Lipid Panel Case Study: Lab Interpretation for New Grad NPs
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Show notes:
Interpreting lipid panels in primary care can be deceptively confusing! It's a routine lab that you'll see (or already see) every day in primary care. We need to know when to order it, how to interpret it, and what next steps to take.
It can be tricky to know which guidelines to use, what numbers to treat, and which medications to choose if you need to go that route!
Managing High Cholesterol in Primary Care
In this video, using a case study, you'll learn:
Which patients to test for high cholesterol
How to decide who gets treatment (and what kind)
When to follow up with patients after starting treatment
IMPORTANT NOTE: this applies for non-pregnant adults only, and statins are contraindicated in pregnancy, so be mindful when managing patients of childbearing age/potential.
Lab Interpretation Crash Course
If you liked this episode, it's a sneak preview of how we cover labs inside our comprehensive Lab Interpretation Crash Course. It covers CBC, CMP, Urinalysis, Dipstick & Microscopy, TSH, Lipids & top Endocrine labs in primary care, and comes with lifetime access and continuing education credits! Check it out here.
Resources for Managing High Cholesterol:
Intensities of statin therapy- what dose to pick and which one.
Risk enhancing factors - what would help you decide to treat with medication or not.
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today's topic is one of the most
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requested I've gotten so far and that is
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lipid and cholesterol management so if
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you're new here I'm Liz Rohr from real
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world NP and you're watching MP practice
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made simple the weekly videos to help
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save you time frustration and help you
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learn faster so you can take the best
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care of your patients so I'm gonna be
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using a case study of a patient that
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we've seen before if you've been
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following along I'm gonna do a deep dive
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on his cholesterol panel and management
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how to treat it how to go forward all
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the main questions that you have an
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important note here is that the vast
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majority of patients in primary care are
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going to fall into this pattern in this
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category however there are some caveats
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to think about and so there's no way I
0:36
could cover all of it in one video here
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so if you want to learn more about that
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having over two real-world
0:41
NPM such labs and join us for the lab
0:43
interpretation crash course for new
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nurse practitioners you still have time
0:46
to join it's open until Thursday January
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30th at 10 p.m. Eastern Time not only
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covers more caveats about lipid
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management but CBC CMP is urinalysis gsh
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all that stuff i'll the main things in
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primary care so I'd love to have you
0:58
clearly I'm very excited about it
0:59
because I can't stop talking about it
1:00
but without further ado I'm gonna share
1:02
my screen with you so this is the
Case Study
1:04
hyperlipidemia case study so this is
1:06
roll so if you watch this last week you
1:08
can I'm gonna leave a timestamp on the
1:10
top right corner if you want to
1:11
fast-forward you're the recap of this
1:13
case so you can forward ahead but if not
1:16
this is Raul he's 58 years old he's here
1:18
for follow-up of diabetes and again this
1:20
is not his real name or his photo so he
1:22
had requested a refill the month prior
1:24
for medications but he hadn't been in
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the office for about 18 months had been
1:28
asking for refills so I gave him a
1:30
month's worth of medication and then had
1:31
him schedule a follow-up appointment
1:32
because I'm I never met him before I'm a
1:35
new PCP for him at my new clinic and so
1:38
he was asymptomatic that day just really
1:39
when it's in refills was a little
1:40
annoyed with me the a1c at that time for
1:44
the point-of-care test right in the room
