, HDL 45, LDL 124, TG 205. According to ACC/AHA guidelines, what statin benefit group does ag fall into? Clinical ASCVD LDL-C ≥190 mg/dL Diabetes Type I or 2 and age 40-75 yo ≥ 7.5% estimated 10-yr ASCVD risk and age 40-75 yo Technically A and C, but we will treat him based on A since this is technically worse. This treatment will technically be secondary prevention, because he has already developed disease and experienced an event.

AG is a 45 yo male recently diagnosed with hyperlipidemia AG is a 45 yo male recently diagnosed with hyperlipidemia. He has a pmh of t2dm, tia three years ago, and htn for which he takes amlodipine. his fh includes his mother experiencing an mi at age 64. he denies cigarette or regular alcohol use. His 10-yr ASCVD risk score is 7.4%. His most recent lipid panel included the following: TC 210, HDL 45, LDL 124, TG 205. The decision is made to initiate statin therapy. What would be the most appropriate initial therapy based on acc/aha guidelines? Simvastatin 40 mg Lovastatin 20 mg Atorvastatin 20 mg Rosuvastatin 20 mg D- high intensity statin because has clinical ASCVD, and other risk factors. High intensity statins provide LDL lowering on average of about 50%. (or should if the patient is not resistant)

TIA is a form of coronary artery disease assuming that it was due to an atherosclerotic cause. So we will put him into the clinical ASCVD category because he has had an actual event.

CS is a 45 yo male recently diagnosed with hyperlipidemia CS is a 45 yo male recently diagnosed with hyperlipidemia. He has a pmh of t2dm, tia three years ago, and htn for which he takes amlodipine. his fh includes his mother experiencing an mi at age 64. he denies cigarette or regular alcohol use. His 10-yr ASCVD risk score is 7.4%. His most recent lipid panel included the following: TC 210, HDL 45, LDL 124, TG 205. based on nla guidelines, how many ascvd risk factors does ag have? 1 2 3 4 C

Pravastatin 20 mg + Zetia (ezetimibe) 10 mg AG is a 45 yo male recently diagnosed with hyperlipidemia. He has a pmh of t2dm, tia three years ago, and htn for which he takes amlodipine. his fh includes his mother experiencing an mi at age 64. he denies cigarette or regular alcohol use. His 10-yr ASCVD risk score is 7.4%. His most recent lipid panel included the following: TC 210, HDL 45, LDL 124, TG 205. Based on NLA guidelines, what is the most appropriate initial treatment? Atorvastatin 40 mg Pravastatin 20 mg + Zetia (ezetimibe) 10 mg Welchol 625 mg 3 tablets BID Niacin ER 2000 mg A. Non-HDL C = 210-45 = 165. Consider drug therapy for very high risk patient whenever you are at goal, and this patient is 65 above goal of 100. consider moderate to high intensity statin treatment. Not a candidate for non-statin therapy at this time because we are initiating treatment. Statins are first line.

Very high because he has ASCVD Very high because he has ASCVD. He also has T2DM and 3 ASCVD risk factors, so he is doubly very high risk.

Our patient is above both of his treatment goals, so we are going to definitely initiate drug therapy When do we initiate drug treatment in low risk? >60 above goal When do we initiate drug treatment in moderate risk? >30 above goal When do we initiate drug treatment in high risk? At goal Consider initiating drug therapy in very high risk patients when they are at or above treatment goal

Use this case to answer the following 4 questions: WD is a 70 yo male with a 10-yr ascvd risk of 7.9%. He has been compliant taking his atorvastatin 20 mg daily for the past 3 months. At his most recent doctor’s visit, his cholesterol panel results were the following: TC 184, HDL-c 39, ldl-c 110, tg 175. What is the Recommended treatment goal according to acc/aha guidelines? Non-HDL-C <130 mg/dL LDL-C <100 mg/dL Non-HDL-C <100 mg/dL None of the above D- ACC/AHA does NOT provide any definitive treatment goals in regards to LDL or non-HDL cholesterol

