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Paradigm Shift for Hyperlipidemia Treatment

Srinivas R. Bapoje, MD, MPH, FACC

Dr. Bapoje is a graduate of Osmania Medical College in India. He completed his residency and fellowship in cardiovascular medicine at the University of Arkansas for Medical Sciences.

Eliminating target LDL levels and using fixed dose statin therapy are some of the key highlights in the 2013 American College of Cardiology/American Heart Association’s updated guidelines for treating blood cholesterol and decreasing AtheroSclerotic Cardiovascular Disease (ASCVD) risk in adults. The guidelines also identify four statin benefit groups.

“The update was prompted by evidence from large clinical trials, prospective data that has accumulated over the last 10 years and a better understanding of the risk factors involved,” said Srinivas R. Bapoje, MD, MPH, FACC, with Meritas Health Cardiology.

A recent study determined that incorporating the new guidelines into standards of care could prevent up to 60,000 additional cardiovascular events over a 10-year time period when compared with the previous guidelines.

Statin Benefit Groups

The four primary- and secondary-prevention groups that would benefit from high- or moderate-intensity statin therapy include individuals with:

  • Clinical ASCVD (history of myocardial infarction, acute coronary syndrome, coronary angioplasty or stent placement, bypass surgery, peripheral vascular disease, cerebrovascular accident or transient ischemic attack)
  • LDL-cholesterol levels of ≥190 mg/dL
  • Diabetes mellitus, 40-75 years old with LDL-cholesterol levels between 70-189 mg/dL, and without evidence of ASCVD
  • Without diabetes mellitus or evidence of ASCVD, 40-75 years old, with an estimated 10-year ASCVD risk ≥7.5%

To calculate a patient’s 10-year risk of heart disease and stroke, the guidelines recommend using the ASCVD algorithm available at cvriskcalculator.com.

Results of a recent study involving U.S. adults between 45-75 years old indicate the 10-year ASCVD risk threshold of ≥7.5% recommended in the treatment guidelines has a cost-effectiveness ratio of $37,000/quality-adjusted life year (QALY).

For patients who do not fall under one of the four identified groups, additional factors such as a family history of premature ASCVD and their coronary artery calcium score should be considered when deciding to prescribe statin therapy.

Shift Away From Target LDL Levels

Based on new data analyzed, the guidelines encourage physicians to shift their treatment focus away from specific target LDL levels. Focusing care only on LDL levels could lead to undertreatment or overtreatment with statin drugs.

“I agree with the elimination of target LDL levels,” Dr. Bapoje said. “Under the new guidelines, the focus shifts toward treating the patient, not the numbers.”

Increased Use of Statin Therapy

One result of calculating patients’ risk score using the ASCVD algorithm is an increase in the number of people who meet the criteria for using statin therapy. The consensus in the cardiovascular community is that statin therapy is definitely indicated for patients with known ASCVD, diabetes mellitus and/or LDL-cholesterol levels of ≥190 mg/dL.

However, opinions differ on the validity of the ASCVD risk score and over the use of statin therapy in patients whose risk score is ≥7.5%. The score does not factor in premature cardiovascular disease, triglyceride levels, body mass index or lifestyle habits. “There is a gray zone,” Dr. Bapoje said. “If a patient has a risk score of 7.6%, it doesn’t necessarily mean the patient needs a statin. The treatment has to be individualized.”

Safety Concerns

Prior to initiating statin therapy, physicians must consider possible side effects, including myalgias, liver toxicity and diabetes mellitus, among others.

Focus on Lifestyle Modifications

“Primary care physicians have an essential role in the guidelines because they prescribe statins and see patients with diabetes and stroke that we do not see,” Dr. Bapoje added. “It’s important they understand the guidelines as they pertain to prevention of heart disease. However, it’s incumbent upon the individual primary care physicians and the patient to work together to decide what is best. Lifestyle modifications still remain the cornerstone of therapy, not statin drugs.”