1:46
was a 10.8 and he was taking Humalog mix
1:51
which I'm not super familiar with its
1:53
list bro protein and list bro insulin 30
1:55
units once a day instead of twice a day
1:57
as prescribed and that's a intermediate
2:00
acting with a shorter acting one and I
2:01
actually can't remember if it's a short
2:03
acting or a rapid acting one but I
2:05
believe it's short acting for the second
2:07
one and not he was also not taking that
2:09
form in a thousand milligrams twice a
2:11
day neither was he taking lisinopril
2:13
five milligrams
2:13
set in 10 as we had asked him to in the
2:16
past
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so his past medical history what had
2:18
hypertension obesity diabetes and
2:21
hyperlipidemia he hadn't had any
2:23
surgeries before but he his brother had
2:25
diabetes luckily he's a nonsmoker no
2:28
alcohol or drugs and his blood pressure
2:30
was was great at this visit 135 over
2:32
eighty one heart rate of 67 oxygen of 96
2:35
his BMI was rather high though at 45 he
2:37
had a normal physical exam overall aside
2:39
from obesity he had normal heart and
2:42
lung sounds cardiovascular respiratory
2:43
and extremity exam so plan I'm really
2:46
gonna be focusing today on lipids but
2:48
I'll talk about the other components of
2:49
his care at the end and so I checked
2:52
some labs for him I checked a CBC a CMP
2:54
a lipid panel and then urine micro
2:57
albumin
2:58
so overall aside from some hyperglycemia
3:01
his BMP was normal his lfts and a CBC
3:04
were also normal the year and micro
3:06
albumin was not normal but that is the
3:08
subject of last week's case study if you
3:10
want to go back and watch that if you
3:11
haven't seen that already so this is his
3:13
cholesterol panel and these are all in
3:14
the u.s. kind of standard units if
3:16
you're watching from Canada or outside
3:18
the country outside the states rather so
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total cholesterol here is 230 everything
3:25
is abnormal but the total cholesterol is
3:26
230 the LDL is 150 which is high HDL 30
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which is low and triglycerides which are
3:33
high at 160 and luckily these are
3:35
actually not that high compared to how
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high his blood sugar was and typically
3:38
that tends to go together so pausing
3:41
referral for a second when we're talking
3:42
about hyperlipidemia we're talking about
3:44
assessing a s CVD risk atherosclerosis
3:47
Collor disease risk cuz it's very
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different from other labs that we're
3:51
talking about whereas potassium you're
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much worried much more worried about
3:54
like what's going on in this moment and
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bringing it down you're not really
3:57
titrating the labs as much in this case
4:00
study so just stick with me for a second
4:02
so the number one thing I want you to
4:03
think about when it comes to clip-ins
4:05
is what is their risk of a s CVD because
4:08
it doesn't really matter like an LDL of
4:11
a certain number or an H deal of a
4:13
certain number doesn't necessarily
4:14
matter if their risk factors are not
4:16
also there so step back for a second so
4:19
clinical a s CVD so sign somebody has a
4:22
thermo sporadic disease our heart attack
4:24
and stroke are the most common ones we
4:25
think about right but I just want to
4:26
remind you that
4:27
arterial disease some causes of renal
4:30
artery stenosis not all of them some of
4:31
them are from other reasons right but
4:33
mesenteric ischemia very uncommon
4:36
diagnosis but those are all signs of
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atherosclerosis and those patients are
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treated differently and so that's the
4:43
well that's what we're talking about
4:44
that what is their risk of developing
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those things and thinking about what is
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their baseline risk and then would it
4:49
improve with treatment because you can
4:51
have and I think that makes a lot of new
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grads and students uncomfortable because
4:54
they look at labs and they're like well
4:55
you're not treating them and they're
4:56
just there and it's like well the
4:58
guidelines we don't have to treat them
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because it's not about titrating numbers
5:01
and getting them perfectly aligned it's
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about what is their risk of having one
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of those clinical ASC VD events and what
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is their baseline risk compared to what
5:10
it would if it would improve with
5:12
treatment right and the biggest concern
5:14
here is actually LDL and so there's a
5:16
lot of numbers there's total cholesterol
5:17
HDL triglycerides all that stuff
5:19
triglycerides have their own caveats
5:21
which I'm not going to talk about in
