PRImary care Medical Education

Lipid Management in the

Philippines
For PRIME Academy

Myla Gloria F. Salazar-Supe, MD, FPCP, FPCC, FPSE

Philippine Heart Center
July 21, 2017
Myla Gloria Salazar-Supe,MD
Medical Specialist 2, Philippine Heart Center
Head of the Section of General Cardiology, Philippine
Heart Center (PHC)
Training Officer, Division of Clinical Cardiology, PHC
President, Philippine Society of Echocardiography

Fellow and Diplomate, Philippine College of Physicians

Fellow and Diplomate, Philippine College of Cardiology
Fellow, Philippine Society of Echocardiography (PSE)
• Atherosclerotic cardiovascular disease
remains the number 1 cause of death in the
Philippines and world-wide
Atherosclerotic Cardiovascular Disease (ASCVD)

Stroke CAD PAD

 Cholesterol plays a central role in atherosclerosis
Hypertension Dyslipidemia Diabetes

Endothelial Dysfunction

Reactive Oxygen
 Nitric Oxide Inflammatory markers
Species (ROS)
 Risk of AMI associated with Risk
Factors in the Overall Population
Risk Factor % Cont % Cases PAR (99% CI)
ApoB/ApoA-1 20.0 33.5 54.1 (49.6, 58.6)
Current Smoking 26.8 45.2 36.4 (33.9, 39.0)
Diabetes 7.5 18.5 12.3 (11.2, 13.5)
Hypertension 21.9 39.0 23.4 (21.7, 25.1)
Abdominal Obesity 33.3 46.3 33.7 (30.2, 37.4)
Psychosocial - - 28.8 (22.6, 35.8)
Vegetable & Fruits daily 42.4 35.8 12.9 (10.0, 16.6)
Exercise 19.3 14.3 25.5 (20.1, 31.8)
Alcohol 24.5 24.0 13.9 (9.3, 20.2)
Combined - - 90.4 (88.1, 92.4)

Salim Yusuf, Steven Hawken, Stephanie Ôunpuu, Tony Dans, Alvaro

Avezum, Fernando Lanas, Matthew McQueen, Andrzej Budaj, Prem INTERHEART
Pais, John Varigos, Liu Lisheng, on behalf of the INTERHEART Study
Investigators* STUDY, 2004
 Multiple Risk Factor Intervention
n=356,222

• LDL–c is the predominant cholesterol-carrying

lipoprotein ~ 75% of the non-HDL cholesterol

• There is a log linear relationship between LDL-c

and cardiovascular events
 for every 1 mmol/L decrease in LDL-c there is a
corresponding decrease in CV events by 20-24%
~ Cholesterol Treatment Trialists (CTT)
Lancet 2010; 376: 1670-81

The LDL
Hypothesis:
the lower
the better
Treatment modalities to lower LDL-c

AIM HIGH Investigators. N Engl J Med 2011;365:2255-67.

STATINs decrease CV events

Cholesterol Treatment Trialists (CTT)

Lancet 2010; 376: 1670-81
STATINs as the cornerstone in the treatment of atherosclerosis
 LDL-C Goals for High-Risk Patients
Have Become More Intensive Over Time
As part of therapeutic lifestyle changes, including diet,
LDL-C treatment goals for high-risk patients have been lowered over time
1988 1993 2001 2004 2006 2010
ATP I ATP II ATP III ATP III Update 2° AHA/ACC ADA

Goal:
<130 mg/dL1
Goal: Goal: Goal: Goal: Goal:
100 mg/dL2 <100 mg/dL3 <100 mg/dL4 <100 mg/dL5 <100 mg/dL6
Very-high-risk ptsa High-risk pts Overt CVD
Optional goal: Reasonable goal:
<70 mg/dL6
<70 mg/dL4 <70 mg/dL5

Definition of high-risk or highest-risk patient:

