cuando, porque y como disminuir el colesterol en mis pacientes?

manejo de hipercolesterolemia en mis pacientes con estatinas para disminuir el riego cardiovascular.

1. CUANDO, PORQUE
Y COMO DISMINUIR
EL COLESTEROL EN MIS
PACIENTES?
DR. JUAN M. VARGAS ESPINOSA
INTERNISTA/CARDIOLOGO
FACULYAD DE MEDICINA UMSNH

2. CUANDO, PORQUE Y COMO DISMINUIR
EL COLESTEROL EN MIS PACIENTES?
Laenfermedad cardiovascularateroesclerotica
(ASCVD)eslaprincipalcausademuerteenel
mundo.
Elincrementoenlasconcentracionesplasmaticas
deapolipoproteinasricasencholesterol(apoB)son
lacausadelaASCVD yaldisminuirlas
concentracionesdeLDL-Cconestatinasyno
estatinas,sereducenloseventoscardiovasculares.
Cannon CP, Blazing MA, GiuglianoRP, et al. Ezetimibe added to statin
therapy after acute coronary syndromes. N EnglJ Med 2015; 372:2387–
2397.

3. En años recientes, la mortalidad por ECNT
se ha incrementado en México.
Entre ellas, las tasas de mortalidad: por diabetes, de 71.6
en 2012 a 84.1 por 100 000 habitantes en 2017.
Por hipertensión arterial, de 16.4 a 18.7 por 100 000
habitantes.
Por enfermedades isquémicas del corazón, de 63.3 en
2012 a 81.9 por 100 000 habitantes para 2017
Instituto Nacional de Estadística y Geografía. Comunicado de prensa Num600/22
Estadísticas de defunciones registradas 2021. México: INEGI

6. QUEPERSONASTRATAR
COMOTRATARLAS

7. Elbeneficiodelaterapiahipolipemiante
dependedelnivelinicialderiesgo:
Mayorriesgo,mayorbeneficio.
Nohaydiferenciasentrehombresymujeres,
jovenesyviejos,inclusiveindividuos>75años,
sinembargolosbeneficiosenmujeresjovenes
nohansidoprobados.
EuropeanJournalof Preventive
Cardiology19(4) 585–667

9. Tratamiento Farmacológico:
Dosis-Respuesta de Estatinas
% Reducción de cLDL
Lovastatina
20/80 mg
Fluvastatina
20/80 mg
Simvastatina
20/80 mg
Pravastatina
20/80 mg
Atorvastatina
10/80 mg
Respuesta a dosis mínimas y máximas
31
37
*
40
47
55
Adaptado de Illingworth. Med Clin North Am.2000;84:23.
*pravastatin PI.
*rosuvastatin para estudio control en proceso PI.
Rosuvastatina
10/40 mg
19
27 28
35
46
12
10
12
12
18
37
0
10
20
30
40
50
60
55
–51%
Inhibición dual
10/20mg
(n=86)

10. Ezetimibe + Simvastatin:
Efectos sobre el colesterol LDL
Mean % Change
10 mg
EZE 10 mg
+
Simva
10 mg
80 mg40 mg20 mg
Simvastatin
* p<0.01 combinación versus estatina
Davidson M et al. ACC 2002: Abstract.

11. 2.In patients with clinical ASCVD, reduce low-
density lipoprotein cholesterol (LDL-C) with
high-intensity statin therapy or maximally
tolerated statin therapy.
The more LDL-C is reduced on statin therapy, the
greater will be subsequent risk reduction.
Use a maximally tolerated statin to lower LDL-C
levels by ≥50%.