5:22
this video but biggest concern here is
5:24
LDL because what we know is based on the
5:26
data based on the research rate we're
5:28
talking about long-term risk of a s CVD
5:31
and so what we know is that high LDL
5:34
increases risk for that and when you
5:35
lower it it reduces the risk whereas the
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same thing is not necessarily true with
5:40
all of the other labs which is why we
5:42
kind of quote don't care about them we
5:43
still care about them but we're not
5:44
gonna like chase them down with
5:45
medications which you'll see in a second
5:47
and again this presentation is
5:49
specifically talking about the scenario
5:52
of primary prevention so for this
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patient he has not had clinical a s CVD
5:56
he's never had a stroke or heart attack
5:57
for quality Ria's the peripheral
5:59
arterial disease things like that so
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these are only these recommendations are
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only for people who have not had that
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happen before so it doesn't include
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people who have had an mi stroke all
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those other things or high triglycerides
6:10
again have their own caveats so who
6:13
should be tested this is about screening
6:15
because again we're talking about
6:16
primary prevention and so this is a
6:18
little bit controversial I mean it's
6:19
actually not really controversial but
6:21
it's just there are some differing
6:22
thoughts on it and so an expert level of
6:25
opinion is that patients um if you're if
6:27
you treat kids you familiar with the AAP
6:30
guidelines you American Academy of
6:31
Pediatrics has recommendations about
6:33
lipid screening in childhood and so the
6:35
thought is is that if you're in internal
6:37
medicine because this presentation is
6:38
all about adults here I should
6:40
that at the beginning but if you have
6:42
somebody who's 18 who you don't have any
6:44
pediatric records for like probably you
6:46
can get us one time screening and kind
6:48
of assess that what their risk is but
6:50
definitely check those guidelines if
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you're taking care of kids
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so risk factors for again clinical AS
6:56
CVD heart attack stroke etc the risk
6:59
increases and these risk factors are
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important so the risk increases with age
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men more than women smoking diabetes
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hypertension sedentary lifestyle obesity
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and then family history of coronary
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artery disease especially in
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first-degree relatives of men under the
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age of 55 and then women under the age
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of 65 so their mother or father things
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like that and then the USPSTF is not the
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only screening guideline organization
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right but it's a pretty solid one to
7:28
follow and their recommendation is that
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men over the age of 35 and women over
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the age of 45 should be screened however
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anybody under those ages above the age
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of 20 could be screened if they have
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those risk factors that laundry list
7:41
that I just mentioned like if they smoke
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they've diabetes obesity hypertension
7:45
etc etcetera or family history so
Treatment
7:48
treatment I'm gonna jump into this first
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because before I talk about assessing
7:51
risk and deciding if they need treatment
7:52
because I'm gonna reference it a bunch
7:54
so it makes more sense to talk about it
7:55
now so number one is lifestyle
7:57
modification right you know that you
7:58
learned that in school however one thing
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I really want to highlight here what
8:02
we're talking about a saturated fat and
8:04
cholesterol patients talk about like oh
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like should I stop eating eggs like what
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has cholesterol in it
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quite honestly without getting too much
8:10
into it and I get more into this into
8:12
the lab course if you're interested but
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um what we're talking about here is that
