Overview of Atherosclerotic Cardiovascular Diseases (ASCVD) and Hypercholesterolemia

Erin D. Michos, MD, MHS, FACC, FASPC: Hello, and welcome to this Peer Exchange titled, “Evolving Strategies for Cholesterol Management and Atherosclerotic Cardiovascular Disease Risk Reduction.” I’m Dr Erin Michos; I’m an associate professor in cardiology at Johns Hopkins University. I’m coming to you today from MJH Studios® in Cranberry, New Jersey.Joining me today in this discussion are two of my fantastic colleagues. I have my good friend, Dr Pam Taub here, who is a professor of medicine at University California, San Diego School of Medicine in the division of cardiovascular medicine. We have Dr Jorge Plutzky, who is the director of the vascular disease prevention program and director of preventive cardiology at Brigham and Women’s Hospital in Boston, Massachusetts. To my left, I have Dr Bob Busch, who practices endocrinology, diabetes, and metabolism at Albany Medical Center Endocrine Group in Albany, New York. Last but not least, I have my wonderful colleague, Dr Alison Bailey, who’s a cardiology specialist at Centennial Heart at Parkridge in Chattanooga, Tennessee.

Our discussion today will focus on the management of hypercholesterolemia and atherosclerotic cardiovascular disease [ASCVD]. We will discuss the importance of achieving treatments goals and review recently released guidelines on the management of hypercholesterolemia and patients with statin intolerance. Welcome everyone, let’s get started with our discussion. In our first segment, we’re going to talk about hypercholesterolemia and atherosclerotic cardiovascular disease risk reduction. Setting the stage, I was hoping Dr Taub could discuss the burden and prevalence of ASCVD and how high cholesterol contributes to ASCVD pathogenesis.

Pam Taub, MD, FACC, FASPC: When we talk about atherosclerotic cardiovascular disease, we need to be very clear that we’re not just talking about heart attack. Atherosclerotic cardiovascular disease encompasses peripheral arterial disease, stroke, TIA [transient ischemic attack] and of course heart disease, which includes heart attacks. It is really a broad definition, and that’s the first thing we need to keep in mind. When you think about how broad the definition is, it impacts a huge number of patients. The statistics are probably an under-call on the true prevalence of atherosclerotic cardiovascular disease because peripheral arterial disease is not well diagnosed. In the United States, it’s estimated that about 20 million people have atherosclerotic cardiovascular disease; however I think it’s much higher. One of the most important aspects of atherosclerotic cardiovascular disease is LDL [low-density lipoprotein] cholesterol. When I talk to patients about atherosclerotic cardiovascular disease, I talk about LDL as being the single most modifiable risk factor. I also give them the analogy that it is the fuel for the fire. When you look at an atherosclerotic plaque, the core of that plaque is LDL cholesterol, and one of the most important things we can do is come up with strategies, both from a lifestyle perspective and a pharmacologic perspective, in reducing LDL cholesterol. The great thing about strategies such as pharmacology and lifestyle is, it attacks the systemic nature of the disease. Atherosclerotic cardiovascular disease is not a focal disease, and you can’t just put a stent in and solve the whole problem. It’s a systemic disease, and you have to address it in a systemic way.

Erin D. Michos, MD, MHS, FACC, FASPC: Great. Dr Busch is our endocrinologist on this panel, and I was wondering if you could mention the impact of comorbidities, particularly diabetes, which I’m sure you see a lot of, and how those comorbidities impact or accelerate cardiovascular risk.

Robert Busch, MD: My day is spent seeing patients with diabetes, and there are many other comorbidities as seen on the slide in terms of smoking and premature family history of heart disease. But seeing patients with diabetes all day long, when I walk into the exam room with someone with diabetes, I’m treating them the same way as you cardiologists would treat someone who has had a MI [myocardial infarction] in the past. It may not be equal risk just because of the diabetes, but the diabetes doesn’t stand alone. Usually, there’s a lot of other baggage the patient carries in terms of obesity, other metabolic syndrome problems with high triglycerides, low HDL [high-density lipoprotein], hypertension: these are all risk enhancers to the diabetes. The big one that’s often missed is chronic kidney disease. Those patients with stage III or IV, a GFR [glomerular filtration rate] under 60, they probably have higher risk than the patients with diabetes. When they have both together, that’s a risk multiplier, it’s 3 times the risk of cardiovascular mortality. When something is missed, it’s not often in the problem list that the patient has chronic kidney disease. I think cardiologists will be getting more into urine microalbumin [tests] in the future, but you certainly look at GFRs. If I see someone with diabetes and a low GFR, that’s someone for whom I have to do everything I can to help prevent heart disease.

Erin D. Michos, MD, MHS, FACC, FASPC: That’s a really important point for the cardiologists out there; we’ll miss a lot of kidney disease if we only measure eGFR and the importance of also measuring urine albumin.

Transcripts edited for clarity