Lipids 2020: Beyond Statins

Outcomes Data

Improve-IT Trial

Reference: N Engl J Med 2015; 372:2387-2397

Top 10 Take-Home Messages

1. In all individuals, emphasize a heart-healthy lifestyle across the life course.

Secondary Prevention

2. In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.

3. In very high-risk ASCVD, use an LDL-C threshold of 70 mg/dL to consider addition of nonstatins to statin therapy.

Severe Primary Hypercholesterolemia

4. In patients with severe primary hypercholesterolemia (LDL-C level greater than or equal to 190 mg/dL), without calculating 10-year ASCVD risk, begin high-intensity statin therapy.

If the LDL-C level remains greater than or equal to 100 mg/dL, adding ezetimibe is reasonable. If the LDL-C level on statin plus ezetimibe remains greater than or equal to 100 mg/dL and the patient has multiple factors that increase subsequent risk of ASVCD events, a PCSK9 inhibitor may be considered, although the long-term safety (> 3 years) is uncertain and economic value is low at mid-2018 list prices.

Diabetes

5. In patients 40 to 75 years of age with diabetes mellitus and LDL-C greater than or equal to 70 mg/dL, start moderate-intensity statin therapy without calculating 10-year ASCVD risk.

In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity stain to reduce the LDL-C level by greater than or equal to 50%.

Primary Prevention

6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician-patient risk discussion before starting statin therapy.

7. In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels greater than or equal to 70 mg/dL, at a 10-year ASCVD risk of greater than or equal to 7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.

8. In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy.

ASCVD Risk Estimator Plus Link:

https://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/

Primary Prevention Continued

9. In adults 40 to 75 years age without diabetes mellitus and with LDL-C levels 70 mg/dL to 189 mg/dL, at a 10-year ASCVD risk of 7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC.

Patients Over 75

Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials

"In conclusion, statin therapy produces significant reductions in major vascular events, irrespective of age. There is less definitive direct evidence of benefit in the primary prevention setting among patients older than 75 years, but evidence supports the use of statin therapy in older people considered to have a sufficiently high risk of occlusive vascular events."

Cholesterol Treatment Trialists Collaboration. Lancet 2019; 393: 407–15

Follow-Up

10. Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.

P&T. December 2015. Vol. 40. No. 12. 826-857

Methods

N Engl J Med 2019; 380:11-22; Media, Quick Take

Cumulative Incidence of Cardiovascular Events

Results

Hierarchical Testing of Endpoints

Cost

Atorvastatin:

Rosuvastatin:

Ezetimibe:

Icosapent Ethyl:

Evolocumab:

Alirocumab:

$16 per month

$15 per month

$21 per month

$268 per month

$475 per month

$465 per month

GoodRx.com

Small Interfering RNA

R. Scott Wright, AHA Scientific Sessions 2019, Philadelphia, Pennsylvania

ORION-10

R. Scott Wright, AHA Scientific Sessions 2019, Philadelphia, Pennsylvania

Karol E. Watson, MD, PhD AHA Scientific Sessions November 2019

Karol E. Watson, MD, PhD AHA Scientific Sessions November 2019

Karol E. Watson, MD, PhD AHA Scientific Sessions November 2019