Thread by @RosenelliEM

Here is a #medtweetorial recap of @thecurbsiders Episode #191 #Lipids Update and #CardiovascularRiskReduction with Erin Michos MD @erinmichos. Listen here
thecurbsiders.com/podcast/191-li…

@MedTweetorials @cjchiu @DoctorWatto @BrighamSK @PaulNWilliamz

Lifestyle changes r the cornerstone and foundation of cardiovascular prevention & should never be neglected in our conversations w/ patients. “Primordial prevention” is key! A patient’s risk of plaque burden isn't only from the magnitude of LDL elevation but duration of exposure

In primary prevention, the new ASCVD risk categories include low risk (< 5%), borderline risk (5 to <7.5%), intermediate risk (7.5 to <20%), and high risk (≥20%). The focus of the 2018 lipid guideline update is on risk-enhancing factors.

Use risk-enhancers (e.g. family history, chronic inflammatory disorders, pregnancy-related adverse outcomes) to guide management for patients in the borderline and intermediate risk groups

Biomarkers that can be checked include Lp(a), ApoB, & high-sensitivity CRP, & can be helpful to further risk-stratify. Dr. Michos usually checks Lp(a) once in patients w/ strong family history & personal history of premature CAD.

ApoB is checked when close to LDL goal to assess further need for reduction.

Coronary artery calcium scoring is a very useful and reliable tool for the tie-breaker in starting a statin, especially in patients who are reluctant to start a statin.

The risk of rhabdomyolysis from statins is < 0.1% and risk of liver injury is 1 in 100,000.

Start low and go slow! Dr. Michos offers great advice in working with patients who claim to have statin “intolerance”, which the guidelines say to call “statin-associated muscle symptoms”. She recommends starting patients at a low dose and working your way up.

LDL reduction goals depend on statin intensity: with a high-intensity statin, expect an LDL reduction by > 50%, 30%-49% with moderate-intensity, and < 30% with low-intensity statin.

For follow up, the guidelines recommend checking LDL 4-12 weeks after initiation, then 3-13 months depending on the individual patient’s situation. In stable patients, you can check yearly, and as often as every 4-6 years in younger patients.

In secondary prevention, add ezetimibe when LDL goal has not been met, followed by PCSK9 inhibitor for further LDL reduction.

Aspirin for primary prevention is now falling out of favor (a IIb recommendation and class III recommendation in elderly > 70). Statins and lifestyle modification are first line for patients with triglycerides > 500, however fibrates can be added when triglycerides > 1000.

Icosapent ethyl is a great option, reduced major cardiovascular events by 25% in the REDUCE-IT trial, but insurance coverage may still an issue. Fish oil and icosapent ethyl are NOT the same!