8:15
lipids LDL specifically hold on to all
8:19
of those fats and and turns it into
8:21
atherosclerosis right and so we're
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talking about saturated fats which come
8:24
from meat products people talk about red
8:27
meat but chicken and fish almost have as
8:29
much saturated fat so typically what I
8:31
recommend to patients you don't
8:32
necessarily have to go for a plant-based
8:34
diet it's actually worth considering if
8:36
you have severe clinical AAS CVD but
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that's another story for another day but
8:40
you know reducing portion sizes talking
8:42
about portion size as a deck of cards
8:43
for me plate method meatless Monday is
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like how can we think about this and be
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thoughtful about it and if they're not
8:50
willing to reduce it their very least
8:51
monitoring it that's kind of what I
8:53
recommend
8:54
the motivational interviewing thing and
8:56
then exercises especially in patients
8:57
who are obese have been shown to lower
8:59
the LDL and raise the HDL so definitely
9:01
worth recommending and the standard
9:03
recommendation is like 30 minutes five
9:05
days a week that kind of thing of low
9:06
intensity exercise and the medication is
9:09
statins I'm sure you've learned about
9:11
the ATP three guidelines about all the
9:14
different medications and pharmacology
9:15
which i think is also really
9:16
overwhelming for new nurse practitioners
9:18
and for students as well but honestly
9:20
quite honestly the vast majority of the
9:22
data again this is not about titrating
9:24
numbers this is about reducing risk over
9:26
time the best data for actual morbidity
9:28
mortality protection over time
9:30
preventing that heart attack stroke and
9:32
death is statins and it's again it's not
9:34
necessarily about I mean it's no it's
9:37
tied to lowering the LDL but it isn't
9:39
necessarily just about that because I
9:41
think that in terms of the other studies
9:42
we have of other medications that may
9:44
also help with that don't necessarily
9:45
confer that same benefit again not just
9:48
about lowering numbers and then the
9:50
recommendations are when they talk about
9:53
it's actually low moderate and high
9:54
intensity statins and for the vast
9:56
majority of patients they're going to
9:57
recommend and moderate based on the
9:59
guidelines they're gonna make them in a
10:00
moderate intensity and how versus a high
10:02
intensity is for certain populations and
10:04
that just has to do with what medication
10:06
we're talking about and then what dose
10:07
we're talking about higher doses and
10:09
certain medications are considered high
10:11
intensity so okay that's the treatment
Evaluation
10:14
we know who does tests for we know kind
10:16
of why we care about it so how do we
10:17
evaluate and manage people and again
10:19
we're assessing their baseline risk and
10:20
deciding if the treatment is actually
10:22
going to help them with those outcomes
10:24
right not the numbers so we're looking
10:27
at the ACC hi-8 guidelines so ASC VD
10:30
risk calculator if you have not seen
10:31
this before is a thing of beauty if you
10:34
need to use it because that is the most
10:36
up-to-date guidelines I'm managing
10:38
lipids it's not about guessing it's all
10:39
about looking at numbers it's literally
10:41
you take this tool you plug in some
10:42
stuff and then it tells you what to do
10:44
it's beautiful and you do have to use
10:46
your brain you still have to think but
10:47
what it does is assesses the next 10
10:49
year risk of having those clinical ASC
10:51
VD events if you really want to sound
10:53
really smart you can take one who is DVD
10:56
actually know maybe that sounds kind of
10:57
dumb but I feel like when I read about
10:59
and I learn about it people always talk
11:00
about that anyway heart attack and
11:02
stroke and then their lifetime risk so
11:04
this is problematic because it assesses
11:07
risk for
11:07
white patients and black patients well
11:09
or fairly but it doesn't necessarily
11:12
count for other races and ethnicities
11:14
and it also doesn't take into account
11:15
family history because this is based on
11:17
very large studies of patients and
11:20
outcomes and that's where they develop
11:22
the tool it was made in 2013 and there
11:25
was an update in 2018 I believe and they
11:27
talked about quote risk enhancers and
11:28
I'm gonna link to the to the resources
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below I don't have the rights to kind of
11:33
use the images but I'll link to the
11:35
website to kind of give you more
11:36
information but thinking about their
11:38
risk enhancers this is where you kind of
11:39
have to use your brain right where you
11:40
have to think about not just the score
11:42
it's giving you in the direction that's
11:43
told you but thinking about does this
11:46
fully capture their risk right so way to
11:49
make it super easy and primary
11:51
prevention again people who have not had
11:53
a heart attack or stroke there's for
11:54
high risk categories one patients who
11:56