• ATP I: definite CHD or 2 other CHD risk factors1 • 2° AHA/ACC 2006: established coronary and other
• ATP II: prior CHD or other atherosclerotic disease2 atherosclerotic disease5
• ATP III and the 2004 update: CHD or CHD risk equivalents 3,4
• ADA 2010: overt CVD6
aFactors that place a patient at very high risk are multiple components of the metabolic syndrome, established CVD plus any of the following: multiple major risk factors
(especially diabetes), severe and poorly controlled risk factors (eg, cigarette smoking), multiple components of the metabolic syndrome (especially TG ≥200 mg/dL +
non–HDL-C ≥130 mg/dL with HDL-C <40 mg/dL), and recent acute coronary syndromes.4
1. NCEP ATP I. Arch Intern Med. 1988;148:36–69; 2. NCEP ATP II. JAMA. 1993;269:3015–3023; 3. NCEP ATP III.
JAMA. 2001;285:2486–2497; 4. Grundy SM et al. Circulation. 2004;110:227–239; 5. Smith SC Jr et al. Circulation.
2006;113:2363–2372; 6. ADA. Diabetes Care. 2010;33(suppl 1):S11–S61.
A Major Shift in Paradigm
The target is not a LAB value …

It’s HEART DISEASE!

DO NOT treat numbers!
Treat the PATIENT!!!
THE WHO?
Identifying those who will benefit with treatment
Which patient require statin therapy?

• 40/F • 74/M • 35/M

• Hypertensive • Smoker • Non-HPN
• Transient R- • cc: chest pain • Diabetic
sided weakness • Refused • Smoker
• No residuals angiogram • Gangrene L foot
• LDL-c: 100 mg/dl • LDL-c: 130 mg/dl • LDL-c: 70 mg/dl
Established Regardless Regardless
ASCVD of LDL-c of age

High-intensity Statins
LDL-c reduction > 50%
 Secondary prevention
1 Clinical ASCVD
CHD, Stroke, PAD

STATIN
BENEFIT
GROUPS

Cholesterol Treatment Guidelines 2013

Intensity of Treatment depends on % LDL reduction

High-Intensity Statin Moderate-Intensity Low-Intensity

Therapy Statin Therapy Statin Therapy
Daily dose lowers LDL–C Daily dose lowers LDL–C Daily dose lowers LDL–C
on average, by on average, by on average, by <30%
approximately ≥50% approximately 30% to
<50%
Atorvastatin (40†)–80 mg Atorvastatin 10 (20) mg Simvastatin 10 mg
Rosuvastatin 20 (40) mg Rosuvastatin (5) 10 mg Pravastatin 10–20 mg
Simvastatin 20–40 mg‡ Lovastatin 20 mg
Pravastatin 40 (80) mg Fluvastatin 20–40 mg
Lovastatin 40 mg Pitavastatin 1 mg
Fluvastatin XL 80 mg
Fluvastatin 40 mg bid
Pitavastatin 2–4 mg
2015 Philippine Clinical Practice Guideline

50%

50%
Would this patient require a statin?
• 20 year old female
• LDL > 190 mg/dl
• Significant FMHx for
premature CAD / SCD
tendon xanthomas

xanthelasma

Familial Dyslipidemia
Arcus corneae

Lipemic plasma
Criteria for HeFH by
MedPED & WHO

Definite FH: score >8

Probable FH: score 6-8
Possible FH: score 3-5
No diagnosis: score <3
Dutch Lipid Network Criteria

Heterozygous Familial Dyslipidemia

Would this patient require a statin?
• 20 year old female
• LDL > 190 mg/dl
• Significant FMHx for
premature CAD / SCD

High-intensity Statins
LDL-c reduction > 50%
Would this patient require a statin?
• 39-year old male
• Recently diagnosed
with type 2 diabetes
mellitus
• LDL of 100 mg/dl
 American Diabetes Association 2015

age
Would this patient require a statin?
• 39-year old male
• Recently diagnosed
with type 2 diabetes
mellitus
• LDL of 100 mg/dl
Would this patient require a statin?
• 39-year old Filipino
• Recently diagnosed
with type 2 diabetes
mellitus
• LDL of 100 mg/dl
 Primary Prevention of ASCVD in DM
RECOMMEND:
ALL DIABETIC FILIPINO PATIENTS,
REGARDLESS OF AGE, or
DURATION OF DIABETES SHOULD
BE GIVEN STATIN THERAPY FOR
PRIMARY PREVENTION OF ASCVD

Appropriate Statin Treatment Goal:

