Dx^{1, 2}

$$\text{LDL-C} = \text{TC} - \frac{\text{TG}}{5}-\text{HDL}$$

Calculation is inaccurate if LDL < 70, and adjustments exist in that circumstance.

Normal Labs

Lab	Normal	Abnormal
TG	< 150	≥ 200
HDL		< 40 (men) < 50 (women)
LDL	< 100	≥ 160
Non-HDL	< 130	≥ 190

Tx¹

Statin Classification

Low	Medium	High
< 30% LDL reduction	30-49& LDL reduction	≥ 50% LDL reduction
Simvastatin 10mg	Atorvastatin 10-20mg	Atorvastatin 40-80mg
Pravastatin 10-20mg	Rosuvastatin 5-10mg	Rosuvastatin 20-40mg
Lovastatin 20mg	Simvastatin 20-40mg
Fluvastatin 20-40mg	Pravastatin 40mg
	Lovastatin 40mg
	Fluvastatin 40mg BID or 80mg XL QD
	Pitavastatin 1-4mg

Statin Initiation

• Pt has Clinical ASCVD
  • Stratify based on risk
  • Clinical ASCVD: ACS, Hx of MI, Stroke, TIA, PAD
  • Major Events
    • ACS w/i 12mo
    • Hx of MI
    • Hx of ischemic stroke
    • Symptomatic PAD
  • High-risk Conditions
    • ≥ 65yo
    • Familial hypercholesterolemia
    • Prior CABG or PCI
    • DM
    • HTN
    • eGFR < 60
    • Smoker
    • LDL ≥ 100 despite maximal statin therapy
    • CHF
• Very High ASCVD Risk
  • Multiple ASCVD events or 1 major event w/ multiple high-risk conditions
  • High-intensity statin
  • Add ezetimibe if LDL ≥ 70
  • Add PCSK9 if LDL ≥ 70 or non-LDL ≥ 100 w/ ezetimibe and statin
• All other risk stratification
  • > 75 yo: Consider moderate or high-intensity statin as tolerated
  • ≤ 75 yo: High intensity statin, followed by ezetimibe if LDL-C ≥ 70
• All DM pts 40-75yo receive moderate intensity, if not higher
• All pts 20-75yo w/ LDL ≥ 190 receive high-intensity
• ASCVD Risk ≥ 7.5% w/ other risk factor or ≥ 20% get high intensity statin
• All pts 40-75 w/ LDL 70-189 receive intermediate statin
• Use lower intensity statins if high-intensity not tolerated

Statin Adjustment

NLA Risk Stratification

• Low
  • 0-1 major ASCVD risk factors
• Moderate
  • 2 major ASCVD risk factors
• High
  • ≥ 3 major ASCVD risk factors
  • DM
  • CKD 3B or 4
  • LDL ≥ 190
  • ≥ 15% ASCVD 10-Year Risk
• Very High
  • ASCVD
  • DM w/ ≥ 2 other risk factors or end organ damage
• Major Risk Factor
  • M ≥ 45yo or F ≥ 55yo
  • FHx of Early CHD
    • < 55yo for M relatives
    • < 65yo for F relatives
  • Current Smoker
  • BP ≥ 140/90 or currently on BP meds
  • HDL < 40 (M) or < 50 (F)

Treatment Goals

Risk Category	Non-HDL	LDL	Apo B
Low	< 130	< 100	< 90
Moderate	< 130	< 100	< 90
High	< 130	< 100	< 90
Very High	< 130	< 70	< 80

See NLA Part 2 for Special Population Management (Jentzer 2015)³

Misc Drug Therapies

Drug	ΔLDL	ΔNon-HDL	ΔHDL	ΔTG
BAS	↓ 15-30%	↓ 4-16%	↑ 3-5%	↑ 0-10%
Nicotinic Acid	↓ 5-25%	↓ 8-23%	↑ 15-35%	↓ 20-50%
Fibrates	↓ 5- ↑ 20%	↓ 5-19%	↑ 10-20%	↓ 20-50%
Omega-3s	↓ 6-↑ 25%	↓ 5-↑ 14%	↓ 5-↑ 7%	↓ 19-44%
Cholesterol Absorption Inhibitors	↓ 13-20%	↓ 14-19%	↑ 3-5%	↓ 5-11%

Do not use fibrates with statins

References