Coronary Artery Disease and Cholesterol
Angina types, lipid targets and lipid-lowering drugs
Stable angina
Predictable chest pain with exertion or stress; relieved by rest or nitroglycerin within minutes.
Unstable angina
New, at rest, or worsening; not relieved by rest. Treat as ACS: emergency.
Variant (Prinzmetal)
Coronary vasospasm, often at rest/night. Treated with CCBs and nitrates; avoid triggers (smoking, cocaine).
Lipid values (adults)
| Lab | Desirable |
|---|---|
| Total cholesterol | <200 mg/dL |
| LDL ("bad") | <100 mg/dL (lower targets, e.g. <70 or <55, in people with heart disease) |
| HDL ("good") | Men ≥40 mg/dL; women ≥50 mg/dL |
| Triglycerides | <150 mg/dL |
Some guides reverse the HDL numbers by sex. It's women ≥50, men ≥40.
Risk factors
Can't change
- Age (men ≥45, women ≥55)
- Family history of early CAD
- Sex, genetics
Can change
- Smoking, high BP, high LDL
- Diabetes, obesity, inactivity
- Unhealthy diet, heavy alcohol use
- Chronic kidney disease
Lipid-lowering drugs
| Drug | Key points |
|---|---|
| Statins (atorvastatin, rosuvastatin, simvastatin) | First-line; lower LDL most. Report muscle pain, weakness, dark urine (myopathy, rhabdomyolysis: check CK). Baseline liver tests. Simvastatin and lovastatin are taken in the evening; atorvastatin and rosuvastatin any time. Avoid large amounts of grapefruit with simvastatin, lovastatin, atorvastatin. Usually stopped in pregnancy. |
| Ezetimibe | Blocks cholesterol absorption; added to a statin. |
| PCSK9 inhibitors (evolocumab, alirocumab), inclisiran | Injections for very high risk or statin intolerance; large LDL reductions. |
| Bempedoic acid | Oral option for statin intolerance; can raise uric acid (gout). |
| Bile acid sequestrants (cholestyramine) | Constipation; bind other drugs: give other meds 1 h before or 4–6 h after; may ↓ fat-soluble vitamins. |
Tests
- Stress test: avoid caffeine 12–24 h before; some meds (e.g. beta blockers) may be held as ordered.
- Cardiac cath: check allergies, kidney function, anticoagulants; metformin may be held around contrast if kidney function is poor.
- Lipid panel: fasting not always required; follow the lab's instructions.
Memory hook
HDL = Happy/Healthy: you want it High.
LDL = Lousy: you want it Low.
Nystatin is an antifungal, not a statin.
LDL = Lousy: you want it Low.
Nystatin is an antifungal, not a statin.