HYPERLIPIDEMIA

Aidan Milner, MD
Week 21

Educational Objectives:

1. Use validated tools to determine if a patient would benefit from a statin for primary
prevention of cardiovascular disease (CVD).
2. Determine if additional lipid-lowering therapies are warranted for CVD risk reduction.
3. Identify patients who qualify for triglyceride-lowering therapies.

CASE ONE:

Mr. L. DiLella is seeing you in clinic for follow-up. He is 56 years old and last saw you one
year ago. He has no medical conditions and takes no medications. He does not smoke
cigarettes or drink alcohol and has no family history of premature atherosclerotic
cardiovascular disease (ASCVD). He works in accounting and tries to exercise twice a week
but has gained 30 lbs. in the last year despite trying to improve his diet. His BMI is 34, BP
124/78, and physical exam is unremarkable. You check a lipid panel which reveals a total
cholesterol of 208 mg/dL, HDL 26 mg/dL, LDL 146 mg/dL, and triglycerides of 178 mg/dL.

Questions:

1. What are the indications for statin therapy for prevention of cardiovascular
disease? What tools and guidelines can be used to determine if statin therapy is
warranted?

2. What is Mr. D’s 10-year ASCVD risk? Would you start him on a statin and if so,
which statin would you recommend?

Hyperlipidemia. Yale Office-based Medicine Curriculum, Eleventh Edition, Volume 2, 2022

CASE TWO:

Mr. T is a 28-year-old who is seeing you for the first time. He reports no past medical
conditions but is concerned about his weight. He has a family history of premature ASCVD
and does not smoke cigarettes or drink alcohol. His BMI is 36, BP 108/64, and exam is
otherwise unremarkable.

3. Should you screen this patient for dyslipidemia?

CASE TWO CONTINUED:

You check a fasting lipid panel which reveals a total cholesterol of 262, HDL 43, LDL 199,
and triglycerides of 482 mg/dL. Other routine labs are checked and are unremarkable, the
patient does not have diabetes mellitus.

4. Would you recommend a statin for this patient? What are some common and rare
side effects of statins? How soon should he follow-up?

CASE TWO CONTINUED:

After discussions of the common side effects of statins, you both agree to start atorvastatin
40mg daily. He returns 12 weeks later with incorporation of lifestyle modifications and
reports no side effects from his medication. He has lost 12 pounds (5% of body weight). His
repeat LDL-C is now 97 mg/dL and fasting triglycerides are 398 mg/dL.

5. Would you make any further changes to his regimen?

Hyperlipidemia. Yale Office-based Medicine Curriculum, Eleventh Edition, Volume 2, 2022

CASE THREE:

Your next patient is Mrs. M, who comes to you after moving to the area. She is 68 years old
with well-controlled type 2 diabetes mellitus, hypertension, and two prior myocardial
infarctions requiring a total of three drug-eluting stents. Her records show she has been on
atorvastatin 80 mg daily for the last several years without any issues. Her BMI is 31, BP
118/74, and physical exam is unremarkable. You check basic laboratory studies including
lipid panel which reveals an LDL-C of 94 mg/dL and triglycerides of 202 mg/dL.

You discuss diet and lifestyle modifications including weight loss and physical activity.

6. What changes, if any, would you make to her lipid management? When would you
check her lipids again?

CASE THREE CONTINUED:

Mrs. M returns six weeks after starting ezetimibe. She has incorporated the lifestyle
modifications you discussed, with repeat fasting studies showing LDL-C of 69 mg/dL and
triglycerides of 192 mg/dL.

7. Are there any additional therapies you could offer her at this time?

Hyperlipidemia. Yale Office-based Medicine Curriculum, Eleventh Edition, Volume 2, 2022

Primary Reference:

1. Grundy SM, Stone NJ, Bailey AL, et al. 2018

AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA
Guideline on the management of blood cholesterol: A report of the American College of
Cardiology/American Heart Association Task Force on clinical practice guidelines.
Circulation. 2019;139(25): e1083-e1084.
http://dx.doi.org/10.1161/CIR.0000000000000625

Additional References:

1. Bhatt DL, Steg PG, Miller M, Brinton EA, et al. Cardiovascular Risk Reduction with
Icosapent Ethyl for Hypertriglyceridemia. N Engl J Med. 2019;380(1):11-22.
2. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary
Prevention of Cardiovascular Disease: A Report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Circulation. 2019 Sep 10;140(11):e597, e602.
http://dx.doi.org/10.1161/CIR.0000000000000678
3. Karlson BW, Wiklund O, Palmer MK, et al. Variability of low-density lipoprotein
cholesterol response with different doses of atorvastatin, rosuvastatin, and simvastatin:
results from VOYAGER. Eur Heart J Cardiovasc Pharmacother. 2016 Oct;2(4):212-7.
doi: 10.1093/ehjcvp/pvw006. Epub 2016 Mar 29. PMID: 27533947.
4. Marston NA, Giugliano RP, Im K, Silverman MG, O'Donoghue ML, Wiviott SD,
Ference BA, Sabatine MS. Association Between Triglyceride Lowering and Reduction of
Cardiovascular Risk Across Multiple Lipid-Lowering Therapeutic Classes: A Systematic
Review and Meta-Regression Analysis of Randomized Controlled Trials. Circulation.
2019 Oct 15;140(16):1308-1317. doi: 10.1161/CIRCULATIONAHA.119.041998. Epub
2019 Sep 18. PMID: 31530008; PMCID: PMC6791781.

Aidan Milner is a graduate of Albert Einstein College of Medicine and is a chief resident in the
Yale Traditional Internal Medicine Residency Program. He is planning to pursue fellowship in
cardiovascular disease.

Hyperlipidemia. Yale Office-based Medicine Curriculum, Eleventh Edition, Volume 2, 2022

Knowledge Questions

1. Mr. F is a 24-year-old man who presents to your primary care office to establish
care. He has no medical conditions and feels well. He does not smoke tobacco or use
any recreational drugs. He drinks four alcoholic beverages per week and runs
several miles a week. He has no family history of ASCVD. His BMI is 21, BP is
108/54, and exam is unremarkable. When would you screen Mr. F for lipid
abnormalities?

a. At this visit
b. Age 35
c. Age 40
d. Age 55

2. Ms. S is a 67-year-old woman non-smoker who has well-controlled rheumatoid

arthritis. She has family history of premature ASCVD in her father. Her BMI is 27
and BP is 125/84. She has routine lipids checked and has total cholesterol of 248,
HDL-C of 38, LDL-C of 172, and triglycerides of 172 mg/dL. In addition to diet and
lifestyle modification, what do you recommend for her?

a. Atorvastatin 20 mg
b. No additional interventions
c. Coronary artery calcium (CAC) scoring
d. a or c

3. Mr. L is a 62-year-old man with a history of DM, PAD requiring stenting, and
multivessel coronary disease requiring CABG several years ago. He has been on
atorvastatin 80 mg daily for several years without issue. Follow-up lipid panel shows
an LDL-C of 68 mg/dL, HDL of 42 mg/dL, and fasting triglycerides of 182 mg dL.
What would you recommend to this patient?

a. Continue atorvastatin at the current dose

b. Add ezetimibe
c. Add icosapent ethyl
d. Add fenofibrate

Hyperlipidemia. Yale Office-based Medicine Curriculum, Eleventh Edition, Volume 2, 2022