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Evolving Strategies for Cholesterol Management and Atherosclerotic Cardiovascular Disease Risk Reduction - Episode 3

Impact of Lipid Lowering on Risk for ASCVD

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Drs Erin Michos, Pam Taub, Robert Busch, Alison Bailey, and Jorge Plutzky discuss the impact of lipid lowering on the risk of ASCVD.

Erin D. Michos, MD, MHS, FACC, FASPC: I think since we’ve been talking about ASCVD [atherosclerotic cardiovascular disease] risk assessment, the next thing we should talk about is treatment goals. I’m going to turn back to you, Dr Plutzky, to talk about the impact of LDL [low-density lipoprotein] lowering on the risk of ASCVD, and what recommendations or guidelines are you following for certain LDL goals for which types of patients?

Jorge Plutzky, MD: The relationship between LDL and cardiovascular risk is one of the great triumphs of the modern era of medicine. To have the initial notion of does cholesterol matter and do you extend life, evolve into what we now know about LDL lowering and the impact it has on reducing events is really a triumph. It is an amazing story, and it is amazing how many chapters keep coming in terms of therapies and additional risk factors. It’s really an opportunity; of course, none of that matters if you don’t apply them. We all have different phraseology we tend to use, but I have a patient who’s having an issue with adherence and I say, “There are a lot of studies that show that pills don’t work if you don’t take them.” Treatments don’t work if you don’t take them. Part of that onus is on us as physicians to make the case for why a patient would want to do that. People are not trying to harm themselves. Establishing the very clear-cut relationship between LDL and risk is important. Then, we’re usually using the current guidelines, the updated guidelines that came along previously. We like the idea of being very clear for clinicians to think, does a patient fall in one of these groups? Do they warrant treatment, the 4 primary groups of: people who have had a prior event, people who have an LDL greater than 190 mg/dL, people who have diabetes, people who calculate risk that warrants treatment. And now we are embracing the update, the ACC [American College of Cardiology] update, the idea of risk-enhancing factors.

We had not liked the movement away from the idea of treatment goals. I even tried that in the clinic a few times when it first came out, I found it very hard to talk to a patient without saying, “This is the number we want to get to.” We hadn’t applied that, and I’m happy to see a returning to the idea of thresholds, of trying to get people lower. Especially when the risk is high, trying to get down, closer to 55 mg/dL, along the lines of what the European Society of Cardiology had embraced, but we’re now seeing that endorsed much more. Gauging the degree of your LDL lowering with the extent of risk I think always makes sense. Trying to get people down under 100 mg/dL, in most cases, which has already been advocated for, but trying to use judgment about when you need to be more aggressive because you think someone’s at risk. Including genetic inputs, where people have higher LDL levels younger. We have very interesting studies that say, if you have a genetic basis for an elevated LDL that’s not reaching the threshold of greater than 190 mg/dL, those people have more risk. You wouldn’t want to miss that, and recognize that. Matching a given clinical scenario to appropriate LDL treatment goals is important, and we have to embrace that. Being more aggressive, getting people down to appropriate LDL numbers is really helpful. There are so many great resources with the ACC expert consensus update, as well as the prior guidelines.

Erin D. Michos, MD, MHS, FACC, FASPC: I like to talk to my patients about that concept of LDL years or cholesterol years, akin to pack years. It’s not only in the magnitude of elevation, but it’s the duration of exposure. Even mild to moderate hypercholesterolemia, with a sufficient number of years, these individuals have earlier onset of ASCVD compared to their peers with lower LDL. That’s one way I talk about it with patients. We want lower LDL for longer and getting there faster. Dr Taub, what do you think about patients’ awareness of their LDL goals or the impact of LDL on ASCVD, and how do you talk to your patients to increase awareness?

Pam Taub, MD, FACC, FASPC: There can be a lot of confusion among patients because there are multiple cholesterol parameters. There’s total cholesterol, there’s HDL [high-density lipoprotein], there’s LDL, and triglycerides. A lot of times, patients focus on total cholesterol and just worry about that number, but I try to refocus them and educate them that LDL is what we really need to focus on. Similar to what endocrinologists have done with diabetes and talk about A1C [glycated hemoglobin] as the primary target, we need to do a better job in educating patients about LDL. What I do in my practice is, I have a graphic of LDL cholesterol, and the lower levels correspond with an artery with no plaque and higher levels correspond with an artery that has plaque. We map it; we say, “OK, well your LDL is 120 mg/dL, the target is less than 55 mg/dL because you’re a high-risk patient.” We start medication, and we follow the trajectory. It’s beneficial for patients to see over time how their numbers change with treatment. That also promotes increased adherence to treatment. It’s about educating patients that LDL causes plaque. We need to follow the endocrinologists and get the message of LDL to a very prominent position, like A1C, so that every patient knows their LDL, just like a diabetic knows their A1C.

Robert Busch, MD: Thank you for highlighting that. Being surrounded by such a wonderful panel of cardiologists, I’ve been playing preventive cardiologist my entire career, and it’s exactly what you said. We were A1C directed, but once we get that down, it’s a lot easier to get LDL down than A1C. We must juggle a lot more drugs in general. For LDL, we’ll talk about the nonstatin therapies. That’s something we get the patient to buy into on day 1. In fact, if I’m starting the statin, and everyone with diabetes unless it’s a woman who’s pregnant or going to get pregnant, gets a statin. That was the CARDS study, which showed if you gave 10 mg of atorvastatin, you lowered events by 37%; that’s primary prevention. Even if your LDL was below 70 mg/dL to start with, you lowered events. I tell a patient, “You can’t be too rich, too thin, or have too low an LDL.”

Jorge Plutzky, MD: Dr Busch, so much of diabetes is managed by internists in primary care, and not getting to see you. Do you think that community of internists or primary care physicians are approaching diabetes with this full recognition that control of diabetes includes control of LDL?

Robert Busch, MD: It’s a great point. Our job is a lot easier. We have to do eyes, heart, kidneys, feet, and then lipids, and A1C. Whereas they have to do everything in a 15- to 20-minute follow-up visit. I don’t know how they do all of that, especially if the patient brings up something like, “I’m worried about COVID-19.” Well, that’s the whole discussion, and they still want to focus on the LDL. That’s mandatory, every visit, “Is your LDL at goal?”

Transcript edited for clarity