Management of

dyslipidemia
Amir M. Hanaf
PGY1

Objectives
To know who are the Major 4 statin
beneft groups
To know how to calculate ASCVD risk
To have a clear understanding of how
statins are used in the 4 beneft
groups
To know the need to address
hypertriglyceridemia.

Based on AHA guidelines of

2013

Statin Beneft groups

The evidence:
The Expert Panel found extensive and consistent
evidence supporting the use of statins for the
prevention of ASCVD in many higher risk primary
and all secondary prevention individuals.
In the RCTs reviewed, initiation of moderateintensity
therapy (lowering LDLC by approximately 30% to
<50%), or high-intensity statin therapy (lowering
LDLC by approximately 50%), is a critical factor in
reducing ASCVD events.
Statin therapy reduces ASCVD events across the
spectrum of baseline LDLC levels >70 mg/dL.

Statin Beneft groups

(Contd.)
The groups:
1. Individuals with clinical ASCVD.
2. Individuals with primary elevations of LDLC
>190 mg/dL.
3. Individuals with diabetes aged 40 to 75 years
with LDLC 70 to189 mg/dL and without
clinical ASCVD.
4. Individuals 40-75 with or without clinical
ASCVD or diabetes with LDLC 70 to189
mg/dL and estimated 10-year ASCVD risk
>7.5%.

Clinical ASCVD
Clinical ASCVD is defined by the
inclusion criteria for the secondary
prevention statin RCTs:
1.
2.
3.
4.
5.

acute coronary syndromes

history of MI
stable or unstable angina
coronary or other arterial revascularization,
stroke, TIA, or peripheral arterial disease
presumed to be of atherosclerotic origin).

ASCVD risk estimator (Google play

store - Free)

https://play.google.com/store/apps/details?id=org.acc.cvrisk

10 year risk of ASCVD

Other risk factors to

consider
Primary LDLC 160 mg/dL or other evidence of
genetic hyperlipidemias
family history of premature ASCVD with onset
<55 years of age in a frst degree male relative
or <65 years of age in a frst degree female
relative
Highsensitivity C-reactive protein >2 mg/L
CAC score 300 Agatston score or 75
percentile for age, sex
Ethnicity
ankle-brachial index <0.9

Characteristics predisposing
individuals to statin adverse effects
Multiple or serious comorbidities,
including impaired renal or hepatic
function.
History of previous statin intolerance or
muscle disorders.
Unexplained ALT elevations >3 times ULN.
Patient characteristics or concomitant use
of drugs affecting statin metabolism.
>75 years of age.

 Additional characteristics that may

modify the decision to use higher
statin intensities may include, but
are not limited to:
History of hemorrhagic stroke.
Asian ancestry.

Why are we giving statins to

everyone?!
The fndings support the use of statins to
prevent both nonfatal and fatal ASCVD
events.
This can reduce the burden of disability
from nonfatal stroke (for which women are
at higher risk than men) and nonfatal CHD
events.
Primary and secondary prevention of
ASCVD with statins can reduce rising
healthcare costs.

Why are we giving statins to

everyone?!
high level of evidence was found that statins reduce
total mortality in individuals with a history of prior
ASCVD events (e.g., secondary prevention settings).
In individuals with no prior history of ASCVD events
(e.g., primary prevention setting), there is moderate
evidence that statins reduce total mortality in
individuals at increased ASCVD risk.
It should be noted, 2 meta-analyses published after
the completion of the Expert Panels systematic
review provide strong evidence that statins reduce
total mortality in primary prevention.

Statin therapy: Moderate

and high

Initiating treatment in a patient with

ASCVD

Initiating
treatment
in a
patient
with no
ASCVD

Monitoring
Statin Therapy

Statin intolerance
It is reasonable to evaluate and treat muscle
symptoms, including pain, tenderness, stiffness,
cramping, weakness, or fatigue, in statin-treated
patients according to the following management
algorithm:
To avoid unnecessary discontinuation of statins, obtain a
history of prior or current muscle symptoms to establish a
baseline before initiating statin therapy.
If unexplained severe muscle symptoms or fatigue develop
during statin therapy, promptly discontinue the statin and
address the possibility of rhabdomyolysis by evaluating CK,
creatinine, and a urinalysis for myoglobinuria.

Statin intolerance (contd.)

If mild to moderate muscle symptoms develop
during statin therapy:
Discontinue the statin until the symptoms can be
evaluated.
Evaluate the patient for other conditions that might
increase the risk for muscle symptoms (e.g.,
hypothyroidism, reduced renal or hepatic function,
rheumatologic disorders such as polymyalgia rheumatica,
steroid myopathy, vitamin D defciency, or primary muscle
diseases.)
If muscle symptoms resolve, and if no contraindication
exists, give the patient the original or a lower dose of the
same statin to establish a causal relationship between the
muscle symptoms and statin therapy.

Statin intolerance (contd.)

If a causal relationship exists, discontinue the original
statin. Once muscle symptoms resolve, use a low dose
of a different statin.
Once a low dose of a statin is tolerated, gradually
increase the dose as tolerated.
If, after 2 months without statin treatment, muscle
symptoms or elevated CK levels do not resolve
completely, consider other causes of muscle symptoms
listed above.
If persistent muscle symptoms are determined to arise
from a condition unrelated to statin therapy, or if the
predisposing condition has been treated, resume statin
therapy at the original dose.

Non statins (Niacin)

Non statins (Bile Acid

sequestrants)

Non statins (Chol. Abs.

inhibitors)

Non statins (Fibrates)

Non statins (Fibrates)

Non statins (Omega 3 fatty

acid)

EPA, eicosapentaenoic acid ; DHA, docosahexanoic acid

Hypertriglyceridemia
The most clinically relevant complication
of hypertriglyceridemia is acute
pancreatitis, yet only 10% of cases are a
direct consequence of triglyceride levels.
Because documentation for a specifc
threshold in triglyceride-induced
pancreatitis is lacking, levels associated
with increased risk are arbitrarily defned
as triglyceride levels 1000 mg/dL

 Although borderline-high and high

triglyceride levels (150 to 500 mg/dL)
are not associated with pancreatitis,
they are correlated with atherogenic
RLPs and apo CIII enriched particles.
The elevations in triglyceride levels
serve as a biomarker for visceral
adiposity, IR, DM, and nonalcoholic
hepatic steatosis (fatty liver).
RLP = Remenant LipoProtiens, IR = Insulin resistance

Effect of nutrition on TG

Effect of drugs on TG

Take home messages

The treatment of hyperlipidemia is dependent
on the risk it poses on the patient concerning
ASVCD.
Statins are benefcial in both primary and
secondary prevention of ASCVD.
There is not enough evidence to support that
hypertriglyceridemia directly poses risk as far
as ASCVD.
Hypertriglyceridemia is a marker for other
disease that are directly linked to ASCVD such
as visceral adiposity, IR and DM.

References

Than
k
you