30% or greater reduction of LDL-C from baseline or
less than 70 mg/dL for very high risk patients
2013 ACC-AHA Guidelines for Use of Statin Therapy in Patients at
Increased Cardiovascular Risk
Would this patient require a statin?
• 65 year old female
• Non-HPN
• Non-DM but with impaired glucose tolerance (IGT)

• BP = 138/82
• BMI = 27
• waist circumference = 100 cm

• TC = 180 mg/dl
• LDLc = 128 mg/dl
• HDL = 38 mg/dl
• TG = 198 mg/dl
 CV Risk Calculator

• Based on 25,000 patients

in ARIC, Framingham, and
other cohorts

• Includes stroke, not just MI

and death

• Uses sex, age, race, totalC,

HDL-C, systolic BP, and
treatment for HPN and DM
and smoking
• ACC-AHA Risk Calculator was based on pooled
cohort populations that did not include Filipinos
(or Asians in general)

• Applicability of these risk scoring systems on

Filipinos have not been done.

• There are no POOLED COHORT POPULATIONS of

similar proportion in the Philippines for us to
make a similar Risk Estimator
 Risk Factor Counting
 Male sex
 Postmenopausal women
 Smoker
 Hypertension
 BMI>25kg/m2
 Family history of premature
CHD
 Microalbuminuria / proteinuria
 Left ventricular hypertrophy.
Statement No, 2
For non-diabetic individuals aged ≥ 45 years with LDL-C ≥ 130 mg/dL AND ≥
2 risk factors*, without atherosclerotic cardiovascular disease, statins are
RECOMMENDED for the prevention of cardiovascular events.
Our patient ....
 Male sex
 Postmenopausal women
 Smoker
 Hypertension
 BMI>25kg/m2
 Family history of premature
CHD
 Microalbuminuria / proteinuria
 Left ventricular hypertrophy.
Statement No, 2
For non-diabetic individuals aged ≥ 45 years with LDL-C ≥ 130 mg/dL AND ≥
2 risk factors*, without atherosclerotic cardiovascular disease, statins are
RECOMMENDED for the prevention of cardiovascular events.
Heart Outcomes Prevention Evaluation-3 (HOPE-3) Trial
Canadian Institutes of Health Research
International randomized trial in 21 countries, US not included
China, India, Colombia, Argentina, and Canada contributed the most number of participants

• Inclusion criteria: Exclusion criteria:

• Men ≥55 years, women ≥65
years
• With at least one of the
following CV risk factors:
– Elevated waist-to-hip ratio
– History of a low level of high-
density lipoprotein
cholesterol
– Current or recent tobacco
use, dysglycemia
– Family history of premature
coronary disease
– Mild renal dysfunction
– Women with at least two of
the above risk factors
• Participants with CVD
• Indication for or contraindication
to statins, angiotensin-receptor
blockers, angiotensin-converting
enzyme inhibitors, or thiazide
diuretics
• Number screened: 14,682
• Total number of enrollees: 12,705
• Duration of follow-up: 5.6 years
• Mean patient age: 65.8 years
• Percentage female: 46%

Yusuf S, Bosch J, Dagenais G, et al. N Engl J Med 2016

Heart Outcomes Prevention Evaluation-3 (HOPE-3) Trial
• Inclusion criteria:
• Men ≥55 years, women ≥65
years
• With at least one of the
following CV risk factors:
– Elevated waist-to-hip ratio
– History of a low level of high-
density lipoprotein
cholesterol
– Current or recent tobacco
use, dysglycemia
– Family history of premature
coronary disease
– Mild renal dysfunction
– Women with at least two of
the above risk factors
Exclusion criteria:
• Participants with CVD
• Indication for or contraindication
to statins, angiotensin-receptor
blockers, angiotensin-converting
enzyme inhibitors, or thiazide
diuretics
• Number screened: 14,682
• Total number of enrollees: 12,705
• Duration of follow-up: 5.6 years
• Mean patient age: 65.8 years
• Percentage female: 46%

Yusuf S, Bosch J, Dagenais G, et al. N Engl J Med 2016

 > 65

138
82

128
mg/dl

Intermediate
risk
 Heart Outcomes Prevention Evaluation-3 (HOPE-3) Trial

Rosuvastatin
decreased
LDL-c by 35
mg/dl
 High follow-
up rate
minimal
supervision
Follow-up
No difference in
• Visits at 6 weeks, 6 months, thendiscontinuation
every 6 months rates
thereafter
• BP measured q visit in the first year, then annually
• Lipid levels at 1 year, 3 years and end of trial in an
ethnically representative subsample of 10-20% of
participants
 Implications of HOPE-3 Trial

• Even among Intermediate risk patients

(1% annual risk of CV events) there is
benefit from Rosuvastatin 10 mg
– reduced cardiovascular events by a relative 24%
with an absolute reduction of 1.1%.

