Dyslipidemia: Clinical sciences

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Introduction0:00–0:50

Dyslipidemia, or high lipid levels in the blood, is a condition associated with an increased risk of atherosclerotic cardiovascular disease, or ASCVD for short, which includes myocardial infarction, stroke, and peripheral arterial disease.
Because of this, the management of individuals with dyslipidemia is usually more aggressive if your patient has a history of ASCVD.
Dyslipidemia is usually asymptomatic, but can be found on labs like a lipid panel. Next, consider whether they have severe dyslipidemia or diabetes.
If they do not have any of these conditions, management is based on their 10 year risk of developing ASCVD. The first step when evaluating a patient for dyslipidemia is performing a focused history and physical, and sending labs for a lipid panel.

History, Physical, Labs0:50–2:10

The history will help identify risk factors for ASCVD, like smoking, diabetes, or hypertension. ASCVD is also more common as you get older, and there’s an increased risk in biological males and people with previously diagnosed ASCVD.
Now, the physical exam is usually unremarkable in patients with dyslipidemia. They may have elevated blood pressure, and if the cholesterol level is very high, you might see xanthomas, which are cholesterol deposits in the skin, classically around the eyes.
Next, let’s discuss the lipid panel, which is the best screening test for dyslipidemia. It includes the total cholesterol, or TC for short, high-density lipoprotein cholesterol, or HDL, low-density lipoprotein cholesterol, or LDL-C, and triglycerides, or TG.
The LDL-C value is important for determining which patients need medications for dyslipidemia. You’ll also use TC and HDL values to help predict the 10-year ASCVD risk, which impacts treatment decisions for dyslipidemia.

Patients with ASCVD2:10–4:27

Alright, now that you have the history and lipid panel results, let’s move on to management. Treatment for dyslipidemia varies based on whether the patient has ASCVD.
Patients with ASCVD and dyslipidemia should be started on a high-intensity statin, which inhibits HMG-CoA reductase in the liver and slows down cholesterol production, and aids in plaque stabilization, which helps keep previously formed cholesterol plaques from breaking off and causing arterial occlusion.
After 4 to 12 weeks on a high-intensity statin, you should recheck the patient’s lipid panel. If their LDL-C level is under 70 mg/dL, they should continue the current statin medication.
However, if their LDL-C level is equal to or above 70 mg/dL, you should examine their adherence to the treatment plan. Find out when they are taking their medication or if they missed doses due to forgetting or having adverse effects.
If they are taking their medications, but the LDL-C level is not dropping, you might want to adjust their medications. You have two options here: either maximize the dose of the statin that they are already on, or change them to a different statin.
After this, the lipid panel should be rechecked in another 4 to 12 weeks. If the LDL-C is less than 70 mg/dL, they can continue on their current treatment regimen.
However, if the LDL-C still remains 70 mg/dL or greater, you can add a cholesterol absorption inhibitor, like ezetimibe.
Once again, after 4 to 12 weeks, recheck the LDL-C. If it remains 70 mg/dL or higher, you can add a PCSK-9 inhibitor like alirocumab or evolocumab.
These medications work by inhibiting the enzyme PCSK-9 which indirectly increases uptake of LDL in the liver. Finally, you should discuss lifestyle modifications, like sticking to a healthy diet, smoking cessation, and increasing aerobic exercise.Now, let’s switch gears and discuss individuals without known ASCVD.

Patients with Diabetes4:27–6:18

First, look at their LDL-C level. If the level is between 70 and 189 mg/dL, which is considered non-severe hyperlipidemia, you should first determine whether they have diabetes mellitus, or DM.
If they have DM, and they are between 40 to 75 years old, they should get a statin. The kind they receive depends on their 10 year risk for ASCVD.
This is the risk of having a major ASCVD event, like a heart attack or stroke, within 10 years. The risk is based on information like age, sex, blood pressure, lipid panel values, history of smoking, hypertension, and current medications such as statins or daily aspirin.
Now, individuals whose 10-year risk for ASCVD is less than 7.5 percent should get moderate-intensity statins; while individuals whose risk is greater than or equal to 7.5 percent should be treated with high-intensity statins.
Here are some high-yield facts to keep in mind! Every patient taking statins should have their LDL-C checked within 4-12 weeks after initiating therapy.
If their LDL-C improves, great! Continue the current treatment.
However, if their LDL-C hasn’t improved as expected, it’s important to assess their adherence to the treatment plan. Alright, the treatment is a bit different for individuals with diabetes who are less than 40 or over 75 years old.
These individuals benefit significantly from lifestyle modifications, but you can discuss the risks and benefits of adding a moderate intensity statin if it fits with their health goals.Next, let’s take a look at patients with LDL-C levels between 70-189 mg/dL who don’t have DM.

10-year ASCVD risk6:18–7:36

First, determine their 10-year risk for ASCVD and use the result to classify them into one of four groups: low-risk, borderline risk, moderate-risk, and high-risk.Individuals whose 10-year risk for ASCVD is less than 5 percent are considered low-risk and should be advised on the importance of lifestyle modifications.
Now, individuals whose risk is 5% to 7.5% are considered borderline risk. In addition to advising on lifestyle changes, you should offer these individuals a statin if it fits with their health goals.
Next, if a patient’s 10 year ASCVD risk is 7.5 to 20 percent, they fall into the moderate-risk category, and you should start them on a moderate-intensity statin.
After starting the statin, recheck their lipid panel in 4 to 12 weeks. Now onto our last group, high-risk patients, who have over 20% risk of ASCVD over the next 10 years.
You should start them on a high-intensity statin, and recheck their lipid panel after 4 to 12 weeks.Finally, let’s take a look at individuals without ASCVD who have severe dyslipidemia, or LDL-C levels about 190 mg/dL.

Severe hyperlipidemia7:36–8:08

All of these patients should be started on a high-intensity statin. Once again, remember to recheck their lipid panel in 4 to 12 weeks after starting the statin.
You might also consider doing a workup for familial hyperlipidemia using extensive family history and genetic testing. Alright as a quick recap...

Review8:08–9:00

When treating someone with dyslipidemia, first determine whether they have a history of ASCVD, and if they do, start them on a high-intensity statin.
You should also start statins on patients who don’t have a history of ASCVD but have diabetes mellitus and are between 40 to 75 years old, or patients who have severe dyslipidemia with an LDL-C above 190 mg/dL.
For other patients, calculate their 10 year risk of ASCVD. Their risk level helps you determine the appropriate treatment, which is anything from lifestyle modifications, to moderate intensity statins, to high-intensity statins.
If a patient’s LDL-C doesn’t improve, check to make sure they are adherent to the treatment plan before adjusting statin dosage or changing their medication.