2.  Screening › Who needs screened? › How often?  Diagnosis  Treatment  Questions › What do I do about triglycerides? › What if a patient isn’t at goal? › What about all those warnings on increasing statin doses? › What about low HDL?

6.  USPSTF › Men  35 and older (Grade A)  20-35 with increased risk for CAD (Grade B) › Women  45 and older (Grade A)  20-45 if at increased risk (Grade B) › Increased risk defined as presence of any one of the following:  Diabetes  Previous personal history of CHD or non-coronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis)  A family history of cardiovascular disease before age 50 in male relatives or age 60 in female relatives  Tobacco use  Hypertension  Obesity (body mass index [BMI] >30) › Total cholesterol and HDL-C on non-fasting or fasting  Can check LDL-C, but requires fasting sample › About every 5 years, more frequent if level close to needing treatment

7.  NCEPIII (ATPIII) › Once every 5 years for all people 20 years and older › Patients without CHD or equivalent, re-screen every 5 years unless cholesterol is borderline (>160 with 0-1 risk factors or >130 with 2+ risk factors) then re-screen in 1-2 years › Screen with fasting lipid panel (preferred) or total cholesterol and HDL  AAFP › Males 35 and older, Females 45 and older › Fasting lipid panel or total and HDL

12.  35 year old female › Depression, History of gestational diabetes, obese  Lipid panel › Total 234 › TG 257 › HDL 38 › LDL 145  What do you do?  When do you repeat her lipid panel?

13. Risk Category LDL goalLDL level at which to initiate therapeutic lifestyle changes LDL level at which to consider drug therapy CHD, CHD equivalent or 10-year risk >20% <100>100>130, optional 100-129 2 or more risk factors 10-year risk <20% <130>13010yr risk 10- 20% >130 10yr risk 160 0-1 risk factors <160>160>190, optional >160

14.  48 year old male › Smoker, otherwise healthy  Lipid panel › Total 234 › TG 257 › HDL 41 › LDL 145  What do you do??

15.  CHD equivalents › DM › Symptomatic Carotid Artery Disease › Peripheral Artery Disease › AAA › +/- Renal Failure (Cr>1.5)—not ATPIII  Major CHD Risk Factors › Cigarette Smoking › HTN (>140/90 or antihypertensive meds) › Low HDL (<40) › Family history of premature CHD (1 ST degree relative <55 men,<65 women) › Age (>45 men, > 55 women) › HDL >60 takes away one of the risk factors above

16. Risk Category LDL goalLDL level at which to initiate therapeutic lifestyle changes LDL level at which to consider drug therapy CHD, CHD equivalent or 10-year risk >20% <100>100>130, optional 100-129 2 or more risk factors 10-year risk <20% <130>13010yr risk 10- 20% >130 10yr risk 160 0-1 risk factors <160>160>190, optional >160

17.  Weight loss if overweight › BMI >25  Aerobic Exercise › Moderate exercise most days a week › 30min, 5x per week  Diet › Increase fruits and vegetables, 5+ servings per day › High Fiber › Decrease trans fats  Stick and full fat margarine, commercial baked goods, fried foods, fast food

18.  61 year old male › Diabetic, former smoker (quit 10 years ago, 30 pack year history) › Lipid panel  Total 230  TG 569  HDL 20  LDL 96, Direct LDL 124  What do you do??

19.  ATP III considers DM a CHD equivalent  Another suggestion for looking at DM › Men over age 40 with type 2 DM and any other CHD risk factor, or over age 50 with or without other CHD risk factors › Women over age 45 with type 2 DM and any other CHD risk factor, or over age 55 with or without other CHD risk factors › Men or women of any age who have had DM (type 1 or type 2) for more than 20 years if they have another risk factor or more than 25 years without another risk factor

20. Risk Category LDL goalLDL level at which to initiate therapeutic lifestyle changes LDL level at which to consider drug therapy CHD, CHD equivalent or 10-year risk >20% <100>100>130, optional 100-129 2 or more risk factors 10-year risk <20% <130>13010yr risk 10- 20% >130 10yr risk 160 0-1 risk factors <160>160>190, optional >160

21.  53 year old male › Smoker, HTN (on BP meds, now BP in 130s/70s) › Lipid panel  Total Cholesterol 198  TG 128  HDL 26  LDL 146