• Minimal monitoring
• No dose titration
• Safe
Is this applicable to Juan dela Cruz?
Heart Outcomes Prevention Evaluation-3 (HOPE-3) Trial
Ethnically diverse study population
2%
Juan dela Cruz
7% Chinese
represent!
15% 29% Hispanic
White
South Asian
20% Black
27% others

Philippines = 571
Yusuf S, Bosch J, Dagenais G, et al. N Engl J Med 2016
 Differences in Drug Responses
• Smaller body size of Asians – frequently cited

• body weight accounted for <10% of the

differences between Asian and white patients
in plasma exposure (area under the plasma
concentration-time curve and maximum
plasma concentration) to rosuvastatin.
Lee E, Ryan S, Birmingham B, Zalikowski J, March R, Ambrose H, Moore R, Lee C, Chen Y, Schneck
D. Rosuvastatin pharmacokinetics and pharmacogenetics in white and Asian subjects residing in
the same environment. Clin Pharmacol Ther 2005;78:330–341. [PubMed: 16198652]
 Statin metabolism and drug
sensitivity—
• Much of the data on race/ethnic differences in
statin metabolism have shown that some Asian
subgroups are slower metabolize statins
compared to non-Hispanic white  higher
systemic drug concentrations

• Pk Studies:
• Rosuvastatin plasma concentrations two-fold
higher in Japanese vs NHW
• similarly elevated in other Asian subgroups; these
included Chinese, Malay, and Asian Indians
Effects of Statin Therapy in Asians
Japanese Lipid Intervention Trial (J-LIT)

– an open-label study of in 51,321 Japanese patients,

– the 5-mg Simvastatin, lowered LDL cholesterol by 29% over
23%
6 years, was deemed as effective as the 20-mg dose used
in Western countries.

– A small subgroup (1.4%) labeled “hyper-responders” had a

reduction in total cholesterol of >40% during 6 years of
low-dose treatment.
 Pharmacy

• Higher statin doses are not available in Japan

WHO may NOT BENEFIT from statin therapy?
 Statins in Older Patients
• Age accounts for most of the
attributable risk in patients
older than 75 or 80 years
• Predictive value of elevated
cholesterol decreases with age
• Meta-analysis: 22% relative
reduction in all-cause mortality
with statins
• PROSPER > 75 years
• SAGE (CAD) w/o ASCVD
Statins in Advance Heart Failure

• LVEF < 30%

• Atorvastatin:
• Rosuvastatin:
– CORONA
– GISSI
• Statin does not reduce CVD related
morbidity and mortality in low EF
with ischemic or non-ischemic cause
Statins in Renal Failure

Dialysis
SHARP
Meta-analysis
 KDIGO 2013
• LDL-c
– Cholesterol level is a less useful marker of risk-severity
– not an indicator for pharmacologic treatment

Lipid Management in Chronic Kidney Disease: Synopsis of the Kidney

Disease: Improving Global Outcomes 2013 Clinical Practice Guideline

• guided by absolute
risk for coronary
events
• patient’s age
• eGFR

Ann Intern Med. 2014;160(3):182-189. doi:10.7326/M13-2453

STATINS in Chronic Kidney Disease
SAFETY AND EFFICACY ISSUES
Statin in Asians
Discovery-Asia reported ADR’s
ADRs in Major Statin Trials
 Statin Intolerance
• high-dose statin therapy • disorders of calcium homeostasis
• advanced age (>70 years)
• alcohol abuse
• female sex
• family history of muscle disorders • Asian ethnicity
• history of creatine kinase elevation • low body mass index
• vitamin D deficiency • genetic polymorphisms (e.g.,
• renal and hepatic impairment
genes associated with drug and
• previous history of muscle toxicity with
other lipid-lowering therapy muscle metabolism)
• untreated hypothyroidism • surgery with severe metabolic
demands
• heavy and/or unaccustomed
exercise
• interactions with concomitant
medication
Addressing the FAQ’s