WD is a 70 yo male with a 10-yr ascvd risk of 7. 9% WD is a 70 yo male with a 10-yr ascvd risk of 7.9%. He has been compliant taking his atorvastatin 20 mg daily for the past 3 months. At his most recent doctor’s visit, his cholesterol panel results were the following: TC 184, HDL-c 39, ldl-c 110, tg 175. What is the recommended treatment goal according to NLA guidelines? Non-HDL-C <100 mg/dL Non-HDL-C <130 mg/dL LDL-C <70 mg/dL None of the above B. This patient has 2 risk factors: age (male>45) and low HDL (male<40). Falls into the moderate category, so our goals are Non-HDL <130 and LDL <100. What is the secondary target according to NLA guidelines? ApoB. His goal? <90. Is the current therapy appropriate? Yes. He is on a moderate intensity statin, which is appropriate according to NLA and ACC/AHA guidelines.

WD is a 70 yo male with a 10-yr ascvd risk of 7. 9% WD is a 70 yo male with a 10-yr ascvd risk of 7.9%. He has been compliant taking his atorvastatin 20 mg daily for the past 3 months. At his most recent doctor’s visit, his cholesterol panel results were the following: TC 184, HDL-c 39, ldl-c 110, tg 175. WD’s PCP wants to escalate his statin therapy since he is not at goal. What would be an appropriate statin and dose to initiate at this time? Rosuvastatin 10 mg Pravastatin 80 mg Atorvastatin 80 mg Simvastatin 80 mg C- he is taking the atorvastatin without any side effects or issues it seems, so escalate dose to high intensity. This is still within the confines of both guidelines, because ACC/AHA says with ASCVD score >7.5% you can use mod-high, and NLA says consider mod-high for all classifications.

D/C atorvastatin 80 mg and initiate rosuvastatin 20 mg WD is a 70 yo male with a 10-yr ascvd risk of 7.9%. He has been compliant taking his atorvastatin 20 mg daily for the past 3 months. At his most recent doctor’s visit, his cholesterol panel results were the following: TC 184, HDL-c 39, ldl-c 110, tg 175. After 4 weeks on his new regimen, WD returns to his doctor for another panel. His new numbers are tc 150, hdl-c 40, ldl-c 90, tg 100. since wd has not met his Non-hdl-c goal, what is the best treatment option at this point? Add simvastatin 20 mg D/C atorvastatin 80 mg and initiate rosuvastatin 20 mg Add Welchol (colesevelam) 625 mg 3 tablets BID Add Zetia (ezetimibe) 10 mg QD D- when patient has no ASCVD or DM, but risk > 7.5%, an inadequate response to statin therapy = addition of Zetia first line. Addition of bile acid sequestrant is second line. What are some alternatives to adding a non-statin at this point? Fine-tune statin therapy, could try Crestor 40 mg perhaps. Also could simply reinforce lifestyle modifications, make sure the patient is eating right and exercising more often.

Atorvastatin 20 mg Atorvastatin 80 mg Zetia 10 mg

KG is a 31 yo asian female who has been diagnosed with hyperlipidemia KG is a 31 yo asian female who has been diagnosed with hyperlipidemia. She has no other pre-existing conditions, but she tells her pcp that she wants to become pregnant within the next year. Her fh is significant for her father dying of a heart attack at 45, and she claims that she currently has one glass of wine per night but does not smoke. What is the most appropriate prescription treatment at this time? Simvastatin 20 mg Rosuvastatin 5 mg Niacin 2000 mg QD Zetia 10 mg QD D- this patient wants to get pregnant, and statins are Cat X!! Zetia would be the best option for this patient at this time. Based on what her lipid panel looked like, what else could you recommend? Diet and lifestyle changes. Zetia is Cat C, so not completely without risk If this patient was not trying to get pregnant, what might you suggest? Bc Asian, simva 20 is the max dose. And Crestor 5 mg is what you initiate at.

