PANCE Blueprint Cardiology (13%)

Lipid disorders (PEARLS)

The NCCPA™ PANCE Cardiology System Content Blueprint includes two topics related to lipid disorders


Patient will present as → a 55-year-old obese Caucasian gentleman who arrives at your clinic for a routine check-up after having some blood work done during a routine workplace health screening. He is found to have a total cholesterol level of 430 mg/dL. He complains of calf pain while walking to the convenience store, which only resolves with rest. He states that he has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes.

Subcutaneous xanthomas, premature arcus senilis, lipemia retinalis

  • The U.S. Preventive Services Task Force (USPSTF) recommends screening for patients with no evidence of CVD and no other risk factors should begin at 35 years of age
  • The National Cholesterol Education Program (NCEP) recommends screening all adults at age of 20 years regardless of risk factors

DX: Screening may include total cholesterol alone, total and HDL cholesterol, or LDL and HDL cholesterol levels


  • Statins: Side effects: Elevated LFTs, myalgias
  • Fibrates: Side effects: Gallstones
  • Niacin: Side effects: Flushing
  • Bile acid sequestrants (Cholestyramine): Side effects: Diarrhea

Statin Therapy:

Key Points for Practice (based on the latest treatment guidelines) 

The guideline emphasizes that lifestyle modification remains a critical component of atherosclerotic cardiovascular disease (ASCVD) reduction

Four groups most likely to benefit from statin therapy
  1. Patients with any form of clinical atherosclerotic cardiovascular disease (ASCVD)
  2. Patients with primary LDL-C levels of 190 mg per dL or greater
  3. Patients with diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
  4. Patients without diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%

Risk assessment for 10-year and lifetime risk is recommended using an updated ASCVD risk calculator

TX: Treatment Targets: There are no recommendations for or against specific target levels for LDL-C or non–HDL-C in the primary or secondary prevention of ASCVD.

Secondary Prevention in men and women up to 75 years of age who have clinical ASCVD, high-intensity statin therapy should be initiated unless contraindicated.

  • For persons with clinical ASCVD in whom high-intensity statin therapy is contraindicated but would otherwise be used, or in persons with characteristics predisposing to statin-associated adverse effects, moderate-intensity statins should be the second option, if tolerated.
  • When initiating moderate- or high-intensity statin therapy in persons older than 75 years who have clinical ASCVD, it is reasonable to evaluate for potential risk-reduction benefits, adverse effects, and drug-drug interactions. Patient preferences should also be considered. Continuation of statin therapy is reasonable in persons who tolerate it.

Primary prevention in persons 21 years or older with an LDL-C of ≥ 190

Persons who have LDL-C levels of 190 mg per dL or greater, or triglyceride levels of 500 mg per dL (5.65 mmol per L) or greater should be assessed for secondary causes of hyperlipidemia.

  • Persons 21 years or older who have LDL-C levels of ≥ 190 mg per dL should be treated with statin therapy
    • High-intensity statins should be used unless contraindicated.
    • If high-intensity statins are not tolerated, the maximum tolerated intensity should be used.
  • In persons with untreated LDL-C levels of 190 mg per dL or greater, statin therapy may be intensified to achieve a minimum 50% LDL-C reduction.
  • When the maximum intensity of statin therapy is reached, a non-statin may be added to further reduce LDL-C levels. Potential benefits, adverse events, drug-drug interactions, and patient preferences should be considered.

Primary prevention in persons WITH diabetes and LDL-C of 70 - 189

  • Persons 40 to 75 years of age who have diabetes should start or continue moderate-intensity statin therapy.
  • In those with 7.5% or greater estimated 10-year ASCVD risk, high-intensity statin therapy is reasonable unless contraindicated.
  • In persons younger than 40 years or older than 75 years, potential benefits, adverse events, drug-drug interactions, and patient preferences should be considered when deciding to initiate, continue, or intensify statin therapy.

Primary prevention in persons without diabetes and with LDL-C of 70 - 189

  • The Pooled Cohort Equations should be used to estimate the 10-year ASCVD risk in persons without clinical ASCVD to guide the initiation of statin therapy.
  • In persons, 40 to 75 years of age without clinical ASCVD or diabetes and with an estimated 10-year ASCVD risk of 7.5% or greater, moderate- to high-intensity statin therapy should be used.
  • If the 10-year risk of ASCVD is 5% to less than 7.5%, treatment with a moderate-intensity statin is reasonable.

Before initiating statin therapy, it is reasonable for clinicians and patients to engage in a discussion about the potential for ASCVD risk-reduction benefits, adverse events, drug-drug interactions, and patient preferences.

For persons with LDL-C less than 190 mg per dL who do not fall into a statin benefit group or for whom risk-based treatment is uncertain, other factors may be used to inform treatment decision making.

  • Statin therapy may be considered after evaluating for potential benefits, adverse events, drug-drug interactions, and patient preferences.

Heart failure and hemodialysis

There are no recommendations on initiating or discontinuing statin therapy in patients with New York Heart Association class II through IV ischemic systolic heart failure or in patients on maintenance hemodialysis

High, Moderate, and Low-Intensity Statin Therapy

Daily dosage lowers LDL-C by approximately ≥ 50% on average Daily dosage lowers LDL-C by approximately 30% to 50% on average Daily dosage lowers LDL-C by < 30% average
Atorvastatin (Lipitor), 40 to 80 mg Atorvastatin, 10 (20) mg Simvastatin, 10 mg
Rosuvastatin (Crestor), 20 (40) mg Rosuvastatin, (5) 10 mg Pravastatin, 10 to 20 mg
Simvastatin (Zocor), 20 to 40 mg Lovastatin, 20 mg
Pravastatin (Pravachol), 40 (80) mg Fluvastatin, 20 to 40 mg
Lovastatin (Mevacor), 40 mg Pitavastatin, 1 mg
Fluvastatin XL (Lescol XL), 80 mg
Fluvastatin, 40 mg twice daily
Pitavastatin (Livalo), 2 to 4 mg

Patient will present as → a 17-year-old female brought in by her parents to check her cholesterol due to a family history of hypertriglyceridemia. Her dad and paternal aunt have a history of pancreatitis. Family history is negative for premature arteriosclerotic cardiovascular disease. Her cholesterol panel is as follows: Total cholesterol 188 mg/dL (<200), triglyceride 851 mg/dL (<150), HDL 15 mg/dL (>50), LDL 102 mg/dL (<130).

Obtain a fasting lipid panel beginning at age 20 and repeated every 5 years

  • Normal <150 mg/dL
  • Mild hypertriglyceridemia  150 to 499 mg/dL
  • Moderate hypertriglyceridemia 500 to 886 mg/dL
  • Very high or severe hypertriglyceridemia 886 mg/dL


  • Triglyceride level should be reduced to < 500 mg/dL to prevent this pancreatitis
  • Isolated triglycerides are treated with Fibrates (gemfibrozil and fenofibrate) and Niacin
  • Niacin may cause hyperglycemia, so caution in patients with DM
  • Flushing, treated with daily aspirin, will have a beneficial effect on HDL cholesterol
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