Optimal Management of Hypercholesterolemia



Howard Weintraub, MD: This has been a great discussion.

Alan S. Brown, MD, FACC, FAHA, FNLA: Let’s summarize. You know I love talking with you, so this has been a treat for me.

Howard Weintraub, MD: Yes, me too.We haven’t had a chance to do this. We haven’t spoken since we were trading quips at an ASPC [American Society for Preventive Cardiology] board meeting. It’s great to speak with you, particularly when we agree with each other. That’s always the best. It’s certainly much easier than disagreeing. I hope the listeners or viewers have gained a bit of insight. If not, they’ve hopefully been entertained. I thank you very much for joining me.

Alan S. Brown, MD, FACC, FAHA, FNLA: Yes, Howard. In summary, we covered a lot of ground today. We talked about the importance of lifestyle modification, which is something pivotal in the treatment of people with risk for cardiovascular disease. We talked about certain populations that are at higher risk and the effects of multiple dimensions of diversity from age, to gender, to socioeconomic status, that can affect the risk. We talked about statins, their effectiveness, and how to deal with statin intolerance.

One thing we need to remind everyone is that when you double the dose of a statin, you lower the LDL [low-density lipoprotein] only about 5% to 7%. The idea that taking someone from 20 to 40 mg, or from 40 to 80 mg, is not going to get you more than 5% or 6% percent LDL lowering is something that everyone should be aware of. If you add ezetimibe, you get a 17% to 20% LDL lowering, which is basically the same as tripling the dose of the statin. If you add a PCSK9 inhibitor, you’re talking about 60% additional LDL lowering. It’s important to keep that in mind when you’re deciding your choice of therapy.

We covered the outcome data for PCSK9 inhibitors and the relative safety of those drugs, as well as not to worry about extremely low LDL cholesterol. That doesn’t seem to be a cause of harm. We talked about guidelines, the difference between thresholds and goals, and how to think about that.

Finally, any physician should be comfortable with appropriate LDL lowering therapy, including PCSK9 inhibitors. If you’re not, just have your local pharmaceutical rep show you how it’s done. It’s basically a pen that is refrigerated, and you have to take it out and let it warm up for 30 to 40 minutes so that it’s at room temperature. You put it on your skin and push the button. People should be familiar with that if that’s a barrier for use. We both agree that this is not a medication that has to be given by a specialist, as long as you’re comfortable with the appropriate indications and you use guideline-based therapy.

Finally, you pointed out at the end that having a systematic strategy to treat the highest-risk patients, which are those with acute events, could include initiating it before they leave the hospital. Leaving it to luck that they’re going to follow up and that they’re going to get appropriate adjustments is inadequate.

We covered a lot of ground, and I really enjoyed the conversation. Thanks very much, Howard, for having this conversation with me.

Howard Weintraub, MD: My pleasure.

Transcript Edited for Clarity

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