Questions about managing elevated cholesterol…

Primary prevention means preventing the FIRST EPISODE of a cardiovascular event (like a stroke or heart attack).  Primary prevention is key!  Family physicians make treatment decisions based on clinical risk and risk calculators.  Try this link to find your risk: ASCVD risk calculator. 

What influences the score on the risk calculator?  Obesity, high blood pressure, diabetes and tobacco use influence risk scores significantly more than cholesterol values. 

Who should get a coronary artery calcium score?  Consider measuring this if you are 40-75 years of age (without diabetes and with an LDL less than 190) IF a decision about statin therapy is uncertain.  Coronary artery calcium scoring has not been shown to improve patient outcomes. 

Evidence supports moderate-dose statins as the BEST therapy in primary prevention for patients at increased risk with a mortality rate of 20-30% in 5 years.  Moderate-dose statin drugs are well tolerated with low risk of causing muscle breakdown or diabetes.  High-dose statins show similar cardiovascular benefits (although they have increased risk of causing diabetes or other side effects).  Ezetimibe sometimes is added to the statin but has not been shown to help much.  The goal of statins are to decrease LDL levels by at least 50%.

Who should start on a statin drug for primary prevention?  Patients with a 12% 10-year risk, or in diabetics with a 10-year risk of 6-12%, or in those with LDL of 190mg/dL or more.  Talk to your physician if your 10-year risk is between 6-12%

What should be done for secondary prevention?  Secondary prevention is when a patient has ALREADY had a cardiovascular event (heart attack, stroke, or needed a heart stent).  Moderate-dose statins are the mainstay of treatment. 

Who should start on a PCSK9 inhibitor?  Talk to your cardiologist if your LDL  (not your total cholesterol) is 220 or more, per American College of Cardiology/American Heart Association (ACC/AHA) recommendations.

Should you start on an omega-3 fatty acid to reduce cardiovascular disease risk?  No, research has not shown Omega-3 fatty acids to help.

What if you start on a statin drug and you have side effects?  Talk to your physician and consider stopping the statin.  After a washout period, re-challenge with a different statin or a lower dose.

How often should you have labs to check cholesterol after starting on medication?  The VA/Department of Defense suggests against routine monitoring whereas the ACC/AHA suggests checking 4-12 weeks after statin initiation or dose adjustment and then rechecking every 3 to 12 months, as needed.  Research shows that cholesterol levels are stable for up to 10 years, with most of the change between lab results due to testing variability.  Fasting before cholesterol labs are only needed to accurately evaluate high triglycerides.

I hope this helps.