Mirvat Alasnag, MD is the first female interventional cardiologist in the Gulf region. She is a Woman's champion in the Middle East & serves in numerous committees representing women professionals. She is the Director of the Cardiac Catheterization Laboratory at King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia (currently the only director in the Gulf Region). She is passionate about CHIP & Peripheral Vascular interventions. @mirvatalasnag ‏
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Women in the New Lipid Management Guidelines

Mirvat Alasnag, MD

The American Heart Association‘s annual meeting, Scientific Sessions, remains a Mecca for cardiologists worldwide. Those of us who were unable to attend in person followed the scientific discussions virtually through the Live Streaming option.  This year the much anticipated update to the Lipid Management Guidelines were presented at the meeting.  A focus on women as a special population was addressed separately by Dr. Lynne Braun. As cardiologists, we are not trained to search for atherosclerotic cardiovascular disease (ASCVD) enhancers specific to women, namely premature menopause (less than 40 years old), pregnancy associated disorders such as preeclampsia, gestational diabetes and preterm labor. Moreover, we often fail to discuss pregnancy and contraception with women of childbearing age who require statin therapy based on their ASCVD risk assessment. The majority of our key performance indicators in a cardiac unit or clinic require that patients are discharged on a statin if they are at risk. Yet, women should be advised to discontinue statin therapy 1-2 months prior to attempting pregnancy. It seems counter-intuitive to discuss discontinuation of statin therapy in a system that measures performance by the intensity of the prescribed dose. This in itself requires retraining of cardiologists and the AHA offered a unique opportunity to highlight its importance during Dr. Braun‘s presentation.

Another related topic addressed extensively at this year’s meeting was the role of calcium scoring (CACS) in risk stratification in the new lipid management guidelines. It is noteworthy that several large studies demonstrated that CACS improves risk assessment when combined with the conventional risk parameters.1-3 Women often have lower CACS compared to age-matched men. A meta-analysis by Kavousi et al in 2016 examined 5 large cohorts of women with an ASCVD risk <7.5% (low risk by current guidelines).4  CACS was identified in 36% of the women which led to a 2-fold increase risk of ASCVD. Ensuant to this discussion, is the topic of a coronary artery calcium score of 0 that denotes a very low risk, ie 1.1–1.5% 10-year risk of ASCVD events. This is commonly referred to as the power of zero calcium.5  The latest guidelines suggest CACS may assist in further stratifying women particularly those in the intermediate and borderline categories of risk given the older age of onset of ASCVD in women. It may also assist in the shared decision making with women of different ages and women with additional risk enhancers as discussed above.

As this year’s meeting drew to a conclusion, I’m grateful I could keep pace with the discussions on lipid management in women from the other end of the globe. More importantly, as a woman cardiologist, I was able to go to work the next morning and reevaluate the discussions I have with my female patients. For the first time, I tailored my discussion on statin therapy to the woman sitting across from me, my patient.

 

References:

  1. Paixao, A.R., Berry, J.D., Neeland, I.J. et al. Coronary artery calcification and family history of myocardial infarction in the Dallas heart study. JACC Cardiovasc Imaging. 2014; 7: 679–686
  2. Elias-Smale, S.E., Proenca, R.V., Koller, M.T. et al. Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study. J Am Coll Cardiol. 2010; 56: 1407–1414
  3. Arad, Y., Goodman, K.J., Roth, M., Newstein, D., and Guerci, A.D. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. J Am Coll Cardiol. 2005; 46: 158–165
  4. Kavousi, M., Desai, C.S., Ayers, C. et al. Prevalence and prognostic implications of coronary artery calcification in low-risk women: a meta-analysis. J Am Med Assoc. 2016; 316: 2126–2134
  5. Nasir, K., Bittencourt, M.S., Blaha, M.J. et al. Implications of coronary artery calcium testing among statin candidates according to american College of cardiology/american heart association cholesterol management guidelines: MESA (Multi-Ethnic study of atherosclerosis). J Am Coll Cardiol. 2015; 66: 1657–1668
  6. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
    • Scott M. Grundy, Neil J. Stone, Alison L. Bailey, Craig Beam, Kim K. Birtcher, Roger S. Blumenthal, Lynne T. Braun, Sarah de Ferranti, Joseph Faiella-Tommasino, Daniel E. Forman, Ronald Goldberg, Paul A. Heidenreich, Mark A. Hlatky, Daniel W. Jones, Donald Lloyd-Jones, Nuria Lopez-Pajares, Chiadi E. Ndumele, Carl E. Orringer, Carmen A. Peralta, Joseph J. Saseen, Sidney C. Smith, Laurence Sperling, Salim S. Virani, Joseph Yeboah
      Journal of the American College of Cardiology Nov 2018, 25709