QUIZ

1.
Approach to Dyslipidemia
Based on the 2015 CPG for the Management of
Dyslipidemia in the Philippines

Renz L. Salumbre, M.D.

Dyslipidemia
Defined as elevated total or low-density lipoprotein or low levels of high-density lipoprotein cholesterol
and is an important risk factor for coronary heart disease and stroke.

Fodor, G. Primary Prevention of CVD: Treating Dyslipidemia. Am Fam Physician. 2011 May 15;83(10):1207-1208.
 TC = LDL + HDL + VLDL *(VLDL = TG/5, if TG < 400 mg/dL)
LDL-C “Bad Cholesterol” HDL “Good Cholesterol”
Transports cholesterol to Reverses cholesterol
tissue; taken up by transport, removing it from
macrophages & endothelium tissue; decreased in familial
→ atheromas, endothelial syndromes; drugs (BB, BZD,
dysfunction, platelet steroids), increased by
aggregation→ CAD/PAD aerobic exercise, weight
Strong relationship with loss, smoking cessation, diet.
stroke/CAD risk Low levels is not an
indication to initiate drug
treatment
Triglycerides
FA from diet released by
enterocytes into
bloodstream; increased in
certain genetic diseases,
alcohol, smoking, T2 DM,
obesity, hypothyroidism,
pregnancy, drugs (tamoxifen,
CsA, BB, estrogens, PI)
Evaluation
History Physical Examination

- Lifestyle (activity) - BMI

- Diet - Carotid bruits
- Family history of premature CAD - Peripheral pulses
- Presence of clinical ASCVD - Xanthoma
- Muscle symptoms - Xanthelasma
- Corneal Arcus
Risk Factor Assessment
- Male Gender
- Post-menopausal women
- Smoker
- Hypertension
- BMI > 25 kg/m2
- Family history of Premature CHD
- Microalbuminuria
- Proteinuria
- Left ventricular hypertrophy
Lipid Profile Determination
Request for lipid profile screening in patients at risk (> 45 years + 2 or more risk factors) but without
ASCVD and in suspected FH

Screening may not be necessary in

- Patients with ASCVD with or without DM

- Patients with DM
General Approach
Patients with dyslipidemia should undertake
lifestyle modification regardless of risk profile

Low fat, low cholesterol diet rich in fruit and vegetables

Smoking Cessation

150 minutes of moderate-to-high intensity exercise per week

Low fat, low cholesterol diet
Low fat diet - aimed to reduce fat intake to less than 30% energy from fat and at least partially replace the
energy lost with carbohydrates (simple or complex), protein or fruit and vegetables

Modified fat diet - aimed to include 30% or more energy from total fats and included higher levels of
mono-unsaturated or poly-unsaturated fats than the usual diet

Low cholesterol diet - 150 mg/1000 kcal

Smoking Cessation Exercise Prescription
150 minutes of moderate-to-high intensity
Strongly recommended exercise

Not enough evidence to recommend electronic - Cumulative: 5 sessions per week / 30

nicotine delivery devices minutes each
- Patient should have difficulty in speaking
during exercise but should not have chest
pain, DOB, dizziness
- Swimming, jogging, brisk walking, stair
climbing, cycling, dancing, supervise aerobic
exercise programs
- If patient is incapable, refer to Physiatrist to
improve strength and flexibility
Initiation of Statin Therapy
For non-diabetic individuals aged ≥ 45 years with
LDL-C ≥ 130 mg/ dL AND ≥ 2 risk factors*, without Risk Factors:
atherosclerotic cardiovascular disease, statins are ❏ Male Sex
RECOMMENDED for the prevention of
❏ Post-menopausal women
❏ Smoker
cardiovascular events
❏ Hypertension
❏ BMI > 25 kg/m2
Initiate Statin Therapy in patients with
❏ Family History of Premature CHD
❏ Microalbuminuria
- Diabetic Individuals
❏ Proteinuria
- Established ASCVD ❏ Left Ventricular Hypertrophy
Pleiotropic Effects of
Statins:
- Atherosclerotic
plaque
stabilization/reduct
ion
- Anti-inflammatory
- Conflicting
evidence on
dementia
prevention and
increased risk of
cognitive
dysfunction
Statin Treatment Goal:
30% or greater reduction in LDL-C or an LDL-C level of 70 mg/dL or
less

In comparison with 2013

ACC/AHA Guidelines
High Intensity vs. Moderate Intensity?
The guideline explicitly recommends high-intensity statin in patients diagnosed with ASCVD and is also
recommended to be given within 5 days of ACS.

The guidelines cited some studies that Asians may require a lesser dose and there is evidence that
high-dose statin used may lead to higher risk of ADR.

In effect, an individualized approach to treatment is recommended by the 2015 CPG.

Lipid Monitoring
Patients with ASCVD: After 6 weeks of treatment
to 3-6 months thereafter (1-8 years to achieve
target)
In primary prevention: After 3 months and yearly
thereafter
In diabetics, do lipid monitoring for two reasons
1) Determine the direction and magnitude of
treatment response
2) Determine the triglyceride level since it is
an indirect measure of the adequacy of
glycemic control
Monitoring for Adverse Drug Reactions
Common adverse drug reactions: Myalgias, myopathies, transaminitis

Obtain baseline measurement of hepatic transaminase levels (ALA, AST) before initiation of statin
therapy in patients at risk for developing liver injury.

Serial LFT monitoring in asymptomatic individuals are not recommended.

In patients at risk for development of statin myopathies, baseline creatine phosphokinase and
subsequent monitoring should only be performed when symptoms are present.
Non-Statin Therapy
Fibrates are not recommended as an alternative to statins. It may be considered among men with high
baseline TG and low HDL-C once LDL-C target has been reached.

PUFA or Omega-3 fatty acid is not recommended as an alternative to statins for the secondary
prevention of CV events.

Combination therapy: non-statin (omega 3 FA, ezetimibe, fibrates) + statin - may allow for a greater
degree of LDL-C reduction and results in achievement of goal attainment for primary and secondary
prevention. It is recommended to attempt LDL-C reduction using statin therapy first. Other local
available therapies may be combined if the patient cannot attain the LDL-C goal with statin monotherapy.
Familial Hypercholesterolemia
FH is an autosomal dominant mutation of LDL-R resulting in elevated LDL C. An LDL-C above 190 mg/dL
should raise clinical suspicion. Affected individuals are at increased risk for CV events and premature
CAD. Early detection is deemed crucial for initiation of aggressive lipid-lowering therapy.

Dutch Lipid Network criteria is used for applicability in our setting with the exception of genetic testing.

Due to the high cardiovascular risk of these patients, the lipid profile should be carried out initially as
screening (patients with FH have LDL-C levels > 190 mg/dL) then subsequently for monitoring treatment
response since ALL patients with FH should be on aggressive LDL-C lowering therapy.