Doc,
baka masira
ang liver ko!
Doc, ang
sakit sa
katawan!
To date, high-dose simvastatin (80mg) is the only statin to
receive a U.S. FDA warning for increased risk of muscle damage.
Diabetes and Statins
Carter AA, et al. BMJ. 2013;346:f2610
 RISK FACTORS:
• Metabolic syndrome
• IFG
• BMI >30 kg/m2
• HBA1C > 6%

Ridker et al CV benefits and DM risks of atatin

in primary prevention: An Analysis from the
JUPITER Trial Lancet 2012
 Statin Treatment reduces CV events w/ or w/o risk
factors for Diabetes

Ridker et al CV benefits and DM risks of atatin in primary prevention: An Analysis from the JUPITER Trial Lancet 2012
JUPITER: Risk Reduction with Rosuvastatin
>1 Major Diabetes Risk Factor*
 Statins and Diabetes
• Study reference: meta-analysis of 13 statin trials
– 91,140 subjects; statins (n=2226); control (n=2052)
– n= 4278 had developed diabetes (OR=1.09, 95% CI 1.02-
1.17)
– An OR of 1.09 is LOW in absolute terms, assuming this
phenomenon is REAL.
• The benefits of cardiovascular protection overshadow the risks
(low in absolute terms) for developing diabetes while on statin
therapy.

Lancet 2010, 375:735-742

 Concerns with very low LDL
• The CTT meta-analysis of more than 90,000 patients treated
with statins has not shown an increase in cancers (initially
seen with SEAS)
• the JUPITER trial did not show increases in
– cancers,
– renal or hepatic diseases,
– hemorrhagic strokes
despite ¼ of patients reaching an LDL- C concentration
lower than 44 mg/dL (1.2 mmol/L) for up to 5 years.
• The CTT meta-analysis of statin trials did not identify any
signal of harm in patients treated with statins.
SPARCL
Stroke Prevention by Agressive Reduction in Cholesterol Levels

• intense lipid lowering with atorvastatin 80

mg/day reduced the risk of cerebro- and
cardiovascular events in patients with and
without carotid stenosis
• The carotid stenosis group may have greater
benefit
• In the group with carotid artery stenosis,
treatment with atorvastatin 80 mg/day was
associated with a 33% reduction in the risk of
any stroke

Sillesen H,et al - Stroke 2008

Cognitive Function: Pravastatin in PROSPER
Why choose
a SUPER STATIN?
 JUPITER - Primary Endpoint
Time to first occurrence of a CV death, non-fatal stroke, non-fatalMI, unstable angina
0.08
or arterial revascularization

Placebo

Hazard Ratio 0.56, (95% CI 0.46-0.69)

P<0.00001
0.06
Cumulative Incidence

• No prior CVD or DM
• Men > 50 women > 60
• LDL < 130 mg/dl Rosuvastatin 20 mg
0.04

• HsCRP > 2.0 mg/L

NNT
0.02

2 years= 95
5 years= 25
0.00

Number at Risk 0 1 Follow-up

2 (years) 3 4
Rosuvastatin 8,901 8,631 8,412 6,540 3,893 1,958 1,353 983 544 157
Placebo 8,901 8,621 8,353 6,508 3,872 1,963 1,333 955 534 174
*Extrapolated figure based on Altman and Andersen method Ridker P et al. N Eng J Med 2008;359: 2195-2207
 Intra-individual variability in LDL Cholesterol response to statin
therapy: A JUPITER trial update

Ridker et al, on behalf of the the JUPITER Trial study group. Cholesterol Treatment targets and
clinical outcomes. American Heart Association 2015 Scientific Sessions, November 10, 2015

“clinicians need to pay attention more to percent reduction in LDL-c

rather than focusing on actual LDL levels”
Prevention Guidelines Clinical Vignettes
 Clinical Case 1

? • 52 M
• Coro angio showed 3 vessel CAD
• no history of hypertension, diabetes
mellitus, or smoking
• SBP: 130 mm Hg
• BMI: 26 kg/m2
• exercises regularly and follows a low-
cholesterol diet
 Clinical Case 1

