cholesterol guidelines

hidden

Highlights of AHA18 – Bridging Lifestyle Medicine with Contemporary Medicine through Science

Renee Bullock-Palmer, MD

This year’s annual scientific meeting of the American Heart Association (AHA) held in Chicago, Illinois November 10-12, 2018 was excellent. The abbreviated 3-day meeting received positive feedback as this allowed practicing physicians to attend the meeting over the weekend and be able to return to their practice early in the work week rather than having to spend an extended time away from the office. It was great being a part of the AHA Early Career Blogger group as this allowed access to many of the embargoed sessions. At these sessions I was able to listen to the AHA 2018 updated Lipid Management Guidelines1 as well as The Physical Activity Guidelines for Americans, Second Edition2 prior to their release at the meeting. This gave me a chance to ask the guideline committee several questions related to patient management.

 

Opening Session:

The opening session by Dr. Ivor Benjamin, the President of the American Heart Association, delivered very powerful messages throughout his speech. He highlighted the track of his career and the important role of strong mentors throughout his career and the impact it had on his advancement throughout the field of cardiology. He also discussed both the importance of mentoring and diversity in the cardiology profession highlighting the fact that African American men account for only 3% of Cardiologists in the United States and the need to bridge this gap. I found this session very inspiring and encouraging especially with regards to mentoring and supporting junior colleagues and being grateful for the mentors I have had thus far in my career. I also welcomed the message of the importance of diversity and inclusion as this leads to a healthier work and training environment.

 

Bridging Lifestyle Medicine with Contemporary Medicine through Science:

This year’s meeting highlighted the value of integrating lifestyle medicine with contemporary medicine to achieve the best outcomes for patients with regards to the prevention of cardiovascular disease. This was supported by the release of the updated 2018 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on Lipid Management on the first day of this meeting1. This updated guideline emphasized the importance of the cholesterol management at all stages of adulthood along with the importance of therapeutic lifestyle changes1. The utility of coronary artery calcium (CAC) scoring with cardiac CT was also emphasized as a useful tool to further refine patients’ risk to determine the best management for patients who are at intermediate risk for atherosclerotic cardiovascular disease (ASCVD)1. This guideline also had included ezetimibe and PCSK9 inhibitors as having a complementary role when used with statin therapy in selected patients at high risk for ASCVD1. The release of this updated guidelines will be a useful in my management of patients with regards to primary and secondary prevention of ASCVD. I appreciated the role of CAC scoring which will be very helpful for the management of the intermediate risk patients.

The release of the U.S. Department of Health and Human Services’ second edition of the Physical Activity Guidelines for Americans on the last day of the meeting was also well received2. This second edition emphasized the importance of increasing physical activity for all age ranges throughout the population including women in pregnancy and the postpartum period, as well as adults with chronic diseases or disabilities2. This guideline update will assist me with counseling patients with regards to increasing their physical activity to improve their overall cardiovascular health.

 

Networking Opportunities:

There were many networking opportunities during the meeting. These included the Council on Clinical Cardiology dinner on the first night of the meeting which honored Dr. Judith Hochman the recipient of the James B. Herrick Award for Outstanding Achievement in Clinical Cardiology. Dr. Stacy Rosen was also the recipient of the Women in Cardiology Mentoring Award. This dinner was attended by many leaders in the field of Cardiology and was a great opportunity for me to meet these leaders. The Women in Cardiology Committee also hosted a networking luncheon on the first day of the meeting during which Dr. Sharonne Hayes from the Mayo Clinic was the keynote speaker. Dr. Hayes gave a very riveting interactive talk on leadership for women in cardiology, she was also the recipient of last year’s Women in Cardiology Mentoring Award. Her talk was useful with very powerful messages on navigating your professional and personal life to achieve overall job satisfaction, career success and personal happiness. I learned several tips that I will apply to my own career as well. Dr. Annabelle Volgman and the faculty at Rush University was gracious to host a wonderful networking dinner for Women in Cardiology (WIC) on the second night of the meeting. This dinner provided a great opportunity for me to meet fellow WIC colleagues and to discuss several relevant issues related to our practice in the Cardiology field.

