Episode 183: 183. PART 2 DYSH Out Information on DYSlipidemia, an Evidence Based Approach

DYSh out information on DYSlipidemia: An Evidence-based Update on Cholesterol Management

Please contact me for more information: Andrew Buelt, D.O.

andrewbuelt@gmail.com

Questioning Medicine Podcast

• Athrosclerotic Cardiovascular Disease Risk Calculator (ASCVD)
  • 10 yr ASCVD risk calculator developed in 2013
  • ASCVD event defined as nonfatal myocardial infarction, coronary heart disease (CHD) death, fatal or nonfatal stroke
  • Development of ASCVD calculator used African-American and White men and women age 40 to 79 yrs old (not hispanic, watch for inclusion drift)
  • Risk assessment should occur every 5 yrs in moderate risk individuals and can occur more frequently if the patient is nearing a cutoff for treatment

• Serum Lipid Level
  • Lipid levels are stable over long durations of time
  • Serum lipid lab values have high intra-test variability
  • Testing more frequently than every 10 years leads to overdiagnosis from lab error and not true changes in serum lipid levels.

• Primary Prevention

• Treatment
  • Statins are the only currently approved drug to reduce cardiovascular events in primary prevention patients
  • Primary prevention statins should be used for those with diabetes, LDL ≥ 190, ASCVD 10 yr risk of 11.25%
  • No trial has EVER looked at treatment titration to a specific cholesterol number compared to standard treatment dose...EVER

• Coronary Calcium Scoring
  • No prospective RCT exist
  • Largest observational study currently in existence had 5,185 patients, 58 patients were correctly reclassified, 292 patients incorrectly reclassified, 4,835 patients had no benefit or harm other than lost time, money, resources (0.3% benefit, 6.7% harm, 93% no benefit or harm)

• Secondary Prevention
  • Define as individuals with previous angina, MI with or without intervention, ischemic stroke/TIA, peripheral arterial disease (claudication or abdominal aortic aneurysm)
• Treatment
  • -First Line Treatment = Statin
    • High dose statin reduces major adverse cardiovascular events by 1% more than moderate dose statin
    • High dose statin cause adverse events WITH therapy discontinuation 1% more often moderate dose statin
    • ANY dose statin is better than no statin
    • Statins cause myalgias at a rate that is not statistically different from placebo
  • Second line treatment
    • Increase statin dose to max tolerated then add Ezetimibe
  • Third line treatment
    • PCSK9 inhibitor