primary prevention statin for healthy

1. WHEN TO START LIPID LOWERING
THERAPY IN ASYMPTOMATIC
HEALTHY PERSON??
DR YATENDRA KUMAR PORWAL
MD, DM CARDIOLOGY
INTERVENTIONAL CARDIOLOGIST
MEDANTA HOSPITAL, INDORE

2. KEY QUESTIONS
• When should I take lipid lowering drugs to prevent heart
attack?
• Deranged lipid profile in healthy person: role of lipid
lowering drugs- WHEN & HOW??
• Lipid guidelines for primary prevention???

3. INDIAN CONTEXT..
• Coronary artery disease (CAD) manifests almost a
decade earlier in India than in Western countries.
• Further, the incidence of CAD is increasing most rapidly
among patients younger than 40 years of age.
• About 10%-25% of MI in India occur before the age of 40
years and more than 50% of CAD-associated deaths in
India occur before the age of 50 years.

4. • Alarmingly, the prevalence of dyslipidemia [defined
according to NCEP guidelines] in Indians is very high with
79% of subjects having at least one lipid abnormality, with:
odecreased HDL-C levels in 72.3% subjects,
ohypertriglyceridemia in 29.5% subjects and
oelevated LDL-C levels in 11.8% of subjects.
• Hence, optimal management of dyslipidemia is key to
stem the epidemic of ASCVD along with control of other
risk factors.

5. Common broad principles:
o (1) assessing the global risk of atherosclerotic cardiovascular disease
(ASCVD) by including known risk factors,
o (2) treating patients with established or at high risk of ASCVD; and
o (3) treating patients according to specific targets
• In other adults 40 to 75 years of age, 10-year ASCVD risk should
guide therapeutic considerations. The higher the estimated ASCVD
risk, the more likely the patient is to benefit from evidence-based
statin treatment.
• The risk discussion should also consider several “risk enhancers” that
can be used to favor initiation or intensification of statin therapy.
• When risk is uncertain or if statin therapy is problematic, it can be
helpful to measure CAC to refine risk assessment.

6. RISK STRATIFICATION IN HEALTHY
POPULATION
• For primary prevention, population study-derived ASCVD risk
estimate calculators, such as the Framingham risk score, are
commonly used to decide whether a subject should receive lipid-
lowering therapy or not.
• ACC/AHA developed the pooled cohort equation: 10-year risk of
ASCVD event, applicable to black and non-Hispanic white men and
women through 79 years of age.
• The ESC/EAS used SCORE (Systematic COronary Risk Evaluation).
• The UK NICE guidelines used the QRISK2.
• Although several population specific risk assessment tools exist, none
of the currently available models are derived from or prospectively
validated in Asians.

8. ASCVD RISK ESTIMATOR
• Gender
• Race
• Age
• Total Cholesterol
• HDL- C
• Systolic BP
• On BP medication
• Diabetes
• Smoker
It provides 10 year risk of CVD and lifetime risk of CVD

9. Cardiovascular risk categories ESC 2019
• Very-high risk:
• People with any of the following:
Documented ASCVD, either clinical or unequivocal on imaging. Documented
ASCVD includes
1.previous ACS (MI or unstable angina),
2.stable angina,
3.coronary revascularization (PCI, CABG, and other arterial revascularization
procedures),
4.stroke and TIA, and
5.peripheral arterial disease.
Unequivocally documented ASCVD on imaging includes those findings
that are known to be predictive of clinical events, such as
1.significant plaque on coronary angiography or
2.CT scan (multivessel coronary disease with two major epicardial arteries
having >50% stenosis), or
3.on carotid ultrasound.

10. DM with target organ damage or at least three major risk
factors, or early onset of T1DM of long duration (>20
years).
Severe CKD (eGFR <30 mL/min/1.73 m2).
A calculated SCORE >_10% for 10-year risk of fatal CVD.
FH with ASCVD or with another major risk factor.

11. High-risk People with:
Markedly elevated single risk factors, in particular
1. TC >8 mmol/L (>310 mg/dL),
2. LDL-C >4.9 mmol/L (>190 mg/dL), or
3. BP >_180/110 mmHg.
Patients with FH without other major risk factors.
Patients with DM without target organ damage, with DM
duration >_10 years or another additional risk factor.
Moderate CKD (eGFR 3059 mL/min/1.73 m2).
A calculated SCORE >_5% and <10% for 10-year risk of
fatal CVD.