? • fasting lipid values

• Total cholesterol 290 mg/dL
• HDL-C 50 mg/dL
• Triglycerides 250 mg/dL
• LDL-C 190 mg/dL.
 Clinical Case 1
ACC/AHA CV RISK 52 AA M
CALCULATOR

290 50

130 NO

NO NO

7.0%
Would you treat
this patient? 50%
 1 Clinical ASCVD
CHD, Stroke, PAD

2 LDL C: >190mg/dl

DM
3 > Age 40-75 years
>LDL C: 70-189mg/dl

Diagnosed with ASCVD risk >7%

No diabetes
CAD
4 > Age 40-75 years
>LDL C: 70-189mg/dl

7.0
%
 Choice of Treatment:

High-Intensity Statin Therapy

Daily dose lowers LDL–C on average, by
approximately ≥50%
Atorvastatin (40†)–80 mg
Rosuvastatin 20 (40) mg
 Clinical Case 2

? •
•
•
49 F
Hypertensive, on treatment
Non smoker
• SBP: 140 mmHg
• BMI: 30 kg/m2
• Sedentary lifestyle
 Clinical Case 2

? • fasting lipid values

• Total cholesterol 250 mg/dL
• HDL-C 30 mg/dL
• Triglycerides 200 mg/dL
• LDL-C 220 mg/dL.
 Clinical Case 2
ACC/AHA CV RISK
CALCULATOR
49 AA F

250 30

140 YES

NO NO

Would you treat 5.5%

this patient?
50%
 1 Clinical ASCVD
CHD, Stroke, PAD

2 LDL C: >190mg/dl

DM
3 > Age 40-75 years
>LDL C: 70-189mg/dl

ASCVD risk >7%

LDL –C is 220 mg/dl No diabetes
4 > Age 40-75 years
>LDL C: 70-189mg/dl

5.5
%
 Choice of Treatment:

High-Intensity Statin Therapy

Daily dose lowers LDL–C on average, by approximately ≥50%

Atorvastatin (40†)–80 mg
Rosuvastatin 20 (40) mg
Clinical Case 2

• After 6 weeks of high intensity

statin therapy
• SGPT is 160U/L from a
baseline of 35U/L
 Choice of Treatment:
Moderate-Intensity Statin Therapy

Daily dose lowers LDL–C on average, by approximately 30% to <50%

Atorvastatin 10 (20) mg
Rosuvastatin (5) 10 mg
Simvastatin 20–40 mg‡
Pravastatin 40 (80) mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Fluvastatin 40 mg bid
Pitavastatin 2–4 mg
 Clinical Case 3

? •
•
•
•
55 M , Normal ECG
Hypertensive, on treatment
Diabetic, on treatment
Smoker
• SBP: 160 mmHg
• BMI: 32 kg/m2
• Sedentary lifestyle
 Clinical Case 3

? • fasting lipid values

• Total cholesterol 185 mg/dL
• HDL-C 34 mg/dL
• Triglycerides 220 mg/dL
• LDL-C 151 mg/dL.
 Clinical Case 3
ACC/AHA CV RISK
CALCULATOR
55 AA M

185 34

160 YES

YES YES

Would you treat 38%

this patient?
69%
 1 Clinical ASCVD
CHD, Stroke, PAD

2 LDL C: >190mg/dl

DM
3 > Age 40-75 years
>LDL C: 70-189mg/dl

ASCVD risk >7%

He is a Diabetic No diabetes
4 > Age 40-75 years
>LDL C: 70-189mg/dl

38%
 Choice of Treatment:

High-Intensity Statin Therapy

Daily dose lowers LDL–C on average, by
approximately ≥50%
Atorvastatin (40†)–80 mg
Rosuvastatin 20 (40) mg
 Clinical Case 4

? •
•
•
•
74 M
Hypertensive, on treatment
Non-diabetic
Non-smoker
• SBP: 160 mmHg
• BMI: 30 kg/m2
• Exercises an hour a day
 Clinical Case 4

? • fasting lipid values

• Total cholesterol 160 mg/dL
• HDL-C 40 mg/dL
• Triglycerides 160 mg/dL
• LDL-C 180 mg/dL.
 Clinical Case 4
ACC/AHA CV RISK
CALCULATOR
74 AA M

160 40

160 YES

NO NO

Would you treat 37%

this patient?
NA
 1 Clinical ASCVD
CHD, Stroke, PAD

2 LDL C: >190mg/dl

DM
3 > Age 40-75 years
>LDL C: 70-189mg/dl

ASCVD risk >7%

He has an ASCVD No diabetes
risk of 38% 4 > Age 40-75 years
>LDL C: 70-189mg/dl

38%
Prevention Guidelines Clinical Vignettes
 Case 1

A 63-year-old man is seen in the office 2 weeks after a ST-elevation

myocardial infarction (MI).

