Link To And Excerpts From The Curbsiders’ #191 Lipids Update and Cardiovascular Risk Reduction with Erin Michos MD

I originally posted this resource about a year ago. But I wanted to review it again so I moved it to today.

Prior lipid episodes:

#37 Lipids, PCSK9, and ezetimibe: Lower is better.

#10 Cholesterol, lipids, statins, fish oil. Become a Master Lipidologist.

In this post I link to and excerpt from the Curbsiders‘ [Link is to the episode list] podcast and show notes from #191 Lipids Update and Cardiovascular Risk Reduction with Erin Michos MD: PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE.  JANUARY 20, 2020 By DR. CHRIS CHIU.

All that follows is from the above podcast and show notes.

Lipids Update! Get up close and personal with ASCVD prevention and lipid management guidelines, including changes in the 2018 update, with our discussion with Dr. Erin Michos @erinmichos, preventive cardiologist and associate professor of medicine at the Johns Hopkins University Hospital!

Time Stamps

  • 00:00:00 Intro
  • 00:01:52 Getting to know Dr. Erin Michos
  • 00:O6:50 Picks of the Week*: Sparking Joy- concept for Marie Kondo (book and show), The Life-Changing Magic of Tidying Up by Marie Kondo; Shadowland, book by Peter Straub; The Crown, Netflix series; Catch and Kill, book by Ronan Farrow; Trick Mirror, essay collection by Jia Tolentino; Make it Stick, book by Brown, Roediger, and McDaniel
  • 00:11:50 Digging into ASCVD Risk Calculator
  • 00:16:12 Who should get 10 year ASCVD Risk assessment and what are the categories?
  • 00:18:13 How Dr. Michos discusses healthy lifestyle and “Primordial Prevention”
  • 00:19:42 What are “Risk Enhancing Factors”?
  • 00:22:36 Who should get biomarker testing vs CAC scoring?
  • 00:29:35 How Dr. Michos discusses statin therapy with her patients
  • 00:32:18 How to address risks of side effects
  • 00:37:57 Primary vs Secondary Prevention
  • 00:39:40 “What should my cholesterol be?”
  • 00:42:03 How often to follow-up labs?
  • 00:46:00 Differences between stain intensity
  • 00:47:57 How to manage side effects
  • 00:52:05 PCSK9 inhibitor discussion
  • 00:55:06 Aspirin, Fibrates and Icosapent Ethyl
  • 01:02:13 High Risk vs Stable ASCVD
  • 01:06:50 Take home points and the future
  • 01:10:50 Outtro

Lipids Update – Top Pearls

  1. Lifestyle changes are the cornerstone and foundation of cardiovascular prevention and should never be neglected in our conversations with patients. “Primordial prevention” is key! A patient’s risk of plaque burden is not only from the magnitude of LDL elevation but duration of exposure
  2. In primary prevention, the new ASCVD risk categories include low risk (< 5%), borderline risk (5 to <7.5%), intermediate risk (7.5 to <20%), and high risk (≥20%). The focus of the 2018 lipid guideline update is on risk-enhancing factors. Use risk-enhancers (e.g. family history, chronic inflammatory disorders, pregnancy-related adverse outcomes) to guide management for patients in the borderline and intermediate risk groups
  3. Biomarkers that can be checked include Lp(a), ApoB, and high-sensitivity CRP, and can be helpful to further risk-stratify. Dr. Michos usually checks Lp(a) once in patients with strong family history and personal history of premature CAD. ApoB is checked when close to LDL goal to assess further need for reduction.
  4. Coronary artery calcium scoring is a very useful and reliable tool for the tie-breaker in starting a statin, especially in patients who are reluctant to start a statin.
  5. The risk of rhabdomyolysis from statins is < 0.1% and risk of liver injury is 1 in 100,000.
  6. Start low and go slow! Dr. Michos offers great advice in working with patients who claim to have statin “intolerance”, which the guidelines say to call “statin-associated muscle symptoms”. She recommends starting patients at a low dose and working your way up which helps with building rapport and trust from the patient.
  7. LDL reduction goals depend on statin intensity: with a high-intensity statin, expect an LDL reduction by > 50%, 30%-49% with moderate-intensity, and < 30% with low-intensity statin.
  8. For follow up, the guidelines recommend checking LDL 4-12 weeks after initiation, then 3-13 months depending on the individual patient’s situation. In stable patients, you can check yearly, and as often as every 4-6 years in younger patients.
  9. In secondary prevention, add ezetimibe when LDL goal has not been met, followed by PCSK9 inhibitor for further LDL reduction.
  10. Aspirin for primary prevention is now falling out of favor (a IIb recommendation and class III recommendation in elderly > 70). Statins and lifestyle modification are first line for patients with triglycerides > 500, however fibrates can be added when triglycerides > 1000. Icosapent ethyl is a great option, reduced major cardiovascular events by 25% in the REDUCE-IT trial, but insurance coverage may still an issue. Fish oil and icosapent ethyl are NOT the same!

Lipids Update – Show Notes 

What is ASCVD risk? 

Atherosclerotic Cardiovascular Disease

Atherosclerotic cardiovascular disease, or ASCVD, is defined by atherosclerotic disease such as myocardial infarction (MI), stroke, and sometimes peripheral artery disease. More specifically, this means both fatal and non-fatal MI and stroke when talking about the well-known ASCVD risk calculator.

ACC/AHA ASCVD Risk Calculator 

The ASCVD risk calculator that we all know so well is one of many cardiovascular disease calculators out there, but this one is specifically recommended by the guidelines since 2013 for its use (Goff, 2013). It’s a pooled cohort equation derived from several large studies by the National Heart, Lung, and Blood Institute (NHLBI) in which the endpoints were “hard” cardiovascular endpoints, namely fatal and non-fatal MI and stroke. The calculator, which includes race, sex, presence of specific comorbidites, and other risk factors to estimate 10-year risk of these “hard” endpoints.

Kashlak Pearl: Whose risk should be assessed with this calculator? Anyone who is between the ages of 40 and 75 years-old who doesn’t have diabetes and has an LDL between 70 and 189. You got that?

Why the Update in 2018?

The guideline recommendations in 2013 encouraged widespread use of the calculator for assessing ASCVD risk and, therefore, treatment strategy with statins. But many realized that the calculator is not necessarily perfect, as it does not take into account lots of other risk enhancing factors (more below) that would put someone at a much higher risk for clinical ASCVD than what this calculator would predict. Per Dr. Michos, the 2018 update is much more personalized, and making the decision to start a statin, especially in primary prevention, is much more a patient-centered endeavor (Grundy, 2018). There is also more information in the literature on those who are “borderline” or “intermediate” risk to make a more nuanced recommendation for those who fall into these categories too.

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