Statin therapy

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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.
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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

 
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Statins for Chronic Subdural Hemorrhage: Pleiotropy and Pathophysiology

Neal Parikh, MD

HMG-CoA reductase inhibitors, or statins, are widely used for lipid lowering to risk the risk of cardiovascular disease. Based on the suspected pleiotropic effects of statin medications, such as their anti-inflammatory and endothelial stabilization effects, trials of statin medications for non-cardiovascular indications have proliferated.

Statin medications have been tested for indications ranging from acute respiratory distress syndrome (ARDS) to chronic obstructive pulmonary disease (COPD). Statin therapy was not shown to be beneficial for these indications. So, I was pleasantly surprised to come across a JAMA Neurology publication reporting on a randomized trial of statin therapy for chronic subdural hemorrhage.

Subdural hemorrhage is a common and morbid condition in older individuals. To date, the primary treatment has been neurosurgical. Neurologists are involved in the care of these patients primarily to control seizures.

Jiang and colleagues report the results of a Phase II, randomized, placebo-controlled, double-blind, multi-center trial in which 169 patients with chronic subdural hematoma were randomized to receive atorvastatin or a placebo.1 They followed these patients for up to 24 weeks, and measured hematoma volume, rates of surgery, and clinical outcomes.

Although the size of the study population limits certainty in the results, their results were remarkably consistent across several outcomes, both radiographic and clinical: patients randomized to atorvastatin did better. Remarkably, patients randomized to atorvastatin also less frequently required surgery.

If confirmed, the results of this study speak to the pleiotropic effect of statin medications and inform our understanding of chronic subdural hemorrhage pathophysiology – perhaps further implicating inflammation and endothelial dysfunction. In addition to being clinically useful, these results underscore the value of persistence in clinical investigation.

 

1Jiang et al. Safety and Efficacy of Atorvastatin for Chronic Subdural Hematoma in Chinese Patients. JAMA Neurology. 2018 [E-pub ahead of print].

 

Neal Parikh Headshot

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @NealSParikhMD and contributes to Blogging Stroke as a blogger.