A former smoker with hypertension, he was discharged on atorvastatin 80mg

daily, dual anti-platelet therapy, long-acting metoprolol, and an ACE inhibitor.

One year before the acute MI, he was prescribed simvastatin 40 mg which
was then increased to simvastatin 80 mg. He stopped the simavastatin 80 mg
2 weeks later after developing muscle cramps in his legs. At that time he was
also on a calcium channel blocker for his hypertension.

Although he has no muscle symptoms since he started the atorvastatin 80

mg, he is concerned about having had muscle cramps in the past on a statin
and would like to decrease the atorvastatin to 20 mg daily.
 Which is the best statement?

1. Randomized trials of high intensity statin therapy versus moderate

intensity statin therapy have not shown a significant difference in
outcomes. He should decrease the atorvastatin to 20 mg to
minimize adverse effects.
2. Systematic meta-analyses of randomized clinical trials support using
an intensive statin dose such as atorvastatin 80 mg/day over a
moderate intensity statin. He should stay on atorvastatin 80 mg.
3. He should be followed with creatine kinase (CK) values when his
lipids are checked at each visit for the first year.
4. Although his liver panel was normal in the hospital, he should have
an alanine aminotransferase (ALT) done at each subsequent visit.
 Case 2
After 2 years of treatment with atorvastatin 80 mg daily
free of muscle symptoms, the patient developed
progressive muscle pains in both lower legs. He stopped
the statin 2 weeks prior to his clinic visit but the muscle
pain and weakness did not noticeably improve.
He now wants to know if he can be switched to red yeast
Chinese rice.
On examination, he has mild difficulty getting out of a
chair and also has weakness after doing 3 squats. He
remembers he felt fine doing squats at the gym about 6
months ago.
 Which is the best statement?
1. He should be switched from the atorvastatin 80 mg daily to red
yeast Chinese rice based on evidence in U.S. studies.
2. He should stay off the statin until he is evaluated for possible
causes of his muscle problems. A useful approach is to look for
exogenous causes (e.g., medications, alcohol), systemic causes
(examples include hypothyroidism, rheumatologic disorders such as
polymyalgia rheumatica), and primary muscle disorders. He should
be questioned about a family history of primary muscle disorders or
others in the family with muscle problems taking a statin.
3. He should be switched to rosuvastatin 40 mg daily and given
CoQ10.
4. He should be rechallenged with atorvastatin 80 mg daily.
5. CK levels are not useful in evaluating muscle symptoms.
• Because his muscle symptoms had not shown any
improvement within 2 weeks and the muscle
weakness persisted after discontinuing the
atorvastatin 80 mg, he was evaluated for systemic
causes of myopathy.
• His CK was normal but his erythrocyte sedimentation
rate was over 100 mm/hr
• He was treated for his polymyalgia rheumatica
 Case 3
A 44-year-old woman has a 10-year history of type 2 diabetes.

She is a nonsmoker with well-controlled hypertension and

microalbuminuria.

She is on dietary management, metformin, and takes one omega-3

fatty acid capsule with 840 mg of EPA and DHA. She also takes
lisinopril/hydrochlorothiazide for her blood pressure.

She has a family history of diabetes, but not premature ASCVD.

She has a BP 134/78 and a BMI of 36.0. Her fasting lipid panel reveals
an LDL–C 95 mg/dL, triglycerides 350 mg/dL, and HDL–C 38 mg/dL.
Her hemoglobin A1c is 7.5%.
 LDL–C 95 mg/dL, triglycerides 350 mg/dL, HDL–C 38 mg/dL

Which is the best answer?