22.  CHD equivalents › DM › Symptomatic Carotid Artery Disease › Peripheral Artery Disease › AAA › +/- Renal Failure (Cr>1.5)—not ATPIII  Major CHD Risk Factors › Cigarette Smoking › HTN (>140/90 or antihypertensive meds) › Low HDL (<40) › Family history of premature CHD (1 ST degree relative <55 men,<65 women) › Age (>45 men, > 55 women) › HDL >60 takes away one of the risk factors above

23.  If > 2 risk factors then need to use Framingham calculator  http://hp2010.nhlbihin.net/atpIII/calculat or.asp?usertype=prof http://hp2010.nhlbihin.net/atpIII/calculat or.asp?usertype=prof

24. Risk Category LDL goalLDL level at which to initiate therapeutic lifestyle changes LDL level at which to consider drug therapy CHD, CHD equivalent or 10-year risk >20% <100>100>130, optional 100-129 2 or more risk factors 10-year risk <20% <130>13010yr risk 10- 20% >130 10yr risk 160 0-1 risk factors <160>160>190, optional >160

25.  So, they need treatment….what do you choose and what dose?  What if they have insurance?  What if they have no insurance?

26.  Primary Prevention › Lowering Cholesterol in patient without CHD or CHD equivalents  Lifestyle Modification  Statin therapy  20-30% reduction in CHD events seen in most trials  Moderate dose (40mg lovastatin, pravastatin, simvastatin, 20mg atorvastatin)  Non-statin therapy  Some studies showed increase in noncardiovascular mortality  ATPIII would recommend if can’t tolerate statin or do not achieve goal with statin therapy alone

27.  Secondary Prevention—Known CHD or CHD equivalents › Initiate moderate dose statin therapy › If statin therapy is not tolerated, initiate non- statin › Some suggest starting statins even if LDL is at goal in pts with CHD/CHD equivalents

28. AtorvastatinFluvastatinLovastatinPitavastatinPravastatinRosuvastatinSimvastatin BrandLipitorLescolMevacorLivaloPravacholCrestorZocor LDL  38-54%17-33%29-48%31-41%19-40%52-63%28-48% Dose10-8020-80 1-410-40 10-80 Time of admin EveningBedtimeWith mealsAnytimeBedtimeAnytimeEvening HDL****** TG** Side effect Lipophilic Less Lipophilic Less Hydrophilic Less Hydrophilic Lipophilic Cost$100-140$100$4 WM $140$10/yr then $4/mo Kmart

30.  They’re so good, we should just add them to the water right???  Well, maybe not…

31.  Hepatic Dysfunction › 0.5-3% occurrence of persistent elevation of LFTs, may not be that much more than placebo › Mixed recommendations on whether or not to monitor LFTs › If elevated look for drug interactions, other causes of liver disease › Consider decreasing dose or changing meds if persistently 3x upper limit of normal

32.  Muscle injury › 2-11% myalgias, 0.5% myositis, <0.1% rhabdo › Myalgias can occur with normal CK › Usually occurs weeks-months after starting statin and returns to normal days-weeks after stopping › Less likely with pravastatin or fluvastatin › Hypothyroidism increase risk › Increased risk with gemfibrozil

33.  Proteinuria—mixed results  Cognitive Function › possible slowing, memory loss › Higher in lipophilic (Simvastatin, rosuvastatin)  Diabetes—probably small increased risk  Neuropathy  Cataracts  Pregnancy and Breastfeeding

34.  Coumadin › Use pravastatin, fluvastatin, rosuvastatin  Avoid rosuvastatin with protease inhibitors  Gemfibrozil › Use pravastatin or fluvastatin  Cyclosporine › Use pravastatin  Plavix › Any statin OK

35.  Chronic Kidney Disease › Atorvastatin and Fluvastatin—no dose adjustment  Chronic Liver Disease › Pravastatin at low dose, and complete abstinence of ETOH › In patient with NASH—ok to use

36.  What if the patient can’t tolerate statins?  What if not at goal with statin alone?

37.  Bile Acid Sequestrans › cholestyramine (Questran), colestipol (Colestid), coleselvelam (Welchol) › Reduce LDL by 10-15% › Side effects—nausea, bloating, cramping › Work in conjunction with statin or nicotinic acid › $80-$100/month

38.  Nicotinic Acid › 1500-2000mg › Reduce TG by 15-25% › Raises HDL by 30-35% › Monitor glycemic control carefully in diabetics › Flushing in 80% of patients, Nausea, puritis and parasthesias in about 20%, reduced by taking 325mg of ASA 30min prior to Nicotinic Acid › Can lead to hepatocellular injury, must monitor LFTs › OTC preparations not regulated  Slo-Niacin $25  Niaspan $100

