< 55 mg/dL (< 1.4 mmol/L) in very high risk patients < 70 mg/dL (< 1.8 mmol/L) in high risk patients. A Show 4 more As per AHA 2019 guidelines, initiate moderate-intensity statin therapy in 40-75 years old patients with diabetes mellitus, regardless of estimated 10-year ASCVD risk. A Show 6 more Patients with chronic kidney disease, management: As per EAS/ESC 2020 guidelines, view patients with KDOQI stage 3-5 CKD as high or very high risk patients for ASCVD. A https://web.pathway.md/diseases/receTcWVpm18Q5oo1 13/19 6/29/23, 10:23 PM Dyslipidemia Pathway Show 2 more As per PCNA/ASPC/APhA/AGS/ADA/ACPM/ABC/AAPA/ACC/AHA 2019 guidelines, consider initiating a moderate-intensity statin or moderate-intensity statins combined with ezetimibe in 40-75 years old patients with LDL cholesterol 70-189 mg/dL, a 10-year ASCVD risk of 7.5% and CKD not treated with dialysis or kidney transplantation. C Landmark trials: SHARP In patients with advanced CKD, simvastatin plus ezetimibe was superior to placebo with respect to major atherosclerotic events. Baigent C et al. Lancet. 2011 Jun 25. As per CCS 2016 guidelines, offer statins or a statin/ezetimibe combination to reduce CVD events in 50 years old patients with CKD not treated with dialysis or a kidney transplant. A Landmark trials: SHARP In patients with advanced CKD, simvastatin plus ezetimibe was superior to placebo with respect to major atherosclerotic events. Baigent C et al. Lancet. 2011 Jun 25. Patients on hemodialysis: As per ESC 2020 guidelines, consider continuing statins, ezetimibe or a statin/ezetimibe combination in patients already using these medications at the time of dialysis initiation, particularly in patients with ASCVD. C As per AHA 2019 guidelines: Consider continuing statin therapy in adult patients with CKD initiating dialysis and already receiving statin therapy. C Avoid initiating statin therapy in adult patients with advanced kidney disease requiring dialysis treatment. D Landmark trials: AURORA In patients, 50 to 80 years of age, who were undergoing maintenance hemodialysis, rosuvastatin was not superior to placebo with respect to death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke (events per 100 patient-years). Fellstrom BC et al. N Engl J Med. 2009 Apr 2. As per CCS 2016 guidelines: Consider continuing lipid-lowering therapy in adult patients with dialysis-dependent CKD already receiving it at the time of dialysis initiation. C https://web.pathway.md/diseases/receTcWVpm18Q5oo1 14/19 6/29/23, 10:23 PM Dyslipidemia Pathway Consider avoiding lipid-lowering therapy in adult patients with dialysis-dependent CKD. D Landmark trials: AURORA In patients, 50 to 80 years of age, who were undergoing maintenance hemodialysis, rosuvastatin was not superior to placebo with respect to death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke (events per 100 patient-years). Fellstrom BC et al. N Engl J Med. 2009 Apr 2. Patients with inflammatory diseases and HIV: initiate moderate-intensity statin therapy or high-intensity statin therapy in 40-75 years old patients with LDL cholesterol levels 70-189 mg/dL, a 10-year ASCVD risk 7.5% and chronic inflammatory disorders or human immunodeficiency virus. B Show 2 more Patients with solid organ transplants: consider initiating statins as first-line therapy in patients with solid organ transplants. Initiate statins at low doses with carefully titrating upwards and with caution regarding potential drug-drug interactions, particularly for patients receiving ciclosporin. C Show 2 more Patients with endocrine disorders (evaluation): obtain a lipid panel for the assessment of triglyceride levels and for calculating LDL cholesterol in adult patients with endocrine disorders. B Show 3 more Patients with endocrine disorders (thyroid disease): avoid treating hyperlipidemia until the patient becomes euthyroid in order to more accurately assess the lipid profile in patients with overt hypothyroidism. D Show 2 more Patients with endocrine disorders (Cushing's syndrome): obtain cardiovascular risk assessment and initiate treatment in adult patients with cured Cushing's syndrome as in the general population. E Show 3 more Patients with endocrine disorders (adult growth hormone deficiency): assess lipid profile at diagnosis to screen for dyslipidemia in adult patients with GH deficiency. B Show 2 more Patients with endocrine disorders (acromegaly): consider obtaining usual lipid profile before and after treatment of GH excess in adult patients with acromegaly. C Patients with endocrine disorders (PCOS): Obtain a fasting lipid panel at diagnosis to assess cardiovascular risk in patients with PCOS. B Avoid using lipid-lowering therapies for the treatment of hyperandrogenism or infertility in patients with PCOS. D https://web.pathway.md/diseases/receTcWVpm18Q5oo1 15/19 6/29/23, 10:23 PM Dyslipidemia Pathway Patients with endocrine disorders (testosterone deficiency): consider initiating testosterone therapy as symptomatically indicated and not as an approach to improve dyslipidemia or CVD risk in patients with low testosterone levels. C 7. Patient education Shared decision-making: As per AHA 2019 guidelines, promote shared decision-making when initiating lipid-lowering therapy, and discuss the potential benefits and adverse effects of treatments, as well as the potential for drug-drug interactions. B Show 2 more As per CCS 2016 guidelines, share the results of cardiovascular risk assessment with the patient to support shared decision-making and improve the likelihood of reaching lipid targets. A 8. Follow-up and surveillance Monitoring for adherence to treatment: As per VA 2020 guidelines, consider offering intensified patient care (such as phone calls, emails, patient education, drug regimen simplification) to improve adherence to lipid-lowering medications. C As per AHA 2019 guidelines, assess adherence to changes in lifestyle and effects of LDL cholesterol-lowering medication by measurement of fasting lipids and appropriate safety indicators 4-12 weeks after statin initiation or dose adjustment and every 3-12 months thereafter based on need to assess adherence or safety. A Monitoring for adverse effects of statins: As per AHA 2019 guidelines, conduct a clinician-patient risk discussion before initiation of statin therapy to review net clinical benefit, weighing the potential for ASCVD risk reduction against the potential for statin-associated side effects, statin-drug interactions, and safety, while emphasizing that side effects can be addressed successfully. A Show 8 more As per CCS 2016 guidelines, evaluate all purported statin-associated symptoms systematically incorporating observation during cessation and reinitiation of statins (same or different statin, same or decreased potency, same or decreased frequency of dosing) to identify a tolerated, statin-based therapy for chronic use. B Clinical findings Symptoms Past medical history Ankle swelling Cushing's syndrome Chest pain Diabetes mellitus Difficulty breathing Genetic abnormality https://web.pathway.md/diseases/receTcWVpm18Q5oo1 16/19 6/29/23, 10:23 PM Dyslipidemia Pathway Fainting Human immunodeficiency virus infection Fatigue Hypercholesterolemia Heartburn Hypothyroidism Leg pain IBD Nausea Metabolic disorders Palpitations Obesity Sweats PCOS Swelling Social history Family history Alcohol consumption Genetic predispositions Lab findings serum LDL serum cholesterol serum triglycerides Studies 2023 RACING In adult patients with diabetes mellitus and ASCVD, moderate-intensity statin plus ezetimibe combination therapy was not superior to high-intensity statin monotherapy with respect to the composite of cardiovascular death, major cardiovascular events, or nonfatal stroke at 3 years. Yong-Joon Lee et al. 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