Melissa Walton-Shirley, MD


November 11, 2018

The information presented on the first day of the American Heart Association (AHA) Scientific Sessions 2018 has proven we are finally getting somewhere with regard to lipid management. The mighty coronary artery calcium score, so long a bridesmaid but rarely a bride,  got some love  in the new American College of Cardiology/AHA cholesterol management guidelines, albeit as a recommended "tie breaker" test rather than a screening tool.[1] The power of the 0 calcium score was brought to the forefront  for patients who don't smoke and don't have diabetes or a history of coronary events.  A 90-year-old patient with supraventricular tachycardia with a calcium score of 0, for instance,  can finally stop his statin and win his ongoing argument with his prescriber.

Recognition for Women

In these new guidelines, women were validated as worthy targets of lipid management, with recommendations for screening of pregnancy-associated conditions, including preeclampsia, gestational hypertension and  diabetes, low birth weight, and premature delivery.[1]

Firm recommendations were made to stop statins 1 to 2 months prior to planned pregnancy.  There was specific direction to discuss the need for effective birth control in statin-treated women of child-bearing age and  to stop statins the moment an unplanned pregnancy is known. It's great to see these oft-spoken commonsense pieces of advice become  official recommendations.

In contrast to most cardiovascular trials,  women made up a whopping 74% of the Japanese EWTOPIA trial  looking at ezetimibe monotherapy.[2] This study included an elderly cohort (≥75 years) with an average low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL and at least one of seven conditions:  diabetes, hypertension, low high-density lipoprotein cholesterol (HDL-C), elevated triglycerides, smoking,  prior cerebrovascular accident, and peripheral artery disease (but no history of coronary artery disease). It found that ezetimibe lowered both LDL-C and non-HDL-C, resulting in a reduction of  atherosclerotic cardiovascular events. This lop-sided number of women is likely due to longer life expectancy in women, but it was interesting to see the outcomes. 

No Fasting Required

We can forget the need to order a "fasting" status for lipid levels.  It doesn't mean we won't need to retest individuals with very elevated triglyceride levels, but as vice-chair of the cholesterol guideline committee, Neil  Stone, MD, stated in the press conference, we can "avoid those long lines at the lab at 7:30 am" and send our patients down the hall to the lab no matter their fasting status. It will no doubt increase adherence with testing for validation of efficacy.

Undetected Diabetes

Although the presence of diabetes is a key decision point for the addition of statin therapy, we aren't doing a very good job of diagnosing the condition. According to the Centers for Disease Control and Prevention,  1.5 million new cases of diabetes were diagnosed in 2015; nearly 1 in 4 adults are living with diabetes, including 7.2 million Americans who don't know it.[3] I'm often the first to break it to a patient that a previously documented but missed or ignored elevated fasting blood glucose level or abnormal hemoglobin A1c shows they have diabetes. Many more have never been screened. 

Though a majority of AHA attendees polled just prior to the DECLARE trial presentation expressed confidence in treating their high-risk diabetic patients with dapagliflozin (a sodium-glucose cotransporter-2 inhibitor), we can't treat a condition if we don't know the patient has it.[4] It's time for cardiologists to share ownership with primary care providers in the diagnosis and treatment of diabetes.

Are Some Recommendations Practical?

Recommendations for  conversations regarding lifestyle management were prominent in the new cholesterol  guidelines,  but is that a practical goal for the hamster wheel of today's office medicine? Physicians barely have time to do a physical exam, review meds and office labs, and hear new or ongoing concerns. With the RVU police firmly attached to the backs of nearly all providers, who really has time for an adequate conversation on lifestyle management? It should be a number 1 priority, but instead it's rarely an afterthought. After today,  reimbursement patterns should shift toward better equalization for the time it takes for that conversation compared with the time it takes to obtain an angiogram, for instance.

Do the Guidelines Need an Instant Update?

Fish oils are not mentioned in the cholesterol guidelines; maybe they should be. The REDUCE-IT trial demonstrated that  2 g twice daily of icosapent ethyl—a highly purified fish oil—reduced cardiovascular events by 25% in patients with elevated triglycerides.[5]  The similar STRENGTH trial  testing 4 g of a mixed fish oil is due to be completed late 2019. If it is also positive, proprotein convertase subtilisin/kexin type 9 inhibition may be pushed farther down the ladder of recommendations.

I'd like to thank the guidelines writers and other trialists for their diligent work. The fruits of their labors will sustain us long beyond our lifetime, but only if we apply them in our everyday practice.    


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