have an LDL over 190 perfect you don't
11:58
even have to do the risk calculator they
12:00
just get a moderate intensity Saten
12:01
moderate to high you could plug it in
12:03
and it can come and give you those
12:04
directions actually but typically those
12:06
patients need a statin I don't remember
12:08
off the top of my head
12:09
diabetes patients with diabetes with
12:11
ages 40 to 75 you basically don't have
12:13
to do the calculation either because
12:15
most patients qualify for moderate
12:17
intensity satin they are recommended to
12:19
take that however you may consider
12:21
entering the data because it may point
12:23
you into the direction of a higher
12:24
intensity statin and off the top of my
12:27
head it's atorvastatin and more Suba
12:28
statin or the high intensity ones at the
12:30
higher doses and then modern at moderate
12:32
intensity extends and include a lot more
12:35
types of medications patients who have
12:37
an AS CVD risk greater than 20 recommend
12:40
medication treatment and then a SCV DRS
12:42
greater than seven and a half to 20
12:44
percent are considered intermediate risk
12:46
so those are not necessarily like one
12:47
offs right but those are kind of easier
12:49
so treatment if it's less than five they
12:53
recommend lifestyle modification they
12:55
don't need medication intermediate seven
12:57
and a half to twenty we always want to
12:59
talk about lifestyle however it's a
13:00
discussion of treatment because we're
13:03
looking at again those risk enhancers
13:04
family history menopausal status things
13:07
like that
13:08
however this is a caveat down here
13:11
because there is some expert level of
13:12
evidence opinion that anybody greater
13:15
than 10% really should have both
13:17
lifestyle and medication and then
13:19
patients who have less than 10% if their
13:21
LDL
13:21
is greater than 160 they probably should
13:23
have medication too so that's again
13:25
expert level of opinion so that's a kind
13:28
of a lot of information that I've thrown
13:29
at you but literally you pull up this
13:31
risk calculator you plug it in you if it
13:33
recommends a statin awesome and then if
13:36
it doesn't you want to think about are
13:37
they greater than 5% are they gradient
13:39
7i 7.5% then think about what are the
13:41
risk factors that could push them into
13:43
statin category so four steps so
Recap
13:47
reversal recapping number one making
13:49
sure this is primary prevention versus
13:51
secondary because I'm not talking about
13:52
secondary they have their own
13:53
recommendations so number two what is
13:55
there a s CVD risk plug it in
13:57
it's beautiful tool number three is
14:00
lifestyle plus or minus medications
14:03
depending on their score and then what's
14:05
the follow up I'm actually going to take
14:06
a pause right here and I'm going to
14:08
share my screen with you for that tool
14:11
and I plugged it in for this gentleman
14:13
whoops spoiler alert there's a CVD risk
14:16
there I wanted to make sure it's all
14:17
filled out for you so basically what you
14:19
do is you fill in again it has that note
14:20
here only primary prevention
14:22
he has ages 58 he's a man he is Latino
14:25
so it doesn't count
14:27
well it doesn't count it doesn't it's
14:28
not as fair so definitely something to
14:31
think about and so blood pressure
14:34
systolic diastolic total cholesterol HDL
14:36
LDL do they have diabetes do they smoke
14:39
do they hate hypertension treatment are
14:41
they honest and they also an A on
14:43
aspirin therapy which is lovely because
14:44
I feel a little bit conflicted about
14:47
recommending aspirin sometimes and it
14:48
gives you a nice recommendation and then
14:50
they can refine current risk based on
14:52
their previous data if you want to do
14:53
that and it literally tells you what to
14:55
do so you view the advice and he has a
14:57
pretty high risk and so he actually
15:00
definitely consider qualifies for
15:02
spoiler alert codes for moderate
15:04
intensity stat and versus possible high
15:07
intensity statin so going back to here
15:10
though so he so those are the four steps
15:14
and so what I want to talk about so
15:16
let's go back to a rule so what's next
15:17
so spoiler alert he um
15:19
he automatically gets treatment because
15:21
he's in a high-risk group um but again
15:23
we do I I always do I always complete
15:26
the ASU VD risk score even if they have
15:28
diabetes just because I want to see if
15:29
they qualify for high-intensity
15:30
treatment and it's not it's sometimes I
15:33
think what they're I know what the risk
15:34
was going to be and then I plug it
15:35
it's like less than 1% and then other
15:37
times it's like 25% and I don't know
15:40
anyway that's what I recommend so I
15:42
recommend um also lifestyle modification
15:44
and weight loss for him because his BMI
15:45
is 45 and so management I just wanted to
15:49
quick other notes to talk about when
15:51
you're talking about statin therapy it's
15:54
recommended expert level of evidence a
15:57
expert opinion level of evidence to
15:59
check a baseline lfts and a baseline CKD
16:01
is quote helpful but there are no
16:03
guidelines I have to be honest I've
16:04
never checked a baseline CKD i have
16:05