Social Media Coverage:

There was also a broad social media coverage of the meeting on Twitter and this was assisted by the AHA Early Bloggers writing group. I was able to share live tweets during several sessions and this generated a lot of discussion amongst members on Twitter. This also allowed many colleagues who were unable to attend the meeting to be able to follow and comment on several meeting highlights.

 

Looking Forward to AHA 2019:

This year’s AHA Scientific Sessions embrace of lifestyle medicine and the value of preventive cardiology was refreshing and empowering. This meeting highlighted the importance of not only treating ASCVD but also the importance of preventing disease and empowering our patients to take responsibility for their health as well. In the words of Goethe as mentioned in Dr. Ivor Benjamin’s opening session “Choose well….your choice is brief, and yet endless.” We look forward to next year’s AHA 2019 meeting in the beautiful city of Philadelphia.

 

References:

1. Grundy SM, Stone NJ, Bailey AL, Beam LT, Birtcher KK, et al. 2018AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. JACC Nov 2018, 25709; DOI: 10.1016/j.jacc.2018.11.003

2. The Physical Activity Guidelines for Americans: THe HHS Roadmap for an Active Healthy Nation. Second Edition. ADM Brett P. Giroir, MD.

 
hidden

New Cholesterol Guidelines From A Neurologist’s Perspective

Siddharth Sehgal, MD

The American Heart Association’s annual premier conference “Scientific Sessions 2018” concluded on Monday. This meeting showcases the latest advancements and discoveries in the field of cardiovascular medicine and is attended by clinicians and researchers from across the world.

Being a vascular neurologist, I have attended the International Stroke Conference organized by the AHA several times, however, this was my first time attending Scientific Sessions. I was able to attend the conference via Live Streaming while sitting in my office in Burlington, Massachusetts.

There are a lot of overlaps between cerebrovascular and cardiovascular disease and I was particularly interested in attending the sessions pertaining to stroke prevention and brain health. One of the most anticipated presentations was the release and discussion of the new AHA/ACC Cholesterol Clinical Practice Guidelines.

Some key takeaways from the updated guidelines:

  • The guidelines continue to underscore the role of lifestyle and dietary habits in addition to lipid lowering medication use to treat cholesterol disorders. There is emphasis on the concept of shared decision making with the patient which should include discussion of their individual risk and the treatment options to reduce that risk.
  • Addition of Ezitimibe and subsequently PCSK-9 inhibitors is now recommended in patients who cannot achieve target LDL levels despite maximum tolerated statin doses. There is some concern about the cost effectiveness of PCSK-9 inhibitors, but these medications are expected to become cheaper in the future.
  • Risk enhancing factors are introduced as part of a personalized approach to risk assessment prior to initiating statin therapy. These include persistent elevation of LDL>160 mg/dL, history of pre-eclampsia, family history of premature atherosclerotic cardiovascular disease, history of chronic kidney disease and chronic inflammatory disease, among others.
  • There is a recommendation for expanding use of calcium score as part of the risk assessment, especially in patients where risk benefit analysis is uncertain.

 

In addition to the guidelines for medications and lifestyle changes to treat cholesterol disorders, I especially enjoyed Dr. Laurence Sperling’s talk about the safety of statins.

Patients should be prescribed statins again at a lower dose or modified drug regimen if the reason for discontinuation was mild side effect symptoms. Although rare, but some patients do develop severe myopathy with statin use. These patients should be prescribed alternate non-statin therapies to achieve the target cholesterol levels. There has not been any proven benefit of Co Q10 to prevent or treat statin associated muscle symptoms. Despite the increased risk of diabetes mellitus with statins, it is recommended to continue the drug in patients who may be at risk or develop new onset DM. These patients should be counseled about the net clinical benefit of these drugs for long term cardiovascular event prevention. It appears reasonable to initiate statin therapy in the presence of an appropriate indication despite a history of stable liver disease. In patients without hepatic disorders, there is no clinical benefit of routine creatine kinase and liver enzyme measurements.

Very often patients have questions and concerns about initiating and continuing their statin medication. I believe that these data and recommendations further reinforce my personal practice to encourage patients to continue their statin medication as the risk benefit ratio remains favorable despite mild side effects.
hidden

The 2023 Cholesterol Guidelines

Akl Fahed, MD, MPH

A few days ago, the long-anticipated 2018 AHA/ACC Cholesterol Clinical Practice Guidelines were released at the American Heart Association Scientific Sessions 2018 in Chicago.

