Case-Based Evidence for Cardiovascular Risk Reduction - Episode 3
Deepak Bhatt, MD, MPH: We can pivot a little to cardiovascular disease risk reduction and prevention. Jamie, since you’re on a roll, what are the treatment goals in managing hypercholesterolemia? In particular, what are lipid levels in general as far as targets for people with high blood pressure, for people with diabetes? What do you recommend in your practice? What does the evidence say?
Brett Nowlan, MD, FACC, RPVI: In our practice, we try to follow the current guidelines. In primary prevention we’re talking about patients with type 1 or type 2 diabetes. We always start with the risk assessment, and we heard a little about risk assessment already. Calculating 10-year risk is an important part of that.
Anyone over the age of 40 years old with diabetes should be on a statin, period. That should be moderate intensity. That is, unless they have additional risk factors. That’s why risk assessment is so key as part of managing patients with type 2 diabetes. As far as a target, the target is LDL [low-density lipoprotein]. Goals? We have moved away from that because, again, everyone should be on a statin that’s either moderate or high intensity based on their risk.
Patients with hypertension generally have other comorbidities. This is based on their risk-assessment model, whether they have subclinical atherosclerosis based on a CT [computed tomography] scan and other what we call risk-modifying concerns: Do they have an elevated lipase protein A? Do they come from populations of risk or family history?
Again, we would try to target them with moderate to high-intensity statin based on their reasonable risk status. I would tell you that if we were looking for a magical number in primary prevention it certainly would be 100 mg/dL. But we try to get away from goals in LDL lowering right now and focus on the appropriate risk management for those patients, which is first getting them on statin.
Deepak Bhatt, MD, MPH: Those are really terrific points and something probably everyone in the audience is facing—when do you exactly pull the trigger in terms of LDL management? Along those lines, Matt, what factors do you consider when choosing among statins of varying intensity? Once you’ve made that decision, what percentage of the patients actually fail to meet cholesterol-lowering targets despite statin use and despite using whatever you think is appropriate and that the patient can tolerate?
Matthew J. Budoff, MD, FACC, FAHA: Building on what Jamie had just said, looking at where their LDL is and what their target is for most of us, for high-risk LDL targets, it will be less than 70 mg/dL. Our goal will be to be more aggressive from a pure LDL perspective. Unfortunately, a vast majority of patients fail to meet those goals. There are great data out of multiple guidelines. The PINNACLE Registry, with 1.9 million people, mentioned that 21% of patients who had established heart disease were not on statin therapy and had no history of lipid-lowering therapy use at all. About 5 of 6 patients did not achieve that LDL target of less than 70 mg/dL.
When we think about targets that are potentially even more stringent, the AACE [American Association of Clinical Endocrinologists]/ACE [American College of Endocrinology] Clinical Practice Guidelines, for example, talk about LDL targets of 55 mg/dL. The Europeans have targets as low as 40 mg/dL, yet we’re just not achieving even a modest goal of 70 mg/dL in the vast majority of our patients.
Deepak Bhatt, MD, MPH: That’s such an important point that we can do more with respect to LDL reduction, even just with the statins, and of course there are other things such as ezetimibe and PCSK9 inhibitors. Before getting more into that, perhaps I can turn to you, Brett, when considering simple stuff to do. We talked about statins, though as I was saying, it’s not always so simple to implement. What about your thoughts on icosapent ethyl and its potential role in cardiovascular risk?
Brett Nowlan, MD, FACC, RPVI: Icosapent ethyl is of course the darling right now for very good reason. It is an incredibly exciting therapy, and I use it very enthusiastically in my office. Here, you have something that seems to be very safe, and it’s very well tolerated. It has excellent patient acceptance and seems to be cost effective, and we have tremendous data for major adverse cardiovascular event reduction from the REDUCE-IT trial.
It does it in a theoretical, completely unique mechanism from what we’ve been targeting up to now, which is focused on LDL lowering. It’s an orphan drug or an orphan therapy in the space. As we move historically from our patients who are more pure hypercholesterolemia in the past to more mixed dyslipidemia now and driven by the tidal wave of hyperinsulinemia and metabolic syndrome and type 2 diabetes, a therapy like this—with this theoretical mechanism of action—is very important. This antioxidant effect, anti-inflammatory effect, platelet inhibition, antithrombosis effect, and plaque stabilization is very exciting, and I’ve embraced it fully in my practice.
Deepak Bhatt, MD, MPH: That’s really encouraging to hear.
Transcript Edited for Clarity