Who to screen?
- Men >=40yo
- Women >=50yo or postmenopausal
- Pt with the following conditions
- Smoker or COPD
- Obesity – BMI >27
- DM or CKD (eGFR<60) or Arterial HTN
- Clinical evidence of atherosclerosis, AAA,
- Clinical evidence of hyperlipidemia (xanthomas, xanthelasmas, premature arcus cornealis)
- Family Hx of premature CVD ( 1o relative men<55 or women <65)
- Erectile Dysfunction
- Inflammatory disease: RA, SLE, AS, IBD, psoriatic arthritis
- HIV
How to Screen
- Hx + examination
- Non-HDL, LDL, HDL, TG, glucose, eGFR
- Cardiovascular age calculation
- CV age = pt’s age – (estimated remaining life expectancy – Canadian average remaining life expectancy)
- FRS Calculation
- Q3-5 for men 40-75yo & women 50-75yo or when expected risk changes
- Younger if + risk factors for premature CVD
- Double % risk for family Hx of premature CVD (1o relative men) “modified FRS”
- Screen Q1y if FRS >=5% & Q3-5y if FRS <5%
- Optional / secondary testings:
- urine ACR (if eGFR<60, poorly controlled HTN, or DM2) Q1y
- Apo B (instead of standard lipid panel)
- hsCRP (men>50 women>60) Q3y, repeat 2-4 wk if >2mg/L)
- A1C (FPG >5.6 mmol/L) Q1-5y, more freq if wt gain or increased FPG
- Lp(a) (fam Hx of premature CVD), repeat testing not required
- Optional Noninvasive Testing:
- Graded exercise stress test
- Carotid U/S
- ABI
- Coronary artery calcium
When to use secondary testings: Use is optional – see below for further details
- Further risk assessment in intermediate-risk (10-19% FRS after adjustment for family hx) who are not candidates for lipid Tx based on conventional risk factors (LDL<3.5, non-HDL<4.3, apoB<1.2)
- Consider for low-intermediate risk pt with 5-9% FRS & LDL < 5who has a
- strong family hx of premature CAD,
- abdominal obesity,
- South Asian,
- impaired glucose tolerance.
Stratify by risk features – FRS & cardiovascular age
High risk
- FRS>=20% or
- high risk features:
- Clinical atherosclerosis (vascular bruits, ABI <0.9, documented CAD by testings) , AAA, CKD, high-risk HTN
- DM & >=40yo or >=15yr + >=30yo or microvascular dz
Modified FRS – double FRS for family hx of premature CVD.
Tx
- Nutrition:
- mod caloric intake to maintain a healthy body weight
- Daily fibre intake >30g – diet rich in fibre (vegetables, fruit, whole-grain cereals) & Om3
- Limit cholesterol to 200mg/d
- DASH / mediterranean diet
- Cholesterol lowering: increase phytosterols, soluble fibre, soy and nut intake
- Avoid Trans fats, limit saturated fat <7% and total fat <30% of total caloric intake
- Exercise – 150min mod to vig aerobic activity / wk in bouts of 10min or more
- Smoking cessation and limit EtOH intake to <30g/day (1-2 drinks)
- Smoking cessation, wt loss, exercise, mod alcohol intake increase HDL
- Statins are 1st line (20% RR reduction for LDL dec by 1
- Consider adding non-stain agent if not at target while on max statin dose
Low Risk FRS<10%
- Tx if LDL-C>=5 or genetic dyslipidemia (eg. familial hypercholesterolemia)
- (target 50% dec in LDL)
- FRS <5% – re-evaluate Q3-5y & no 2o testing
- FRS 5-9% – re-evaluate Q1y & consider 2o testing
Intermdeiate Risk FRS 10-19%
- Tx if LDL >=3.5 or apoB>=1.2 or non-HDL >=4.3 (target LDL<=2 or 50% dec)
- Alt target: apo B <=0.8 or non-HDL<=2.6
- Consider 2o testing if LDL<3.5, apoB<1.2, non-HDL<4.3 – +ve may prompt Tx
High-Risk
- Tx in all (Target LDL<=2 or 50% dec)
- Alt Target: apo B<=0.8 or non-HDL<=2.6
- NO 2o testing req – warrant Tx in all
Lipid Lowering medications
- Statins (little effect on HDL)
- Atorvastatin (Lipitor) 10-80mg
- Rosuvastatin (Crestor) – less myalgia
- ↓↓ LDL, modest TG↓, HDL ↑ – at higher doses)
- Inhibit bile acid resorption – ↓ LDL
- Cholestyramine
- Colesevelam (Lodalis) has A1C-lowering effect
- GI s/e worse w/ ↑ dose & may ↑ TG
- Cholesterol absorption inhibitors ↓ LDL
- Ezetimibe – effective with statin
- Fibrate (raise HDL 5-10%) ↓ TG
- Fenofibrate 48-200mg – ↑ Creatinine & homocysteine
- Gemfibrozil – ↑ myopathy & rhabdomyolysis with statin (c/i with statin)
- Niacin (raise HDL 15-25%)
- Nicotinic acid 1-3g – cause dose-related ↓ glycemic control
- Long-acting niacin ↑ hepatotoxicity & ↓ efficacy
TG
- lower associated with dec CVD risk
- Health behaviour are first line
- Fibrate may prevent pancreatitis in pt with TG>10mmol/L
Combination Tx
- Statin + niacin – pt with combined dyslipidemia + low HDL
- Statin + fibrate – close pt f/u req
- Statin + om3 fatty acid – lower TG
- Statin should not be withheld on the basis of a potential, small-risk of new-onset DM in long-term Tx
- Statin-associated s/sx should be evaluated systematically, observation during cessation, reinitiation (same or diff statin, same or lower potency, same or dec freq of dosing) to identify a tolerated, statin-based tx for chronic use
- Vit, minrerals, supplements for statin-related myalgia not recommended.
- Factors increase Statin-induced myopathy
- Age >80yo – especially women, small body fram & frailty
- higher dose of statin, multiple medications, concomitant with fibrates (gemfibrozil)
- multisystem dz – CDK, hypothyroidism
- ETOH abuse, xs grapefruit juice consumption
F/U:
- Serum transaminases in first 3mo
- CK if myalgias develop
- Routine ALT or CK not req after
- Ref if unexplained atherosclerosis, severe dyslipidemia, genetic lipoprotein disorders, refractory to Tx
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