12. • Moderate-risk:
Young patients (T1DM <35 years; T2DM <50 years) with
DM duration <10 years, without other risk factors.
Calculated SCORE >_1 % and <5% for 10-year risk of
fatal CVD.
• Low-risk:
Calculated SCORE <1% for 10-year risk of fatal CVD.

13. ESC 2019 Lipid Guidelines

14. ESC 2019 Lipid Guidelines

15. Recommendations for cardiovascular imaging for risk
assessment of atherosclerotic cardiovascular disease

16. Recommendations for lipid analyses for
cardiovascular disease risk estimation

17. Recommendations for lipid-lowering therapy in very high-
risk patients with acute coronary syndromes

19. Recommendations for lipid-lowering therapy in very high-
risk patients undergoing percutaneous coronary
intervention

20. Recommendations for the treatment of dyslipidemias
in diabetes mellitus

21. Recommendations for the treatment of dyslipidemias in
older people (aged >65 years)

22. Treatment algorithm of LDL-C for primary prevention
2022 Taiwan lipid guidelines for primary prevention

23. LAI 2020

24. How often should lipids be tested?
• Before starting lipid-lowering drug treatment, at least two
measurements should be made, with an interval of 1-12
weeks, with the exception of conditions where prompt
drug treatment is suggested, such as ACS and very high-
risk patients.

25. How often should a patient’s lipids be tested
after starting lipid-lowering treatment?
• After starting treatment: 8 (±4) weeks.
• After adjustment of treatment: 8 (±4) weeks until
the goal is achieved.

26. How often should lipids be tested once
a patient has achieved the target or
optimal lipid level?
• Annually (unless there are adherence problems or other
specific reasons for more frequent reviews).

27. How often should liver enzymes (ALT)
be routinely measured in patients on
lipid-lowering drugs?
• Before treatment.
• Once, 8-12 weeks after starting a drug treatment or after
dose increase.
• Routine control of ALT thereafter is not recommended
during statin treatment, unless symptoms suggesting liver
disease evolve.
• During treatment with fibrates, control of ALT is still
recommended.

28. What if liver enzymes become elevated
in a person taking lipid-lowering drugs?
•If ALT <3 ULN:
 Continue therapy.
 Recheck liver enzymes in 4-6 weeks.
•If ALT rises to >_3 ULN
Stop lipid-lowering therapy or reduce dose and recheck liver
enzymes within 4-6 weeks.
Cautious reintroduction of therapy may be considered after ALT
has returned to normal.
If ALT remains elevated check for the other reasons.

29. How often should CK be measured in
patients taking lipid-lowering drugs?
• Pre-treatment
Before starting therapy.
If baseline CK is >4 ULN, do not start drug therapy; recheck.
• Monitoring:
Routine monitoring of CK is not necessary.
Check CK if patient develops myalgia.
Be alert regarding myopathy and CK elevation in patients at
risk, such as: elderly patients, those on concomitant interfering
therapy, multiple medications, liver or renal disease, or
athletes.

30. What if CK becomes elevated in a
person taking lipid-lowering drugs?
• Re-evaluate indication for statin treatment.
• If >_4 ULN:
• • If CK >10 ULN: stop treatment, check renal function, and monitor CK every 2 weeks.
• • If CK <10 ULN: if no symptoms, continue lipid-lowering therapy while monitoring CK
between 2 and 6 weeks.
• • If CK <10 ULN: if symptoms present, stop statin and monitor normalization of CK, before
rechallenge with a lower statin dose.
• • Consider the possibility of transient CK elevation for other reasons such as exertion.
• • Consider myopathy if CK remains elevated.
• • Consider combination therapy or an alternative drug.
• If <4 ULN:
• • If no muscle symptoms, continue statin (patient should be alerted to report symptoms;
check CK).
• • If muscle symptoms, monitor symptoms and CK regularly.
• • If symptoms persist, stop statin and re-evaluate symptoms after 6 weeks; re-evaluate
indication for statin treatment.
• • Consider rechallenge with the same or another statin.
• • Consider low-dose statin, alternate day or once/twice weekly dosing regimen, or
combination therapy.

31. IN WHICH PATIENTS SHOULD HBA1C
OR BLOOD GLUCOSE BE CHECKED?
• Regular checks of HbA1c or glucose should be
considered in patients at high-risk of developing
diabetes, and on high-dose statin treatment.
• Groups to be considered for glucose control are
the elderly and patients with metabolic syndrome,
obesity, or other signs of insulin resistance.