Latest updated hyperlipidemia guidelines.pptx

Hyperlipidemia

1. Hyperlipidemia Management Amit Gulati, MD Fellow, Cardiovascular Diseases Mount Sinai Beth Israel / West

2. Serum cholesterol is carried by lipoproteins Low density lipoprotein [LDL] Very low density lipoprotein [VLDL] High density lipoprotein [HDL] Population studies suggest that optimal total cholesterol levels are approximately 150 mg/dL (3.8 mmol/L) which corresponds to an LDL-C level of approximately 100 mg/dL (2.6 mmol/L).

3. Scope of the guidelines Although there has been substantial improvement in atherosclerotic cardiovascular disease (ASCVD) outcomes in recent decades, ASCVD remains the leading cause of morbidity and mortality globally. In the United States, it is also the leading cause of death for people of most racial/ethnic groups, with an estimated cost of >$200 billion annually in healthcare services, medications, and lost productivity. Much of this is attributable to suboptimal implementation of prevention strategies and uncontrolled ASCVD risk factors in many adults. Most Americans who have had a myocardial infarction (MI) had unfavorable levels of at least 1 cardiovascular risk factor before their ASCVD event.

4. Important messages for the primary prevention of cardiovascular diseases The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial fibrillation is to promote a healthy lifestyle throughout life. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. In addition, assessing for other risk-enhancing factors can help guide decisions about preventive interventions in select individuals, as can coronary artery calcium scanning. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein and fish. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity.

5. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and achieving exercise recommendations, are crucial. If medication is indicated , metformin is first-line therapy, followed by consideration of a sodium glucose cotransporter 2 inhibitor or a glucagonlike peptide-1 receptor agonist. All adults should be assessed at every healthcare visit for tobacco use. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk discussion.

6. Key aspects of the guidelines on the management of blood cholesterol Recommended risk stratification of patients with ASCVD into “not at very high risk” versus “at very high risk” Advised consideration of ezetimibe and/orPCSK9 inhibitors in selected patients with severe primary hypercholesterolemia or very high risk ASCVD with multiple additional risk factors who are receiving maximally tolerated statins and have inadequate lowering of LDL-C Suggested treatment thresholds, in addition to percentage LDL-C reduction from baseline, in making decisions about the value of adding nonstatins to statins in selected high risk or very high risk patients Suggested for patients with diabetes mellitus the consideration of age, concomitant ASCVD risk factors, duration of diabetes mellitus, and the presence of diabetes mellitus–related complications as an aid in decision making about the intensity of statin therapy  Expanded the discussion of the use of coronary artery calcium (CAC) scoring for selected primary-prevention patients 

7. ASCVD risk calculator

8. For individuals with intermediate predicted risk (≥7.5% to <20%) or for select adults with borderline (5% to <7.5%) predicted risk, coronary artery calcium measurement can be a useful tool in refining risk assessment for preventive interventions (statin therapy). In these groups, coronary artery calcium measurement can reclassify risk upward (particularly if coronary artery calcium score is ≥100 Agatston units (AU) or ≥75th age/sex/race percentile) or downward (if coronary artery calcium is zero) in a significant proportion of individuals.

9. Updates from new expert consensus

10. Patients with ASCVD were categorized into 1 of 2 groups: not at very high risk or at very high risk. Very high-risk patients have a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions. Based on evidence from IMPROVE-IT, FOURIER, and ODYSSEY Outcomes, this very high-risk group of patients has demonstrated cardiovascular benefits from the addition of ezetimibe, evolocumab , and alirocumab. Prospective and observational trials demonstrate a direct and significant relationship between LDL-C level and atherosclerosis progression and ASCVD event risk, and absolute LDL-C reduction is directly associated with ASCVD risk reduction . There appears to be no LDL-C level below which benefit ceases. Current evidence indicates that lifelong very low LDL-C levels in the range of 15-30 mg/dL in patients with hypobetalipoproteinemia or PCSK9 loss-of-function mutations and in shorter-term lipid-lowering clinical trials are associated with a lower incidence of ASCVD without adverse effects.

11. ` <100 mg/dl: Primary prevention <55 mg/dl: Familial hypercholesteremia <55 mg/dl: Very high risk with ASCVD <70 mg/dl: ASCVD All diabetics: moderate intensity statins > if risk enhancers present with 10 year risk >7.5% > high intensity <70 mg/dl: Diabetes with 10 year risk >20%

12. Niacin Clopidogrel Fish oil Ezetimibe Vitamin E

13. Recommendations for monitoring lipid levels

14. Adverse effects of statins

15. Hypertriglyceridemia Classified into moderate (fasting or non-fasting 175 to 499 mg/dL) and severe (fasting triglycerides > 500 mg/dL) Moderate hypertriglyceridemia increases risk of ASCVD due to VLDL In severe hypertriglyceridemia, levels of VLDL and chylomicrons both increase

16. Role of other non-statin drugs Niacin and fibrates reduce TGs but have not been shown to reduce risk of cardiovascular events

17. REDUCE-IT Trial 2019 Randomized 8179 patients with either established ASCVD or Diabetes with ≥1 risk factor for ASCVD randomized to Icosapentethyl vs Placebo Fasting TG levels 135-499 LDL-C >40 and <100 on stable statin therapy for >4 weeks REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial) which showed that among patients with elevated triglyceride levels 135-499 mg/dL and stable ASCVD or type 2 diabetes mellitus despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly lower among those who received 2 g of icosapent ethyl (highly purified EPA) twice daily than among those who received placebo.

18. AHA and ACC scientific statements and expert consensus 2020 recommend consideration of Icosapent ethyl in patients with diabetes mellitus and ASCVD who have elevated triglycerides >135 mg/dL despite lifestyle changes and maximally tolerated statin therapy

19. Questions ?