A 45 year old M with no past medical history, on no medications and using no medications walks in for a annual visit.

“Another day in clinic” I think to myself.  My nurse walks in smiling and hands me the few sheets of paper with the medications and vitals of my upcoming patient as she’s done so for the past two years.

“Here you are Dr Bhatty, next one should be easy!” she says walking away.

I review the chart as my patient comes in and greet him as he sits down. “Hey there! Good to see you again!”

“Hi! Good to see you again. Still alive over here, maybe we should have extended it to a two year follow up?

I laugh. “Yes it looks like you’re doing pretty well, any problems you want to go over today?”

“Actually glad you asked, was wondering what my cholesterol was?”

Cholesterol is always an interesting topic with patients as they are always concerned about the exact number as opposed to the intensity of treatment. Sometimes it’s hard to meet in the middle.

So why do we care about cholesterol? Really because it plays a large role in the development of cardiovascular disease and if using a medication decreases that risk then starting patients on them is beneficial.

That begs the question that, which patients deserve treatment? For that we are really asking ourselves about absolute risk reduction in certain populations i.e is it “worth” starting patients on these medications [will it result in a measurable reduction in cardiovascular risk].

That leads us to the development of calculators. The ACC has a great one on their website; a 10 year risk of >7.5% warrants treatment as well as an LDL >190 independent of comorbidities.  All of this is done to decrease absolute risk down about 20-30% as seen in clinical trials.

Whom should be treated?
A) With DM and LDL 70-189
B) Anyone with ASCVD >7.5% at 10 years
C) LDL >190
D) Clinical atherosclerotic disease

What intensity statin should be used?
For those with high LDLs start with high intensity, for those with CVD risk >7.5% over 10 years use moderate to high dose.

What are the high dose statins?
Atorvastatin 40mg and 80mg
Rosuvastatin 20mg and 40mg

“Well doc, what’s my cholesterol looking like?” he wonders looking at me eagerly.

I swivel my chair to face the computer and wait for the the labs to load as a tap my finger on the desk.

LDL 150  (100-199)
HDL 50 (40-60)
Triglycerides 150
Total: LDL + HLD + Tri/5 = 230

As I tell our patient about his cholesterol results he looks concerned.

“That’s funny, my father had a a LDL of 140 and he was started on lipitor; mine is higher so how come you’re not starting me on it?”

“Well there are four groups of patients that we consider candidates for therapy”.

  • Any patient with clinical cardiovascular disease who can get started on high dose statin irrespective of LDL
    • If over 75 and concerns about safety can consider moderate intensity
  • Those without DM and with LDL >190
    • In these patients we start high dose, then add on second therapy if LDL does not reduce by 50%
  • Patient with DM, 40-75 years old, with LDL 70-189
    • Moderate intensity therapy, unless ASCVD >7.5%, then high intensity
  • Patients without DM, 40-75, with ASCVD >7.5%
    • Moderate to high intensity

“Oh! My dad was diagnosed with diabetes a few years ago that must be why”.

“Yeah that’s it” I reply smiling. It’s always nice to see a patient take interest in their care.

References:

https://www.uptodate.com/contents/management-of-low-density-lipoprotein-cholesterol-ldl-c-in-secondary-prevention-of-cardiovascular-disease?source=search_result&search=hyperlipidemia&selectedTitle=8~150#H3499445902

http://www.aafp.org/afp/2014/0815/p260.html

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