1. Her LDL–C is under 100 mg/dL so she is at “goal” and

does not require a statin.
2. She should start simvastatin 20 mg and fenofibrate 160
mg daily.
3. To reduce her risk of an ASCVD event, the dose of
omega-3 fatty acid should be increased to 4 capsules
daily to lower her triglycerides.
4. If she does not want to start a statin, a bile acid
sequestrant is the next best choice for her.
5. Her 10-year ASCVD risk should be calculated to
determine if she needs a high- or moderate-intensity
statin.
 Case 4
A 26–year-old woman has an LDL–C of 260 mg/dL, HDL–C of 51 mg/dL, and
triglycerides of 102 mg/dL.

She reports having elevated LDL–C > 200 mg/dL since her teens and has tried
various diets without success but has never taken a drug to lower her
cholesterol.

She is worried because her father died suddenly at age 38 and her father’s
brother had a myocardial infarction at age 32. Both were smokers.
She is getting married in 6 months. She has an occasional cigarette and says
that it is “social smoking.”

On exam, BP is 110/60 mm Hg and BMI is 24. She has bilateral inferior pole
corneal arcus, no xanthelasma, and thickened Achilles tendons. Her
cardiovascular examination is normal.
 Which is the best statement?

1. She likely has heterozygous familial hypercholesterolemia

and should start a high-intensity statin.
2. If her fiancée has normal cholesterol values, the likelihood of
her child having her genetic condition is 1 in 4.
3. Cigarette smoking should be stopped because she is thinking
about becoming pregnant.
4. She should have her oral contraceptive stopped and started
on a high- intensity statin.
5. She should have an estimation of her 10-year risk of an
ASCVD event before deciding if she needs statin therapy
Criteria for HeFH by
MedPED & WHO

Definite FH: score >8

Probable FH: score 6-8
Possible FH: score 3-5
No diagnosis: score <3
 Case 5
A 60-year-old woman has asked whether she should be taking a
statin to reduce her risk of stroke, but is worried about the
statin causing diabetes.
Her mother had diabetes and had a stroke at age 62. She is a
nonsmoker.
Blood pressure is 142/88 mm Hg on 2 antihypertensive
medications and BMI is 31.
Her fasting lipid panel reveals a total cholesterol 200 mg/dL,
HDL–C 55 mg/dL, triglyceride 100 mg/dL, and LDL–C 125 mg/dL.
Her fasting blood sugar is 109 mm/dL and hemoglobin A1c is
5.9%.
Her estimated 10-year ASCVD risk is 8.7 %.
 Which is the best answer?

1. She should focus on lifestyle change to improve her

risk factors because lifestyle has been shown to
reduce ASCVD events more than statin therapy.
2. The risk of progression to diabetes with a statin
outweighs any ASCVD risk reduction benefits from
statin therapy. The decision about a statin to be
deferred.
3. She should start a moderate or high intensity statin.
4. A high-sensitivity C-reactive protein (hs-CRP) >2
would be needed before the decision can be made
whether to start a statin.
 Case 6
A 35-year-old man has a strong family history of premature
coronary disease, with both father and brother having an MI
before age 55.
He is a nonsmoker, nondiabetic and exercises for 150
minutes/week.
He has gained 10 lbs since age 18. His BP is 140/90 mm Hg,
weight is 170 pounds, height is 70 inches, and BMI is 24.4.
On a fasting lipid panel, his LDL–C is 160 mg/dL, HDL–C 45 mg/dL
and triglyceride 100 mg/dL. His fasting blood glucose is 92
mg/dL.
He is on a heart-healthy diet and exercises 150 minutes a week.
He and his wife would like to discuss statin therapy given his
strong family history.
Which of the following is likely to be helpful in making a
decision regarding statin therapy in this patient?

1. Strong family history of premature ASCVD

2. Coronary calcium score of 300 units or more
3. hs-CRP ≥2.0 mg/L
4. Lifetime risk of ASCVD
5. LDL–C ≥160 mg/dL
6. All of these factors can be considered
 Which of the following is likely to be helpful in
making a decision regarding statin therapy in this
patient?

1. Strong family history of premature ASCVD

2. Coronary calcium score of 300 units or Feel
more
3. hs-CRP ≥2.0 mg/L free to
4. Lifetime risk of ASCVD ask ☺
5. LDL–C ≥160 mg/dL
6. All of these factors can be considered
Thank you for your attention