Creatine phosphokinase Liver function tests C-reactive protein Use this case to answer the following 2 questions: AT is a 63 yo wf who has been on statin therapy for 1 month. She presents to her pcp’s office today complaining of muscle pain. Her doctor is concerned that her daily dose of simvastatin 40 mg may be causing this effect. What labs might her pcp want to check/monitor at this time? Creatine phosphokinase Liver function tests C-reactive protein All of the above A & B only E- CPK is one of the major monitoring points with statins. Rhabdo = CPK >10x ULN + elevated SCr LFTs are usually transient elevations, but still need to be monitored. LFT > 3x ULN CRP is something you look at more with initiation of therapy, assessing the patient’s ASCVD risk

D/C simvastatin and initiate pravastatin 20 mg AT is a 63 yo wf who has been on statin therapy for 1 month. She presents to her pcp’s office today complaining of muscle pain. Her doctor is concerned that her daily dose of Simvastatin 40 mg may be causing this effect. What would be the most appropriate change to make to the patient’s current regimen? Add Zetia 10 mg QD D/C simvastatin and initiate pravastatin 20 mg D/C simvastatin and initiate atorvastatin 20 mg D/C simvastatin and initiate lovastatin 20 mg B- pravastatin is a hydrophilic statin, which could therefore have fewer side effects! (rosuvastatin is also hydro) All others are lipophilic. If she cannot tolerate at least 2 other statins, then Zetia might be an option to consider. How do you make sure that the myopathy is from statin use? When stop statin, if myopathy resolves in 2 wks, statin-induced. If stop and restart and myalgia comes back within 4 weeks, statin-induced.

Use this case to answer the following 3 questions: CC is a 55 yo male who drives trucks for a living and is unable to get out and exercise much in between trips. His pmh is significant for htn and t2dm, for which he takes amlodipine and metformin respectively. His bmi is 32. His fh is significant for his brother experiencing an MI at the age of 45. he denies smoking, but claims that he has a beer before bedtime each night. CC’s 10-yr Ascvd risk score is 15%. How many modifiable CVD risk factors does cc have? 2 3 4 5 C. sedentary, HTN, DM, and obesity (BMI≥30 is considered obese)

MI and stroke are ultimately what we are trying to prevent, these are considered events that differentiate between primary and secondary prevention.

CC is a 55 yo male who drives trucks for a living and is unable to get out and exercise much in between trips. His pmh is significant for htn and t2dm, for which he takes amlodipine and metformin respectively. His bmi is 32. His fh is significant for his brother experiencing an MI at the age of 45. he denies smoking, but claims that he has a beer before bedtime each night. CC’s 10-yr Ascvd risk score is 15%. How many non-modifiable CVD risk factors does cc have? 1 2 3 4 C. Age (>45), FH, and male.

Stop all alcohol intake CC is a 55 yo male who drives trucks for a living and is unable to get out and exercise much in between trips. His pmh is significant for htn and t2dm, for which he takes amlodipine and metformin respectively. His bmi is 32. His fh is significant for his brother experiencing an MI at the age of 45. he denies smoking, but claims that he has a beer before bedtime each night. CC’s 10-yr Ascvd risk score is 15%. What would be the most appropriate non-pharmacologic recommendation at this time? Stop all alcohol intake Increase exercise to 30 min 5x per week of moderate intensity cardio Reduce intake of carbohydrates in the diet No intervention needed B. It is recommended that you perform at least 150 min per week of moderate-high intensity aerobic exercise to maintain CV health. He would benefit most from additional 25 min of mod-high intensity resistance training or exercise 2 days per week as well. He would need 300 min per week for weight loss, which he would also benefit from.

We wouldn’t stop all alcohol intake, because 1-2 drinks/d in men and 1 drink/d in women can be beneficial to CV health. We don’t want to encourage a low carb diet in this patient, because AHA recommends that you watch your overall eating pattern rather than just one component.

