Risk Assessment and Cholesterol Management Roger S Blumenthal MD The Kenneth Jay Pollin Professor of Cardiology Director Johns Hopkins Ciccarone Center for the Prevention of Heart Disease ID: 1043219
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1. Raging Controversies in CVDRisk Assessment and Cholesterol ManagementRoger S. Blumenthal, MDThe Kenneth Jay Pollin Professor of CardiologyDirector, Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseDisclosures: None
2. April 18, 20152The Statin Reluctant Patient
3. 2013 Prevention Guidelines ASCVD Risk Estimator
4. ASCVD Risk Calculator: Pooled Cohort EquationsRisk FactorUnitsValueAcceptable range of valuesOptimal valuesSexM or F M or F Ageyears 20-79 RaceAA or WH AA or WH Total Cholesterolmg/dL 130-320170HDL-Cholesterolmg/dL 20-10050Systolic BPmm Hg 90-200110Treatment for High BPY or N Y or NNDiabetesY or N Y or NNSmokerY or N Y or NN
5. Results of Risk EstimatorApril 18, 20155
6. The Risk DiscussionPotential for ASCVD risk reduction benefitIf decision unclear, consider LDL>160; FHx of premature ASCVD, lifetime ASCVD risk, abnormal CAC score or ABI, or hs-CRP >2 Potential adverse effects and drug-drug interactionsHealthy lifestyleManagement of other risk factorsPatient preferences
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8. Is Risk Calculator Flawed?April 18, 20158“Dr. Blaha said the problem might be due to the calculator using as reference points data collected more than a decade ago, when more people smoked and had strokes and heart attacks earlier in life. But people have changed in the past few decades, Dr. Blaha said.. “The cohorts were from a different era,” Dr. Blaha said.”
9. Overestimation of Predicted Risk9Ridker and Cook. Lancet. 2013;382:1762-5.Kavousi. JAMA. 2014;311:1416-23.
10. April 18, 201510* New Risk Estimator Innovative and an Improvement* However, Discrimination Remains Suboptimal, Concern for Overestimation in Healthier Groups
11. Percent of U.S. Adults Who Would Be Eligible for Statin Therapy for Primary Prevention, According to Set of Guidelines and Age Group.Pencina MJ et al. N Engl J Med 2014. DOI: 10.1056/NEJMoa1315665
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14. The Statin Reluctant Patient: Principles of Therapy in 1o PreventionPreventive therapies are lifelong therapiesAll medications have some cost and side effectsPatients in general do not want to take medicinesPatients receive absolute benefit in direct proportion to absolute riskPatients who are not destined to have an event receive no benefit from treatmentRisk factor-based approach fails to identify many high risk, and most truly LOW RISK patientsApril 18, 201514
15. ~1 mSv
16. CAC = 0
17. CHD Event Rates (per 1,000 person-years) With Increasing CAC scores, by RF BurdenApril 18, 201517Silverman MG, et al. EHJ. 2014.
18. Biologic Age > Chronologic AgeApril 18, 201518Tota-Maharaj, et al. Mayo Clinic Proceedings. 2014
19. CAC and LDL CholesterolMartin SS, et al. Circulation. 2013.
20. 2047%25%28%
21. MESA JUPITER: Estimated 5-year number needed to treat (NNT)NNH:Statins/Diabetes: 255
22. % of populationCHD event rate(per 1000 patient-years)5-year NNT with 35% event reductionCAC=050%1.8282CAC 1-10037%7.274CAC >10013%12.446JAMA Case: Coronary Artery Calcium Guided Statin Use
23. SUMMARY: CAC, When Individualization of Primary Prevention May Be UsefulApril 18, 201523When Risk/Decision to Treat is UncertainFamily HistoryMetabolic syndromeNon-While, non-AARheumatologic Diseases, etc.Statin Reluctant PatientStatin Intolerant PatientDecisions for Non-Statin TherapyDecisions For Aspirin Therapy
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