Lipid Management in 2015: Risk & Controversies

1. Lipid Management in 2015:Risk & Controversies • Michael Miller, MD • R. Michael Benitez, MD

2. 2013 ACC/AHA Guidelines • Emphasis on statins as first-line therapy due to strong body of supporting evidence • Focus on ‘appropriate intensity’ statin therapy in 3 groups ‘most likely to benefit’ 2013 ACC/AHA Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Stone NJ, et al. Circulation 2013; JACC 2013

3. #1 - Clinical Atherosclerotic CVD • History of CAD, MI, stable/unstable angina • Coronary or other arterial revascularization • CVA / TIA • Peripheral arterial disease

4. #2 - LDL > 190 mg/dl • Targeting familial hypercholesterolemia

5. #3 - Diabetic, age 40-75, LDL 70-189 • Calculate 10 year risk of atherosclerotic CVD • If Risk > 7.5% High-Intensity statin • If Risk < 7.5%, moderate-intensity statin • Lowers LDL 30-50% • Atorva 10-20, rosuva 5-10, simva 20-40, prava 40-80, lova 40, pitava 2 – 4

7. 10 Year ASCVD Risk: Pooled Cohort Equation • Demographics • Age (40-79) • Gender • Race • History • HTN • DM • Tobacco • Measurements • Tchol • HDL • Systolic BP

8. Estimated 10 year risk >7.5% • The guidelines state that the risk estimator does not, and should not determine which patients receive statins • Statin use should be determined after a ‘detailed risk discussion’ between patient and physician

9. Case 1 • Tom is a 55 year old African American man • He had a NSTEMI at age 50, with subsequent PCI of the LAD. • He is on atorvastatin 80 mg/daily, along with aspirin, beta-blocker and ACE-i.

10. “Should I get my cholesterol checked?”

11. Tom’s labs • TChol - 170 mg/dl • Triglycerides - 140 mg/dl • HDL Chol - 42 mg/dl • LDL Chol - 90 mg/dl

12. Questions • Should we still follow levels? • How often should we follow levels? • The current guidelines are very focused on statin therapy . . . • What is the role of non-statin therapy for elevated LDL cholesterol?

13. Case 2 • Tom’s older brother, aged 60, comes to see you. • He had CABG at age 52, is a never-smoker, but has hypertension and type II diabetes, with a hemoglobin A1c of 7%. • He shops with Tom, and they are both on Atorvastatin 80 mg daily. He is on no other lipid lowering medicine.

14. His cholesterol values: • TChol - 164 mg/dl • HDL Chol - 28 mg/dl • LDL Chol - 70 mg/dl • Triglycerides (fasting) - 280 mg/dl

15. Questions? • Should he be treated with another agent for his elevated triglycerides? • Should he receive any treatment targeted towards the low HDL cholesterol?

16. Case 3 • Tom’s younger brother, age 50, also comes to see you. • He is asymptomatic and has no known history of CAD, but he is worried that both of this older brothers had serious heart disease at about his age. • He is a ‘never-smoker’, and is not hypertensive or diabetic. • Tchol 220 / HDL 44 / SBP 132 mm Hg

18. Questions? • How do we account for FAMILY HISTORY under the new guidelines? • Should he be treated? • What is the role of further testing? • Coronary calcium scoring? • Hi-sensitivity CRP?

19. He undergoes Coronary Calcium CT scoring; Agatston score of 28, all RCA

20. Questions? • Does this establish him as having CAD? • Should he be treated with statin? Hi dose? Moderate dose? (what should the target of treatment be - and how should this be followed?)

21. All in the Family • Tom’s mother comes to see you. • She has no history of CAD. She is hypertensive, not diabetic, has never smoked and is not symptomatic. • She is 80 years old.

22. Questions? • What is the role of statin therapy in the elderly ... • for Primary Prevention? • for Secondary Prevention?

23. How Low Should We Go? 53 yo Woman with newly diagnosed CAD Prior to statin: TC=86 TG= 27 HDL= 35 LDL= 46 She was placed on Atorvastatin 80 mg w/o symptoms. Do you continue same or modify regimen?