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 Atheroscle

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?