Dyslipidemia CCS 2012 Guideline

Who to screen?

1. Men >=40yo
2. Women >=50yo or postmenopausal
3. 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

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How to Screen

1. Hx + examination
2. Non-HDL, LDL, HDL, TG, glucose, eGFR
3. Cardiovascular age calculation
   • CV age = pt’s age – (estimated remaining life expectancy – Canadian average remaining life expectancy)
4. 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”
5. Screen Q1y if FRS >=5% & Q3-5y if FRS <5%
6. 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
7. Optional Noninvasive Testing:
   1. Graded exercise stress test
   2. Carotid U/S
   3. ABI
   4. 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.

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Stratify by risk features – FRS & cardiovascular age

High risk

1. FRS>=20% or
2. 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.

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Tx

1. 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
2. Exercise – 150min mod to vig aerobic activity / wk in bouts of 10min or more
3. Smoking cessation and limit EtOH intake to <30g/day (1-2 drinks)
   • Smoking cessation, wt loss, exercise, mod alcohol intake increase HDL
4. 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%

1. Tx if LDL-C>=5 or genetic dyslipidemia (eg. familial hypercholesterolemia)
   • (target 50% dec in LDL)
2. FRS <5% – re-evaluate Q3-5y & no 2o testing
3. FRS 5-9% – re-evaluate Q1y & consider 2o testing

Intermdeiate Risk FRS 10-19%

1. 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
2. Consider 2o testing if LDL<3.5, apoB<1.2, non-HDL<4.3 – +ve may prompt Tx

High-Risk

1. Tx in all (Target LDL<=2 or 50% dec)
   • Alt Target: apo B<=0.8 or non-HDL<=2.6
2. NO 2o testing req – warrant Tx in all

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Lipid Lowering medications

1. Statins (little effect on HDL)
   • Atorvastatin (Lipitor) 10-80mg
   • Rosuvastatin (Crestor) – less myalgia
   • ↓↓ LDL, modest TG↓, HDL ↑ – at higher doses)
2. Inhibit bile acid resorption – ↓ LDL
   • Cholestyramine
   • Colesevelam (Lodalis) has A1C-lowering effect
   • GI s/e worse w/ ↑ dose & may ↑ TG
3. Cholesterol absorption inhibitors ↓ LDL
   1. Ezetimibe – effective with statin
4. Fibrate (raise HDL 5-10%) ↓ TG
   • Fenofibrate 48-200mg – ↑ Creatinine & homocysteine
   • Gemfibrozil – ↑ myopathy & rhabdomyolysis with statin (c/i with statin)
5. Niacin (raise HDL 15-25%)
   • Nicotinic acid 1-3g – cause dose-related ↓ glycemic control
   • Long-acting niacin ↑ hepatotoxicity & ↓ efficacy

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TG

1. lower associated with dec CVD risk
2. Health behaviour are first line
3. Fibrate may prevent pancreatitis in pt with TG>10mmol/L

Combination Tx

1. Statin + niacin – pt with combined dyslipidemia + low HDL
2. Statin + fibrate – close pt f/u req
3. Statin + om3 fatty acid – lower TG

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• 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

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F/U:

1. Serum transaminases in first 3mo
2. CK if myalgias develop
3. Routine ALT or CK not req after
4. Ref if unexplained atherosclerosis, severe dyslipidemia, genetic lipoprotein disorders, refractory to Tx