Transcript 2-mccrary-2013-cardiovascular-summit-lipid-final

Heart Disease and Challenges in
Lipid Management
Sandy McCrary, PA-C
Wellmont CVA Heart Institute
Lipid Clinic
Cardiovascular Summit 2013
Saturday, Feb 2
Disclosure Statement of
Financial Interest
I DO NOT have a financial
interest/arrangement or affiliation with any
organizations that could be perceived as a real
or apparent conflict of interest in the context
of the subject of this presentation.
Sandy McCrary, PA-C
Lipid Clinic
Heart Disease and Challenges in
Lipid Management
 Prevalence of heart disease
 Risk factors for heart disease
 Modifiable risk factors for heart disease
 The cholesterol burden
 Importance of cholesterol reduction
 Roadblocks to achieving cholesterol goals
 Information from Usage Survey
 Remedies to these challenges
Heart Disease – Prevalence
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Age-adjusted Prevalence of Coronary
Heart Disease Among Adults by State
Behavioral Risk Factor Surveillance System, United States, 2010
Risk Factors for Heart Disease
Nine out of 10 heart disease patients have
at least one risk factor.1
 High cholesterol
 High blood pressure
 Diabetes
 Cigarette smoking
 Obesity
 Physical Inactivity
 Age
Modifiable Risk Factors
-Diabetes
-Cigarette smoking
-Inactivity
-High Cholesterol
-Obesity
-Hypertension
Cholesterol Guidelines
NCEP ATP III
 Total cholesterol
 Triglycerides
 HDL cholesterol
 LDL cholesterol
<70 mg/dL
<100 mg/dL
<130 mg/dL
<160 mg/dL
 Non-HDL cholesterol
<200 mg/dL
<150 mg/dL
>40 mg/dL (men)
>50 mg/dL (women)
Very high risk
High risk
Moderately high risk
Lower risk
< 30 + LDL-C goal
America's Cholesterol Burden
 71 million American adults (33.5%) have
high LDL cholesterol.2
 Only 1 out of every 3 adults with high
LDL cholesterol has the condition under
control.2
 Less than half of adults with high LDL
cholesterol get treatment.2
America's Cholesterol Burden
(cont.)
 People with high total cholesterol have
approximately twice the risk of heart
disease as people with optimal levels
 The average total cholesterol level for
adult Americans is about 200 mg/dL,
which is borderline high risk.3
Importance of cholesterol
reduction
 LDL-C remains best-validated target in
atherosclerosis
 Consistent relation of LDL-C to risk in
primary and secondary prevention
studies
 Benefit of statins correlates with extent
of LDL-C reduction
Statins for Secondary Prevention
HPS
Statins in Acute Coronary
Syndromes (ACS)
Myocardial Ischemia Reduction with
Aggressive Cholesterol Lowering (MIRACL)
Death, MI, Cardiac arrest with
resuscitation, or Recurrent
symptomatic myocardial
ischemia with objective
evidence and requiring
emergency re-hospitalization
Schwartz et al JAMA 2001:285:1711-18
Intensive Lipid
Lowering in Stable CAD
Treating to New Targets
(TNT)
LaRosa et al N Engl J Med 2005;352:1425-35
Beyond statins for CV risk
reduction?
AIM-HIGH
Statin + Niacin
Illuminate
Statin + Torcetrapib
dal-OUTCOMES
Dalcetrapib
Clinical Outcomes
AIM-High
Illuminate
dal-OUTCOMES
Clinical Outcomes
AIM-High
Illuminate
dal-OUTCOMES
Beyond statins for CV risk
reduction?
 Niacin
 Fibrates
 Zetia
 Omega-3 Fas
 CETP inhibitors
-torcetrapib
-dalcetrapib
Beyond statins for CV risk
reduction?
 Niacin
 Fibrates
 Zetia
 Omega-3 Fas
 CETP inhibitors
-torcetrapib
-dalcetrapib
More intensive statin is better
than less intensive statin
Importance of cholesterol
reduction
 According to ATP III, for every 1 mg/dL
reduction in LDL-C, the relative risk for
CHD is reduced in proportion by 1%
 Mortality is reduced with statin therapy.
A 20% reduction in cholesterol results in
an all-cause mortality reduction of 22%.
Statin Usage Survey:
Understanding Statin use in America and Gaps in
Education
 Survey developed by National Lipid Association and
Kowa Pharmaceuticals America and Eli Lily
 Largest US statin-patient survey to date
 10,138 patients surveyed from September 21, 2011
through October 17, 2011 – 88% current statin users
12% former statin users
 Designed to help healthcare professionals improve
patient adherence to dyslipidemia treatment
 Evaluated patient attitudes and behaviors re: high
cholesterol and various therapeutic approaches
including TLC’s and medications–statins specifically
USAGE Survey Results
 Lack of adherence & persistence of statin
therapy is a common problem
 ~1/4 of patients discontinued their statin
after a single month
 ~1/2 of patients discontinue within 3 months
 As many as 3/4 of patients discontinue in
the first year
USAGE Survey Results
(cont.)
 Compliance rates are higher for patients who
take statin therapy for a full year
 Even patients who do continue taking statins
often fail to take them regularly
-Average Rx coverage as low as 40% of days
Usage Survey: When and How Statins
Were Stopped
 57% stopped after a side effect and had no
further RX filled
 1/3 stopped without asking or telling their
healthcare provider, however
 32% reported being told they had high risk of
CHD without a statin
 On average, 2 statins were tried before
stopping all together
Drugs don’t work
when patients don’t
take them!!