checked baseline lfts however there are
16:08
recommendations do not routinely check
16:09
these for monitoring you really want to
16:11
go based on symptoms and then the thing
16:13
to watch out for you want to watch out
16:14
for signs of rhabdomyolysis
16:16
rhabdomyolysis this is very uncommon but
16:19
you can't have statin associated
16:20
myalgias so for statin related mileages
16:25
they're typically symmetrical meaning
16:28
both sides and then their proximal more
16:30
than distal so it's like your bilateral
16:31
thighs versus your upper extremities it
16:35
typically happens sooner than later like
16:36
in the first two weeks or so and then
16:39
for rhabdomyolysis you have some other
16:41
concerning signs so red brown urine
16:43
elevated muscle enzyme so the CKD is
16:45
typically above five times the upper
16:47
limit of normal they may also have fever
16:49
malaise tachycardia GI symptoms so
16:51
definitely things to watch out for very
16:52
uncommon but the myalgias can be common
16:54
and that's kind of like a whole topic in
16:57
and of itself how to kind of manage that
16:58
which I talked about in the lab course
16:59
of like how do you adjust statins and
17:03
what if patients have side effects and
17:04
when you do next like things like that
17:05
that's kind of like a whole conversation
17:06
so I'm not going to get into that but
17:08
that's you try your best to keep them on
17:10
statins because again they have the best
17:11
evidence so follow up um I always like
17:15
this question so when do you reach X 2
17:17
lipid when you recheck the lipid panel
17:19
the moral of the story here which I
17:21
think will make you feel a lot better
17:22
and you might be a little bit resistant
17:24
to but the data tells us that just the
17:27
fact that they're on a moderate
17:28
intensity statin especially is really
17:30
protective for them and so the
17:32
recommendations of rechecking lipids are
17:34
typically two to three months after
17:35
starting and that's really to kind of
17:37
assess adherence more than anything else
17:39
because you're expecting to see a 30 to
17:42
50 percent drop in the LDL and if you
17:44
don't and they are adherent you want to
17:46
think about some other things and maybe
17:48
can
17:49
during sending to cardiology it's kind
17:50
of a lot to get into but anyway annually
17:54
um after that though you really want to
17:56
check it annually for primary prevention
17:59
patients we're not talking about
18:00
secondary we're not talking about people
18:01
have had a heart attack and then you
18:03
want to assess their risk factors and
18:04
clinical ASCD like do they need to
18:06
increase the intensity of the statin
18:07
moral majority of the time they really
18:10
don't necessarily need the high
18:12
intensity it doesn't necessarily improve
18:13
their outcomes that much more so
18:15
moderate intensity is usually adequate
18:17
and then do they have any signs of
18:19
clinical CVD because again that changes
18:21
your management altogether but most
18:22
likely if they've had those events
18:23
they're kind of in the care of a
18:24
specialist which is nice but anyway so
18:27
that's it for a lipid so this is role
18:28
again just recap so we called with the
18:30
results by phone both of the lipids and
18:31
the year and micro album image again you
18:33
can go back and watch that if you
18:34
haven't already he wasn't that concerned
18:37
surprised I advised him to come back in
18:40
about a month for diabetes
18:41
he said now but he said he would come
18:43
back in three months and I feel like
18:44
that's that's harm reduction I'm much
18:45
happier than that because he hadn't been
18:48
there in 18 months and he said he's
18:50
gonna restart they re checking the blood
18:51
sugars a note also is that I recommended
18:54
that he kind of go back and start taking
18:55
when he took before and he did agree to
18:57
start restart the metformin and consider
18:59
increasing going back to the 30 twice a
19:02
day of the insulin I am NOT a big fan of
19:04
the of the mixed insulins with the long
19:06
acting or the longer acting intermediate
19:08
acting the short acting they're not my
19:10
favorite to address but it tends to come
19:12
down to insurance and what they're used
19:14
to and all that stuff but I can
19:15
definitely get into uncontrolled
19:17
diabetes I'm in another video for sure I
19:19
definitely have that in the plans but
19:20
I'm kind of just working with what I got
19:22
for right now and and lifestyle
19:24
modification is amazing when patients
19:27
can commit to it and lose weight and
19:28
anyway I could go on and on but anyway
19:30
so that's what he's gonna do and then he
19:32
was due for a physical exam but again
19:33
harm reduction here I'm really just
19:35
focusing on please don't leave again
19:37
please come back let me help you with
19:39
your a1c getting his buy-in you know
19:41
getting his consistency things like that
19:43
but that's it did you like this video if
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there and I'll see you soon
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you
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From Real World NP
Nursing
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