39.  Ezetimibe › Reduce LDL by 17% at 10mg/day › Increases LDL lowering properties of statin, but end-point benefit unclear › May increase incidence of myopathy  Fish Oil › > 3 g per day of EPA/DHA › Reduce TG by 25-30% or more › Raises HDL by 3%

40.  Fibrates › Gemfibrozil (Lopid), Fenofibrate (Tricor) › Reduce TG levels by 20-50% › Raise HDL by 11% › Gemfibrozil increases risk of muscle toxicity with statin › Non TG hyperlipidemia, no real evidence for decrease in mortality › Reduce coumadin dose by 30%

41.  51 year old male › HTN, Tobacco Abuse, depression, chronic back pain › Simvastatin 40mg, Tricor 145mg › Lipid Panel  Total 163  TG 484  LDL 42  HDL 24 › What should you do about TG?

42.  Definition of : › Normal <150 mg/dL (1.7 mmol/L) › Borderline high — 150 to 199 mg/dL (1.7 to 2.2 mmol/L) › High — 200 to 499 mg/dL (2.3 to 5.6 mmol/L) › Very high — ≥500 mg/dL (≥5.7 mmol/L)  Independent risk factor for CHD, possibly for other vascular events  Associated with › low levels of HDL › Insulin Resistance  Disorders that raise TG › ObestiyHIV antiretrovirals › DMGlucocortiocids › Nephrotic SyndromeRetinoids › Pregnancy › Hypothyroism › Estrogen › B-blockers

43.  200-500 (Mild to moderate) › Diet—”eat less,” avoid high carbs, high fructose foods, increase fish consumption › If CHD risk factors, start Statin therapy  >500 aim at reducing TG › Fibrate first then fish oil › Diet—reduce fat in diet, reduce ETOH intake  If CHD risk factors and high TG › Fibrate first to bring TG down below 500 then statin

44.  70 year old, no health care, told BP was high in the past, and has been high at Wal-mart  Initial lipid panel › Total Cholesterol 344 › TG 109 › HDL 63 › LDL 259 VLDL 22  Further testing and eval—Does have HTN, diabetes A1c 6.5

45.  70 year old continued › Started Simvastatin 40mg, walking 1 mile/day › Lipid panel 4 months later  Total Cholesterol 256  TG 118  HDL 65  LDL 167 › NOT AT GOAL, WHAT DO YOU DO?

46. Risk Category LDL goalLDL level at which to initiate therapeutic lifestyle changes LDL level at which to consider drug therapy CHD, CHD equivalent or 10-year risk >20% <100>100>130, optional 100-129 2 or more risk factors 10-year risk <20% <130>13010yr risk 10- 20% >130 10yr risk 160 0-1 risk factors <160>160>190, optional >160

47.  High-risk patients—Stable CHD or High CHD risk › Moderate dose of statin  Lovastatin, pravastain, simvastatin 40mg  Atorvastatin 20mg  Rosuvastatin 5-10mg  Very High risk › Established CHD PLUS Multiple major risk factors (especially diabetes) OR Severe and poorly controlled risk factors (especially continued smoking) OR Multple risk factors of the metabolic syndrome (especially triglycerides ≥200 plus non-HDL- C ≥130 plus HDL-C <40) OR Acute coronary syndrome › Intensive statin thearpy  Atorvastatin 40-80mg  Rosuvastatin 20-40mg  Simvastatin 80mg (higher side effects)  Monitor closely for side effects

48.  46 year old male › Bipolar, schizophrenia, tobacco abuse, hyperlipidemia › “Allergy” to pravastatin-blurred vision, loss of vision, double vision › Zetia 10mg › Lipid Panel  Total Cholesterol 201  TG 131  LDL 149 VLDL 26  HDL 26 › Do you do anything about his HDL?

49.  ATPIII › Benefit has really only been seen in secondary prevention › Could consider in patients with strong family history › Get LDL to goal › Intensify weight management, physical activity and smoking cessation › Treat hypertriglyceridemia

50.  47 year old male › DM, HTN, Hyperlipidemia, Obesity › Simvastatin 40mg, Tricor 145mg › Lipid panel  Total Cholesterol 198  TG 128  HDL 26  LDL 146  VLDL 26 › LDL not at goal, what do you do?