Costs – 17%
Lack of Cholesterol Lowering – 12%
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Mean Levels of LDL Reduction
with Statins
LDL-C reduction
20%
20-30%
Medication and
dosage
Mean LDL Lowering
fom baseline
Lescol 20 mg
17%
Pravastatin 10 mg
19%
Lovastatin 10 mg
21%
Lescol 40 mg
23%
Pravastatin 20 mg
24%
Simvastatin 5 mg
26%
Simvastatin 10 mg
28%
Lovastatin 20 mg
29%
Mean Levels of LDL Reduction
with Statins (cont.)
LDL-C reduction
Medication and
dosage
Mean LDL-C lowering
from baseline
30-40%
Lovastatin 40 mg
31%
Pravastatin 40 mg
34%
Lescol LX 80 mg
35%
Simvastatin 20 mg
35%
Pravastatin 80 mg
37%
Atorvastatin 10 mg
38%
Livalo 2 mg
38%
Mean Levels of LDL Reduction
with Statins (cont.)
LDL reduction
Medication and
dosage
Mean LDL-C lowering
from baseline
40-50%
Simvastatin 40 mg
41%
Crestor 5 mg
45%
Vytorin 10/10
45%
Livalo 4 mg
45%
Atorvastatin 20 mg
46%
Simvastatin 80 mg
47%
Mean Levels of LDL Reduction
with Statins (cont.)
LDL-C reduction
Medication and
dosage
Mean LDL-C lowering
from baseline
50-60%
Atorvastatin 40 mg
51%
Crestor 10 mg
52%
Vytorin 10/20
52%
Atorvastatin 80 mg
54%
Crestor 20 mg
55%
Vytorin 10/40
55%
Vytorin 10/80
60%
Crestor 40 mg
63%
>60%
Statin Side Effects – 62%
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Muscle Pain
 Determine timing of the muscle pain in respect to
statin initiation
 Labs that might be helpful – BMP, CK, TSH, ?Vitamin D
 Physical exam
 Dose and specific statin used
 Pharmacokinetics of the specific statin (hydrophilic vs
lipophilic)
Muscle Pain
(Cont.)
 Consider other clinical conditions or implicating
factors
 Vitamin D – low vitamin D adversely affects muscle
performance and may contribute to myalgias.5 Vitamin
D deficiency has been associated with proximal muscle
weakness, loss of muscle mass and increased risk of
falling. 5,6
 Thyroid disorders – Hypothyroidism should be ruled out.
 Coenzyme Q 10.
- Coenzyme Q 10 levels are known to be reduced on statin
therapy7
Managing Statin Intolerance
 Obtain history, including careful history of prior statin
usage, dosage and side effects
 Stress clinical benefit of taking statins when they are
indicated and restate this benefit frequently
 Consider a number of statin options. Intolerance or
failure with one statin does not indicate failure with
another. (Possibly due to lipophilicity and metabolism
mechanisms of each statin.)4
Managing Statin Intolerance (cont.)
 Drug interactions – polypharmacy; multiple
providers
 Review of SEARCH data prompted FDA cap on
Simvastatin on June 8, 2011 and, shortly thereafter, on
Lovastatin because of incidence of myopathy
 Consider intermittent dosing options with the
most potent statins.
Alternate Statin Dosing
(if high intensity statin dosage not tolerated)
Americans Are Making Progress
 Between 1999 and 2010, the percentage of American
adults with high total cholesterol decreased from
18.3% to 13.4%.8
 The percentage of American adults with high LDL
cholesterol has remained around 34% over the past
decade, but treatment of high LDL cholesterol has
increased from 28.4% in 1999–2002 to 48.1% in 2005–
2008.9
References
1Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics-2010 Update.
Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
Circulation. 2010;121:e1-e170
2CDC. Vital signs: prevalence, treatment, and control of high levels of low-density lipoprotein cholesterol. United
States, 1999–2002 and 2005–2008. MMWR. 2011;60(4):109–14.
3Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the
American Heart Association. Circulation. 2012;125(1):e2–220.
4Cohen JD, et al "Understanding Statin Use in America and Gaps in Patient Education (USAGE): An internetbased survey of 10,138 current and former statin users" J Clin Lipid 2012; 6: 208-215.
5Binkley N, Krueger D, Drezner M. Low Vitamin D Status: Time to Recognized and Correct a Wisconsin Epidemic.
WMJ. 2007;106(8):466-472.
6Holick M, Chen T. Vitamin D deficiency: a worldwide problem with health consequences. AM J Clin Nutr.
2008(87): 10805-65.
7Marcoff L, Thompson PD. The role of coenzyme Q10 in statin-associated myopathy: a systematic review. J Am
Coll Cardiol 2007;49:2231-2237.
8CDC. Vital signs: prevalence, treatment, and control of high levels of low-density lipoprotein cholesterol. United
States, 1999–2002 and 2005–2008. MMWR. 2011;60(4):109–14.
9Carroll, MD, Kit, BK, Lacher, DA. Total and high-density lipoprotein cholesterol in adults, 2009–2010. NCHS data
brief no. 92. Hyattsville, MD: National Center for Health Statistics. 2012.
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