148. Lipids, Cholesterol, Hyperlipidemia--- NEW GUIDELINES!

We stuck purely to the evidence. There was no evidence panel or committee to vote on the evidence like is often done by the American college of rheumatology and no expert opinion statements where their only citation is themselves like can be seen with the ACC. This was purely 100% evidence recommendations.



So lets start try to make it quick because guidelines on a podcast a boring, I want to hit the high points and get out of here



This guideline does not cover 1) adults < age 40 years old o

2) patients with ejection fraction <35%

3) pts with life expectancy less than 5 years

4) Patients with genetic dyslipidemia conditions were also excluded



Now to the recomendations





. test a serum Cholesterol level every ten years!! Yes 10yrs. If you are testing more frequently than that you are likely seeing variability in the test and not a true change. Cholesterol levels are stable! If you see a change it is because you are seeing a change in the point estimate—remember it might say ldl 100 but there are CI around that 100 so you might check it again and it says 115 or 120 and those stastically are the exact same number AND there is intra-varibility. If you test on me Tuesday I might be 100 and test me on Wednesday I might be 130. I am the same person I am not at all of a sudden greater risk one day later it is just the intra-variability that exist within people



BUT just because you are checking a cholesterol once every 10yrs doesn’t mean you shouldn’t do a risk screen more frequent. recommended every 2 years when risk is 6-12% and every 5 years when risk is less than 6%. This risk assessment can use cholesterol levels obtained in the previous 10 years



And you might say well what can I use to help me predict the future, meaning we know some patients that are at 8% risk or really any percent risk will have a cardiovascular event. The ideal situation would be to predict the future and for those individiuals that are going to have an event we make sure that we treat them and we do not treat the individiuals who are never going to have an event. If you are never going to have an event but prematurely placed on therapy that is over diagnosis and that is very bad so we only want to treat the inidivudals that are going ot have an event, in the perfect world.

We we lookg for extra test and

Risk stratification is not improved by additional test including!! NONE! not coronary artery calcium, not high-sensitivity C-reactive protein, and not ankle-brachial index. There is no magic test to help you predict the future.


Risk stratification is not improved by additional test including!! NONE! not coronary artery calcium, not high-sensitivity C-reactive protein, and not ankle-brachial index. There is no magic test to help you predict the future. So forget about it



And speaking of forget about--- Omega-3 fatty acid supplementation forget about it. Other supplements like Fiber, ginger, green tea and red yeast rice forget about it!!! Or at least forget about it if your goal is cardiovascular risk reduction.. the evidence does not support this.



OOO fibrates and Niacin, please never again- not for primary prevention not for secondary prevention, evidence also does not support their use, just purge those drugs from your memory bank



And anytime I say the word purge it makes me thing binge and purge of diet and exercise so lets move onto that---

For a diet- Mediterranean diet decreases rates of cardiovascular events, stroke, type 2 diabetes, and all-cause mortality

For exercise- we recommend aerobic exercise of any shape and size. That’s right we don’t discriminate. We think all exercise is beautiful. Sure we would love for you do to 30 minutes a day but sometimes that is not feasible or reasonable so we say just do something. The largest benefit came in individuals that were sedentary then did something!! So 5 minutes is better than no minutes because ANYTHING is better than no minutes.



Woooo ok ok enough of the rant lets get to the treatment and get out of here



So that means for primary prevention we really ONLY have one drug. ONE drug and that is a moderate dose statin! Don’t do a high dose statin because for primary preention there is no benefit over a moderate dose statin. Moderate dose only.



That is easy to remember but for SECONDARY PREVENTION-



In secondary prevention, we recommend moderate-dose statins as the main treatment to be consistent with trial evidence, and remember if you write for a high dose statin even in secondary prevention you don’t improve fatal events ONLY NON FATAL EVENTS compared to moderate dose statin. And if you patient want to further reduce their CV risk. Then we suggest switching to high-dose statins or adding ezetimibe to moderate dose statin which seem to have pretty similar effects in reduction of nonfatal cardiovascular events. AND if they real high risk and still want to risk reduction we suggest PCSK9 inhibitors. However with pcsk9 inhibitors it is key to remember they were mainly studied in high risk populations, FOR EXMAPLE those with acute or recent MI. AND WE HAVE NO LONG TERM DATA. And they cost more than my house so your pt. needs good insurance. BUT if your pt fits all those criteria then you can go agead and disucss starting PCSK9 inhibitors.









So what do you do—uspstf or the AHA ACC or the VA LIPID

I am bias

Well article on Medscape

The Lipid Guideline I Follow in Primary Care written by Kenny lin a fp physician at georgetown



Until the USPSTF updates its 2016 recommendation statement, I advise mostly relying on the VA/DoD's guidance, particularly for primary prevention. By performing a more comprehensive systematic review of the key clinical questions and not making any recommendations that go beyond the supporting evidence, the VA/DoD ensured that its guideline is the most likely to improve patient outcomes and minimize harms.