The update from 2013 was viewed favorably in the cardiology community, as it reflected a large body of evidence that has accumulated since, specifically the recommendations for targeting LDL< 70 mg/dL in secondary prevention and using non-statin lipid-lowering medications (ezetimibe and PCSK9 inhibitors) with proven incremental reduction in cardiovascular events. In primary prevention, the recommendations for the use of coronary calcium score to decide on statin therapy in intermediate risk patients and the use of several ASCVD risk enhancers in borderline risk patients also reflected a decade of accumulating evidence.

In fact, many cardiologists feel that the new 2018 guidelines finally reflect what they already practice or would like to practice. I definitely feel this way, but are guidelines always meant to come that late after the evidence? Also, should guidelines be static documents at specific time intervals? When writing guidelines that will be used by millions around the globe, it is crucial to strike the right balance in being timely in providing guidance for clinicians but also cautious in not providing premature recommendations based on low levels of evidence, which could result in harm. This is not an easy job and the authors of the current guidelines successfully achieved this balance, in my opinion.

At Scientific Sessions 2018 where the new guidelines were released and made headlines in the morning, new science was being presented in the afternoon showing that these guidelines might already be outdated! The REDUCE-IT trial, which showed that icosapent ethyl 4g/day reduced major adverse cardiovascular events by 25%, was only one example.

I could not but reflect: What will be in the next cholesterol guidelines? How outdated will our current guidelines be if we wait another five years? And if new treatments will target triglycerides and inflammation, should we even change the name to “Atherosclerosis Management Guidelines”?

Here are my predictions for the next set of guidelines:

  • The LDL target cutoffs will be shifted downwards by 20-30mg/dL. In the highest risk patients we will be talking about LDL targets of <50mg/dL for secondary prevention and <70mg/dL for primary prevention. There is accumulating evidence that “lower is better” and that very low LDL (~20mg/dL) is safe, so as we become comfortable with targeting <70mg/dL in the coming few years, it would be reasonable to move the needle even lower.
  • Polygenic Risk Scores (PRS) will be used to risk-stratify patients <40 years of age and target a fraction of the population with high polygenic risk score who would benefit from statin therapy despite their LDL not being  >160mg/dL. The predictive ability of the polygenic risk score for CAD is already established and retrospective data show that statin therapy can attenuate the risk of CAD in those with highest polygenic risk score. Establishing the value of implementing PRS in clinical practice will require prospective randomized trials, and we are likely to see that in the near future.
  • New non-statin therapies to target ASCVD will emerge and have a major role in treatment. Icosapent Ethyl is leading the way, but other triglyceride lowering agents are also promising, specifically inhibitors of Angiopoietin-like 3 (ANGPTL3) and Apolipoprotein C-3 (APOC3). Antisense oligonucleotide inhibitors of  apolipoprotein(a) successfully reduced Lp(a) levels in a Phase 2 trial presented at this year’s scientific sessions. Future phase 3 trials will test whether lowering Lp(a) will reduce CV events. If proven, we might see more emphasis on Lp(a) screening and treatment cut-offs in the next guidelines. Finally and most importantly, the role of heightened inflammation in ASCVD risk is clear. While low-dose methotrexate did not reduce ASCVD outcomes in the CIRT trial, targeted anti-cytokine therapy with canakinumab did improve outcomes in the patients selected for high hsCRP in the CANTOS trial. The next guidelines will likely recommend routine hsCRP screening in secondary prevention to identify patients with residual inflammatory risk (high hsCRP, low LDL) who could benefit from anti-cytokine therapy.
  • And then there’s the atherosclerosis vaccine! A “Cutting Edge in Cardiovascular Science” presentation at Scientific Sessions 2018 by Dr. Klaus Ley highlighted that this is possible in mice. Will it be possible to safely manipulate the adaptive immune system in humans to  create an atherosclerosis vaccine? The answer is probably yes, but it would be wishful thinking to hope for it in the next guidelines.

 

Those are my predictions. What are yours?