What is the guidance for a patient with hypercholipemia (elevated total cholesterol of 219), low high-density lipoprotein (HDL) of 33, elevated low-density lipoprotein (LDL) of 156, and hypertriglyceridemia (elevated triglycerides of 164), with an estimated 4% risk of atherosclerotic cardiovascular disease (ASCVD)?

From the Guidelines

I strongly recommend starting a moderate-intensity statin therapy, such as atorvastatin 20mg daily, to address your concerning lipid profile, in addition to emphasizing a heart-healthy lifestyle. Your total cholesterol of 219 mg/dL is borderline high, but more concerning is your low HDL of 33 mg/dL (optimal is >40 mg/dL), elevated LDL of 156 mg/dL (optimal is <100 mg/dL), and elevated triglycerides of 164 mg/dL (optimal is <150 mg/dL) 1. Your estimated 4% risk of atherosclerotic cardiovascular disease (ASCVD) indicates moderate cardiovascular risk. According to the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline, in adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL, at a 10-year ASCVD risk of ≥7.5%, starting a moderate-intensity statin is recommended if a discussion of treatment options favors statin therapy 1. Although your ASCVD risk is slightly below the 7.5% threshold, the presence of multiple lipid abnormalities and the potential benefits of statin therapy support the initiation of moderate-intensity statin therapy.

Key aspects of your treatment plan should include:

• Starting a moderate-intensity statin, such as atorvastatin 20mg daily
• Focusing on lifestyle changes, including:
  • A Mediterranean diet rich in fruits, vegetables, whole grains, fish, and olive oil
  • Limiting processed foods and saturated fats
  • Aiming for 150 minutes of moderate exercise weekly
  • Maintaining a healthy weight
  • Avoiding smoking
  • Limiting alcohol consumption
• Regular follow-up with your healthcare provider, with repeat lipid testing in 3 months after starting treatment to assess improvement and adjust therapy if needed 1.

It is essential to note that a clinician-patient risk discussion should occur before starting statin therapy, including a review of major risk factors, the presence of risk-enhancing factors, the potential benefits of lifestyle and statin therapies, and patient preferences and values in shared decision-making 1.

From the FDA Drug Label

Therapy with lipid-altering agents should be only one component of multiple risk factor intervention in individuals at significantly increased risk for atherosclerotic vascular disease due to hyperlipidemia Niacin extended-release tablets are indicated to reduce elevated TC, LDL-C, Apo B and TG levels, and to increase HDL-C in patients with primary hyperlipidemia and mixed dyslipidemia

The patient has elevated total cholesterol, low HDL, elevated LDL, and hypertriglyceridemia, which are all indicators of primary hyperlipidemia and mixed dyslipidemia. Given the patient's estimated 4% risk of ASCVD, which is not considered significantly increased, niacin therapy may be considered as an adjunct to diet to reduce elevated lipid levels. However, the patient's risk level and specific treatment goals should be taken into account when making treatment decisions 2.

• The patient's lipid profile suggests the need for lipid-altering therapy.
• Niacin therapy may be indicated to reduce elevated TC, LDL-C, Apo B, and TG levels, and to increase HDL-C.
• The patient's treatment plan should include dietary changes and possibly other nonpharmacologic measures in addition to niacin therapy.

From the Research

Guidance for Managing Hyperlipidemia

The patient's lipid profile shows elevated total cholesterol, low high-density lipoprotein (HDL), elevated low-density lipoprotein (LDL), and hypertriglyceridemia, with an estimated 4% risk of atherosclerotic cardiovascular disease (ASCVD). The management of this condition can be guided by the following points:

• The 2018 American Heart Association/American College of Cardiology (AHA/ACC) cholesterol guideline recommends a maximally-tolerated statin with add-on lipid-lowering therapy, ezetimibe and/or proprotein convertase subtilisin/kexin type 9 (PCSK9) for adults with very-high ASCVD risk to achieve a low-density lipoprotein cholesterol (LDL-C) <70 mg/dL 3.
• For patients with hypertriglyceridemia, statins remain the first line of therapy, but additional reduction in triglyceride-rich lipoproteins and remnant particles may be necessary to further reduce residual CVD risk 4.
• The use of fibrates, niacin, or long-chain omega-3 fatty acids may be considered as add-on therapy to statins for patients with hypertriglyceridemia, but the benefits and risks of these therapies should be carefully evaluated 4, 5.
• Combination therapy with a statin and another lipid-modifying agent, such as ezetimibe or a bile acid sequestrant, may be effective in reducing LDL-C levels and cardiovascular risk in patients who do not tolerate or respond to high-intensity statin monotherapy 6.
• Patients with ASCVD and LDL-C levels above the guideline-recommended threshold are at high risk of recurrent cardiovascular events, and intensification of lipid-lowering therapy with ezetimibe and/or a PCSK9 inhibitor may be necessary to reduce this risk 7.

Key Considerations

• The patient's lipid profile and ASCVD risk should be carefully evaluated to determine the best course of treatment.
• The use of statins and add-on therapies should be tailored to the individual patient's needs and risk profile.
• Regular monitoring of lipid levels and cardiovascular risk factors is necessary to adjust treatment as needed.

Treatment Options

• Statins: first-line therapy for hyperlipidemia and ASCVD prevention
• Ezetimibe: add-on therapy to statins for patients with very-high ASCVD risk
• PCSK9 inhibitors: add-on therapy to statins for patients with very-high ASCVD risk
• Fibrates, niacin, or long-chain omega-3 fatty acids: may be considered as add-on therapy to statins for patients with hypertriglyceridemia
• Bile acid sequestrants: may be considered as add-on therapy to statins for patients who do not tolerate or respond to high-intensity statin monotherapy