Begin a regimen of ASA 81 mg QD Begin a regimen of ASA 325 mg QD A patient enters the pharmacy to pick up his monthly prescriptions of amlodipine, warfarin, clopidogrel and digoxin. He inquires about the possibility of taking a daily dose of aspirin for heart health. He is 63 years old, and his mother died of a stroke at the age of 62. He smoked whenever he was in the navy, but has not smoked since he quit 15 years ago. You quickly calculate his 10-yr ASCVD risk score to be 11%. What is the most appropriate recommendation regarding ASA at this time? Begin a regimen of ASA 81 mg QD Begin a regimen of ASA 325 mg QD Recommend that he is too old to benefit from ASA at this time This patient is not a good candidate for ASA therapy D. He is taking warfarin AND clopidogrel concomitantly, which already puts him at a high bleeding risk. Adding ASA is not a good choice for him at this time. What if the ASA was enteric coated? Still no, because there is no proof that EC formulations reduce the risk at all.

Which of the following patients would derive the most benefit from low-dose ASA treatment? 65 year-old with a 10-yr ASCVD score of 13% 52 year-old with a 10-yr ASCVD score of 10% 55 year-old with a 10-yr ASCVD score of 7.5% 68 year-old with a 10-yr ASCVD score of 15% B. this is the only patient in the age group that derives the most benefit, and also has a high enough ASCVD score. The other patients with ASCVD scores do qualify for ASA treatment, but they do not derive as much benefit as the 50-59 age group does

JB is a 65 yo female recently diagnosed with hyperlipidemia JB is a 65 yo female recently diagnosed with hyperlipidemia. She has no significant pmh, but her cholesterol panel was the following at her last pcp visit: TC 267, ldl-c 194, hdl-c 52, tg 105. Her 10-yr ASCVD risk score is 6.4%. Which of the following regimens would this patient benefit from the most? Atorvastatin 20 mg Rosuvastatin 40 mg Pravastatin 40 mg Simvastatin 80 mg B. This patient fits into the LDL >190 category. We need to treat her with high intensity statin, so rosuvastatin is the only correct choice.

RP is a new patient at your clinic RP is a new patient at your clinic. She is a 75 year old female with pmh of unstable angina, htn, dm, and hld. Her current medication regimen includes hctz, carvedilol, atorvastatin, and metformin. Her htn and dm are currently controlled, but her ihd has been acting up lately. Her 10-yr ASCVD risk score is 15.4%. Her doctor has asked you to fine tune her medication regimen. Based on what you know about primary prevention, which of the below regimens would you deem most appropriate? Atorvastatin 80 mg, ASA 81 mg, lisinopril 10 mg. Maintain metformin, HCTZ, and carvedilol at current doses. Atorvastatin 20 mg, ASA 81 mg, ramipril 10 mg. Maintain metformin and HCTZ at current doses, and D/C carvedilol. Atorvastatin 20 mg, lisinopril 10 mg. Maintain metformin, HCTZ, and carvedilol at current doses. Atorvastatin 40 mg, ASA 81 mg. Maintain metformin, HCTZ, and carvedilol at current doses. C. A moderate intensity statin would be best for her bc of age (75). Also, we do not want to initiate ASA at this time because there is no proven benefit or not enough evidence in this age group. Also, we might want to initiate an ACEI because of her clinical CVD (angina/IHD) and DM. we will want to continue to monitor her HTN since we are adding an additional medication that can lower BP, but keeping her on her current regimen for now is probably best.

Hp is a 62 yo female patient who has presented for the first time to your cardiology clinic. After performing a full laboratory work up, you have found the following: TC 180, ldl-c 120, hdl-c 39, tg 105, crp 2.8. she has a pmh significant for htn, but no significant fh. What treatment recommendation would you suggest at this time? Diet and lifestyle changes, reassess in 1 year. Atorvastatin 10 mg Lovastatin 20 mg Rosuvastatin 10 mg D- this patient’s cholesterol is not hugely elevated, she is not necessarily within treatment guidelines based on NLA or ACC/AHA. But her CRP is ≥ 2, so she is a candidate for treatment with rosuvastatin for primary prevention!

She is over 60, has CRP greater than 2, and also has HTN and low HDL She is over 60, has CRP greater than 2, and also has HTN and low HDL. She is a candidate!

Questions?