12. ESTATINA
DE ALTA
INTENSIDAD
LDL MENOR
DEL 50%
BASAL

13. 3.In very high-risk ASCVD, use a LDL-C threshold of
70 mg/dL(1.8 mmol/L)to consider addition of
nonstatinsto statin therapy.
• Veryhigh-riskincludesahistoryofmultiplemajor
ASCVDeventsor1majorASCVDeventandmultiple
high-riskconditions.
•Inveryhigh-riskASCVDpatients,itisreasonabletoadd
ezetimibetomaximallytoleratedstatintherapywhenthe
LDL-Clevelremains≥70mg/dL(≥1.8mmol/L).
•

14. 3.In very high-risk ASCVD, use a LDL-C threshold of
70 mg/dL(1.8 mmol/L)to consider addition of
nonstatinsto statin therapy.
••InpatientsatveryhighriskwhoseLDL-Clevelremains
≥70mg/dL(≥1.8mmol/L)onmaximallytoleratedstatin
andezetimibetherapy,addingaPCSK9inhibitoris
reasonable,althoughthelong-termsafety(>3years)is
uncertainandcost-effectivenessislowatmid-2018list
prices.

15. 4.In patients with severe primarhypercholesterolemia
(LDL-C level ≥ 190 mg/dL[≥4.9 mmol/L])without
calculating 10-year ASCVD risk, begin high intensity
statin therapy.
5.
If the LDL-C level remains ≥100 mg/dL(≥2.6 mmol/L),
adding ezetimibe is reasonable
6.
If the LDL-C level on statin plus ezetimibe remains ≥100
mg/dL(≥2.6 mmol/L) & the patient has multiple factors
that increase subsequent risk of ASCVD events, a
PCSK9 inhibitor may be considered,

18. 5.In patients 40 to 75 years of age with diabetes
mellitus and LDL-C ≥70 mg/dL(≥1.8 mmol/L),
6.start moderate-intensity statin therapy
7.without calculating 10-year ASCVD risk.
Inpatientswithdiabetesmellitusathigherrisk,
especiallythosewithmultipleriskfactorsorthose50
to75yearsofage,itisreasonabletouseahigh-
intensitystatintoreducetheLDL-Clevelby≥50%.

19. DM2 MAS CUALQUIERA DE LAS 3
DM2 MAS OTROS 2 F. RIESGO CV
DM2 DE ALTO RIESGO

20. 6.In adults 40 to 75 years of age evaluated for primary
ASCVD prevention, have a clinician–patient risk
discussion before starting statin therapy.
Risk discussion should include a review of major risk factors
7.(e.g., cigarette smoking, elevated blood pressure, (LDL-C), hemoglobin A1C [if
indicated], and calculated 10-year risk of ASCVD);
• the presence of risk-enhancing factors.
• the potential benefits of lifestyle and statin therapies.
• the potential for adverse effects and drug–drug interactions; •
8.the consideration of costs of statin therapy.
• the patient preferences & values in shared decision-making.

21. 7.In adults 40 to 75 years of age and with LDL-C levels ≥70 mg/dL
(≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%.
8.start a moderate-intensity statin if a discussion of treatment
options favors statin therapy.
9.If statins are indicated, reduce LDL-C levels by ≥30%
10.and if 10-year risk is ≥20%, reduce LDL-C levels by ≥50%.

22. 8.In adults 40 to 75 years of age without diabetes mellitus and
10-year risk of 7.5% to 19.9% (intermediate risk)
9.Risk-enhancing factors favor initiation of statin therapyinclude:
• Family history of premature ASCVD.
• Persistently elevated LDL-C levels ≥160 mg/dL(≥4.1 mmol/L).
• Metabolic syndrome.
• Chronic kidney disease;

23. 8.In adults 40 to 75 years of age without diabetes mellitus
and 10-year risk of 7.5% to 19.9% (intermediate risk).
9.
10.Risk-enhancing factors favor initiation of statin therapyinclude:
• History of preeclampsia or premature menopause (age <40 yrs)
11.
• Chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis,
or chronic HIV);
• persistent elevations of triglycerides ≥ 175 mg/dL(≥1.97 mmol/L);

24. 9.In adults 40 to 75 years of age and with LDL-
C levels ≥70 -189 mg/dL(≥1.8-4.9 mmol/L),
at a 10-year ASCVD risk of ≥7.5% to 19.9%,
if a decision about statin therapy is
uncertain, consider measuring CAC.

