Paradigm Shifts in Lipid Lowering - Episode 14
Dean Karalis, MD, provides expertise on the appropriate use of statins based on primary and secondary prevention.
Keith C. Ferdinand, MD: Dean, talk about statins. We really don’t want to overlook the benefit of that class of agents.
Dean Karalis, MD: Yeah, I don’t think we should overlook it. They are the foundation of treating this lipidemia, both for primary and secondary prevention. They’re really first-line drugs because they’re effective, they lower LDL [low-density lipoprotein] cholesterol, and they have proved outcomes.
There are 2 issues with regard to using them appropriately to get the best results in improving outcomes, and it varies both on primary and secondary prevention. In secondary prevention, we often can’t get our patients up to what are guideline-based therapy, which is high-intensity statin therapy. Norm mentioned it earlier. If you look at patients admitted with acute myocardial infarction, within 6 months to a year, more than half those patients either had their statin deintensified. They are no longer on a high or even not taking a statin.
We know that if you have an acute cardiac event, and you’re discharged from the hospital on a high-intensity statin, if you stop it or deintensify it, you significantly increase your risk of another event over time. We also know that many of the adverse effects of statins are more perceived than real. We’ve seen that in a number of clinical trials looking at placebo vs statin therapy, where the patients with placebo had as many if not more adverse effects than the people who were put on statin therapy.
Many patients who have failed 1 statin can be tried with another. We can intensify. There’s an inertia among physicians: When someone has been discharged from the hospital or their statin has not been intensified, then for an outpatient we don’t intensify it. The first thing is education, to try to get patients on maximally tolerated statin for ASCVD [atherosclerotic cardiovascular disease]. If they’re not at that LDL goal, which is less than 70 mg/dL or less than 55 mg/dL, then add on therapy.
Keith C. Ferdinand, MD: Dean, we’re not going to talk about vaccines, but the reason I mentioned them is that some of the same bad information about vaccines on social media have been related to statins for years if not decades: liver failure, cataracts. We know it can cause rhabdomyolysis in 1 of a million, especially when used inappropriately. But if you read some of these posts, it sounds as if you take a statin, you’re going to die a slow death. Do they cause liver failure and cataracts? We know the muscle toxicity is real, but how common is it?
Dean Karalis, MD: Yeah, so we all know that several years ago the FDA removed the warnings regarding monitoring liver function studies for statins. With regard to other adverse effects, such as cataracts, it’s really not an issue. Muscle-related symptoms occur. It’s probably real, but it’s very infrequent. Many patients can tolerate statin therapy. The problem is to overcome patients’ concerns, and that’s really a challenge in clinical practice.
The other point is, primary prevention becomes even more of an issue. It’s 1 thing to get someone who’s had a major cardiovascular event and convince them of the need to take a statin over potential adverse effects. In primary prevention it’s that much harder. Norm mentioned it earlier, but calcium scoring has also been a game changer, because it helps identify patients who really would benefit from statins. With other patients, if they have a 0 calcium score may be able to be derisked, then you can withhold statin therapy and work with lifestyle changes.
Norman Lepor, MD, FACC, FAHA, FSCAI: You talk about these antivaxxers and those people who refuse to take their statins. Natural selection will deal with them. But some patients perceive that statins are not for them. It’s not very PC to prescribe a statin these days. I am giving patients diabetes; that’s the new thing. I’m making them diabetic and other things. The patients aren’t going to take them. The reality is that the patients perceive they’re going to have an adverse effect, or they do feel an adverse effect. You’re not going to be able to shove it down their throats, and you might as well presume that you’re going to have to prescribe something else.
Keith C. Ferdinand, MD: If you enjoyed watching this HCPLive® Peer Exchange, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box. Thank you very much for listening to this program.
Transcript Edited for Clarity