Hyperlipidemia

#HLD
Mainly hyperLDL, hyperTG. Likely primary 2/2 diet, lifestyle, weight, genetics. No known secondary etiologies including hypothyroid, DM, nephrotic syndrome, CKD, EtOH, liver disease, meds (OCPs, steroids, antipsychotics, thiazides, BB). No known prior ASCVD. ASCVD 10 year risk *** (https://statindecisionaid.mayoclinic.org/). Likely underestimate given risk enhancers including family history early CAD, CKD, metabolic syndrome, inflammatory disease, south Asian ancestry, TG>175.
- consider TSH, BUN/Cr, UA, A1c, Crp; consider baseline LFTs/CK if starting statin (no need for routine monitoring subsequently)
- if famhx early CAD, borderline/intermediate risk (5-20%), or equivocation about statin consider coronary calcium CT ($150 out of pocket, may be covered by insurance; CAC of 0 = no benefit from statin)
- consider statin if risk>7.5%; strongly encourage if >20%
-- moderate vs high dose per: https://tools.acc.org/ASCVD-Risk-Estimator-Plus/assets/graphics/new-primary-prevention.svg
-- rosuvastatin 10-20mg; atorva 20-80mg (both now generic; QHS may be best)
-- note myalgias are equally common in placebo vs statin groups; statin intolerance extremely rare
-- associated with 10% increased risk of new DM (NNH 100); memory loss may be rare side effect of lipophilic (eg atorva) but not hydrophilic (eg rosuva)
- consider EPA fish oil (OTC vs vascepa) 2g BID for 20-50% TG reduction and 25% MACE reduction
- consider aspirin 80-100mg if ASCVD risk >10% and no increased bleeding risk
-- https://aspirinbenefitharmcalculator.shinyapps.io/calculator/
- note: niacin, fibrates no ASCVD reduction; ezetimibe has clinically insignificant effect
- start fenofibrate for TG persistently >885; for <885 maximize statin and EPA; if fasting TG>500, reduce dietary fat to <20g/day
- avoid NSAIDs (a/w 42% increase in CV death)
- encourage concomitant lifestyle interventions
-- aerobic exercise 30mins 3-4x/wk; wt loss 2%->6% decrease LDL
-- more whole foods including veg/fruits, complex carbs
-- less saturated and trans fats but no restriction on dietary cholesterol
-- quit smoking (up to 40% risk reduction)
-- avoid EtOH (esp if high TG)
- recheck lipids 3 months after regimen changes then q1-3 years when on stable regimen (or more often for adherence)

Risk scores using CAC:
- https://www.mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx
- http://astrocharm.org/calculator-working/

Statin decision aid:
- https://statindecisionaid.mayoclinic.org/