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

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

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

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

#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

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

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

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.

“Should I get my cholesterol checked?”

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

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?

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.

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

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

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

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?

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

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?)

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.

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

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?