26. Top 10
if a decision about statin therapy is
uncertain, consider measuring CAC.
• If CAC is zero, treatment with statin therapy may be withheld or
delayed,exceptin cigarette smokers, those with diabetes
mellitus, and those with a strong family history of premature
ASCVD.
• A CAC score of 1 to 99 favors statin therapy, especially in those
≥55 years of age.
• For any patient, if the CAC score is ≥100 Agatstonunits,
statin therapy is indicatedunless otherwise deferred by the
outcome of clinician–patient risk discussion.

27. 10.Assess adherence and percentage response to LDL-C–lowering
medications and lifestyle changes with repeat lipid measurement
4 to 12 weeks after statin initiation or dose adjustment, repeated
every 3 to 12 months as needed.
• Defineresponses to lifestyle and statin therapy by
percentage reductions in LDL-C levels compared with
baseline.
• In ASCVD patients at very high-risk, triggers for adding
nonstatindrug therapy are defined by thresholdLDL-C
levels ≥70 mg/dL(≥1.8 mmol/L) on maximal statin therapy.

29. 1.In all individuals, emphasize a heart-healthy
lifestyle across the life course.
A healthy lifestyle reduces atherosclerotic cardiovascular
disease (ASCVD) risk at all ages.
2.In younger individuals, healthy lifestyle can reduce
development of risk factors and is the foundation of ASCVD
risk reduction.
In all age groups, lifestyle therapy is the primary intervention for
metabolic syndrome.

30. DIETA
ACTIVIDAD FISICA
DESCANSO
IMC MENOR DE 25

31. CUANDO, PORQUE Y COMO DISMINUIR
EL COLESTEROL EN MIS PACIENTES?
NOMBRE: PRG SEXO: Masculino. EDAD: 60
años
AHF: Padre falleció a los 75 años por EVC. Madre
falleció a los 80 años por complicaciones de DM2.
APP: Tabaquismo positivo desde los 30 años, fuma 5
cigarrillos diario. Hipertensión Arterial Sistemica
desde hace 10 años, Tx. Con combinación de AII
/Diurético

32. CUANDO, PORQUE Y COMO DISMINUIR
EL COLESTEROL EN MIS PACIENTES?
Acude por cefalea occipital de predominio matutino y
acufenos.
Asintomaticocardiovascular.
EF: TA 150/80, fc80xmin, FR 18Xmin, Talla 1.70, Peso 80 Kg
Exploracioncardiovascular irrelevante.
Laboratorio: Glucosa 95, Urea 35, Creatinina 0.9, CT 210
mg/Dl, TG 179, LDL-C 131 mg/Dl, HDL-C 45, VLDL 36 mg/Dl.

33. CUANDO, PORQUE Y COMO DISMINUIR
EL COLESTEROL EN MIS PACIENTES?
1.-Cual es el RIESGO CARDIOVASCULAR a 10 años
de este paciente?

35. CUANDO, PORQUE Y COMO DISMINUIR
EL COLESTEROL EN MIS PACIENTES?
2.-Que opina sobre el tratamiento antihipertensivo?
3.-Que opina sobre el PERFIL DE LIPIDOS?

37. CUANDO, PORQUE Y COMO DISMINUIR
EL COLESTEROL EN MIS PACIENTES?
4.-Cual seria su meta respecto al
nivel de LDL-C?
5.-Como lo trataría?

39. CUANDO?
RIESGO CARDIOVASCULAR
MODERADO/ALTO/MUY ALTO.
PORQUE?
LDL COLESTEROL ES EL DETERMINANTE
PRIMARIO DE ASCVD
Y COMO DISMINUIR
EL COLESTEROL EN MIS PACIENTES?
ESTATINA MODERADA/ALTA INTENSIDAD
EZETIMIBE + ESTATINA MODERADA INTENSIDAD

40. GRACIAS POR SU
ATENCION