Hypercholesterolemia

Incidence in USA: 71 million American adults have high LDL-C levels. Nearly 31 million adult Americans have a total cholesterol level >240 mg/dL.

Risk factors for ASCVD include being a male age >45 y, being a woman age >55 y, family Hx of premature CAD, current cigarette smoking, DM, obesity, obstructive sleep apnea, Htn, CAD, high stress, high LDL-C, and low HDL-C.

The LDL-C level of ≥190 mg/dL and HDL-C <40 increases the risk for CHD.

A high triglyceride level combined with low HDL-C level in adults increases the risk of CHD and stroke.

Familial hypercholesterolemia, an autosomal dominant trait (LDL >260 mg/dL), increases risk for premature CHD.

Perioperative risks:

• Acute coronary syndrome, myocardial ischemia, infarction, and ventricular tachyarrhythmia.

• Cardiac events and worsened CHF.

• Stroke or death.

• Knowledge gap exists on whether statin therapy causes periop cognitive dysfunction or delirium in some circumstances.

New-onset angina or increasing frequency or severity of angina, stent thrombosis, bleeding, periop myocardial ischemia, and infarction

Hypotension, Htn, ventricular arrhythmia, worsening, or new-onset CHF

TIAs or stroke of the CNS

Peripheral atherosclerosis, acute pancreatitis

Association between high level of LDL-C and an increased risk of ASCVD, including coronary heart disease, stroke, and peripheral arterial disease.

Desirable or target cholesterol levels are variable and based on existing CV disease and risk of developing CV disease in future and statin therapy.

The ASCVD risk assessment for 10 y and lifetime can be estimated using various web-based ASCVD risk estimator tools.

Preop treatment with statins is associated with significant improvement in postop mortality and early clinical outcome in pts undergoing cardiac, vascular, and noncardiac surgery.

Can be primary or secondary to systemic illness such as diabetes, nephrotic syndrome, chronic renal failure, hypothyroidism, or drugs that increase LDL such as anabolic steroids.

Obesity, sedentary lifestyles, and diets high in saturated fats, trans fat, and cholesterol increase the risk of high LDL-C.

Lifestyle modification, including dietary, physical exercise, and weight control are critical components of reducing cholesterol and ASCVD risk reduction.

2013 ACC/AHA updated guideline on treatment of blood cholesterol to reduce ASCVD risk in adults emphasizes lifestyle modification and use of high-, moderate-, and low-intensity statin therapy to four groups of pts, including history of clinical ASCVD, history of diabetes, LDL-C level, and estimated ASCVD risk.

HMG CoA reductase inhibitors or statins like rosuvastatin (Crestor), lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), atorvastatin (Lipitor), and fluvastatin (Lescol) are drugs of choice in most pts with hypercholesterolemia, as they reduce LDL levels effectively.

In high-risk pts with high triglyceride or low HDL levels, consideration can be given to combine a fibrate or nicotinic acid with an LDL-lowering drug.

The combination treatment with HMG reductase inhibitor and cholesterol absorption inhibitor (ezetimibe) is highly synergistic in treating high-risk pts.