Lipid lollapalooza at the AHA 2018

The information presented on the first day of the 2018 scientific sessions of the American Heart Association (AHA) proved that we are finally doing something about lipid management. The potent calcium score in the coronary arteries, a long-time, but rarely bridesmaid, has sparked some love in the new guidelines for cholesterol management from the American College of Cardiology / AHA, although it is a recommended test of "tie-breaker" rather than a screening tool.^[1] The power of calcium score 0 has been brought to the fore for patients who do not smoke and are not diabetic or who have a history of coronary events. A 90-year-old patient with supraventricular tachycardia with a calcium score of 0, for example, can finally stop his statin and win his argument with his prescriber.

Recognition for women

In these new guidelines, women have been validated as valid targets for lipid management, with recommendations for screening for conditions associated with pregnancy, including preeclampsia, gestational hypertension and diabetes mellitus, and pregnancy. 39, low birth weight and premature delivery.^[1]

Firm recommendations were made to stop statins 1 to 2 months before the planned pregnancy. There was a specific focus to discuss the need for effective birth control in women of childbearing age treated with statin and to stop statins as soon as an unplanned pregnancy is known. It is good to see these commonly expressed common sense tips become official recommendations.

In contrast to most cardiovascular trials, Japanese women accounted for 74% of the Japanese EWTOPIA trial of ezetimibe monotherapy.^[2] This study included a cohort of elderly (≥ 75 years) with low-density lipoprotein cholesterol (LDL-C) average of 160 mg / dL and at least one of seven conditions: diabetes, hypertension, low-level lipoprotein cholesterol density and high density (HDL). C), elevated triglycerides, smoking, previous stroke and peripheral artery disease (but no history of coronary heart disease). The study found that ezetimibe lowered LDL-C and C-non-HDL levels, resulting in a reduction in atherosclerotic cardiovascular events. This depressed number of women is probably due to the longer life expectancy of women, but it was interesting to see the results.

No fast required

We can forget the need to order a "fasting" status for lipid levels. This does not mean that we will not need to re-test individuals with very high triglyceride levels, but as Vice President of the Cholesterol Monitoring Committee, Neil Stone, MD, said at the press conference, we can "avoid these long queues". lab at 7:30 "and send our patients to the lab hall, regardless of their fasting status.This will undoubtedly increase enrollment in validation testing for effectiveness.

Diabetes not detected

Although the presence of diabetes is a key decision point for adding statin therapy, we are not doing a very good job of diagnosing the disease. According to the Centers for Disease Control and Prevention, 1.5 million new cases of diabetes were diagnosed in 2015; nearly one in four adults live with diabetes, including 7.2 million Americans who do not know it.^[3] I am often the first to explain to a patient that a high fasting blood glucose level or an abnormal hemoglobin A1c level, previously documented but missing or unresponsive, indicates that he is suffering from diabetes. Many others have never been examined.

Although the majority of AHA participants interviewed just prior to the presentation of the DECLARE trial express confidence in treating their high-risk diabetic patients with dapagliflozin (a sodium-containing glucose and cotransporter-2 inhibitor), we can not treat a health problem without knowing it. the patient has it.^[4] It is time for cardiologists to share the responsibilities of primary care providers in the diagnosis and treatment of diabetes.

Are some recommendations practical?

Recommendations for conversations about lifestyle management were an important part of the new cholesterol guidelines, but is it a practical goal for the hamster wheel of the current office medicine? ? Doctors barely have time to do a physical exam, review drugs and labs, and hear about new or ongoing concerns. With the RVU police firmly attached to the backs of almost all providers, who really has the time to properly discuss the management of their lifestyle? This should be a number one priority, but instead, it's rarely an afterthought. After today, reimbursement plans should evolve towards a better equalization of the time required for this conversation compared to the time required to obtain an angiogram, for example.

Do the directives need an instant update?

Fish oils are not mentioned in the cholesterol guidelines; maybe they should be it. The REDUCE-IT trial demonstrated that 2 g twice daily of icosapent Ethyl, a highly purified fish oil, reduced cardiovascular events by 25% in patients with elevated triglyceride levels.^[5] The similar STRENGTH test involving 4 g of a mixed fish oil is expected to be complete by the end of 2019. If it is also positive, the inhibition of proprotein convertase subtilisin / kexin type 9 can be further pushed into the scale of recommendations.

I would like to thank the guideline writers and other trial writers for their diligent work. The fruits of their labors will keep us well beyond our lives, but only if we apply them in our daily practice.