March 22, 2023

NACHC and the CDC are partnered together to reduce heart attacks and strokes to help achieve the Million Hearts® 2022 goals. The current focus has been to implement strategies to reduce undiagnosed hypertension, improve use of statins in high-risk patients, improve hypertension management and control for African Americans, and expanding use of self-measured blood pressure monitoring. Learn more about NACHC’s Million Hearts Initiative by visiting the NACHC website:

Hello my name is kate curley i am a family physician and health services researcher and i’m the director of chronic disease prevention at the american medical association this presentation is about statin management in high-risk groups specifically we’ll recap some of the key highlights from the 2018 acc and aha guideline on the management of blood cholesterol

As i already indicated the purpose of this talk will be to touch on those highlights from the 2018 acc and aha guideline about blood cholesterol and really i’ll focus on reviewing statin management in the three high risk patient groups so first i want to discuss the overall statin management approach outlined in the acc aha 2018 guideline the first step is to

Determine which statin management group your patient falls into after you’ve determined which statin management group your patient is in you’re going to want to do two things first you want to institute lifestyle therapies and simultaneously you want to initiate the appropriate intensity statin therapy it’s important to note that this is not a sequential process

The reason for this is that lifestyle therapy alone will typically not reduce ldl to the degree that we want to see in high risk patient groups so for example diet will typically reduce ldl by less than 10 milligrams per deciliter and exercise really the same thing ldl is reduced by about five milligrams per deciliter with high risk patient groups we want to

See an ldl reduction of 30 percent sometimes more than 50 percent and so that’s why we want to initiate both lifestyle therapies and statin therapy at the same time lifestyle therapy is very important but it’s not the focus of this presentation today after we initiate therapy we want to monitor the patient’s response to therapy and then for certain people who

Are not experiencing an ldl reduction that we would like to see we may consider adding non-statin therapy as well that is also not included in this presentation i’m going to focus primarily on determining risk groups appropriate intensity statin treatment and monitoring patients responses so first let’s review the four statin management groups those with stars

On them are our three high risk groups that this project is focused on the first group is patients with clinical ascvd this includes patients who have a history of acute coronary syndromes patients with a history of myocardial infarction stable or unstable angina coronary or other arterial revascularization stroke tia and people with peripheral arterial disease

That’s presumed to be of atherosclerotic origin the second group are adults aged 20 to 75 who have a very high ldl which is an ldl greater than or equal to 190 milligrams per deciliter most of these individuals have familial hypercholesterolemia the third group are people who have diabetes but do not fall into the previous two groups so this would mean people

With diabetes who do not have ascvd or do not have a very high ldl and instead have an ldl that falls between 70 and 189 the fourth group that is not the focus of this project are people who do not have diabetes or a very elevated ldl or ascbd but need statins for primary prevention now i want to point out that the three high-risk groups with the stars do not

Need to have their 10-year ascvd risk calculated before statin therapy is initiated calculating a 10-year ascvd risk is only required for people who fall into that primary prevention group before i review appropriate intensity statin therapy in the three high-risk groups i want to first talk about how the benefits and risks play out for these three high-risk

Groups so this table here is recapping an analysis of nhanes data and the way to think about this table is that this first row is focused on people who have clinical ascvd what they did in this study was they looked at the sample in nhanes that has ascvd which represents a sample in the u.s of five million seven hundred thirty thousand patients and what we see

If we give these people statins we would expect to see 62 600 fewer ascvd events per year the number needed to treat for this population is nine people meaning that we would need to treat nine people who have ascvd with a statin for 10 years to prevent one incidence of ascbd or 1ascvd event this is actually a very very good number needed to treat indicating that

Statins are highly effective for patients with ascvd same thing for the the next rows so for people who have a very elevated ldl the number needed to treat for 10 years is 19 people again this indicates a highly effective number needed to treat the last rows here look at people with diabetes they’re broken down by their ascvd risk which is not something that you

Need to do in practice but you do need to know that most of your patients with diabetes are going to fall into that row for people who have an ascvd risk of greater than or equal to 7.5 percent and so for this group the number needed to treat is 15 for 10 years so again statins highly effective for all of these high-risk groups and if we compare this to the

Numbers needed to harm we see that we would need to treat about 167 people for five years with statins in order to cause one significant adverse event for high intensity statins the number needed to harm is 63. so in the end the benefit risk tradeoff indicates that for people in this high risk group or these three high-risk groups statin therapy the benefits

Clearly outweigh the risks so now let’s talk about high-intensity and moderate intensity statin therapy high-intensity statin therapy means using a statin that is dosed to reduce the ldl by at least 50 percent there are two options in the united states a torvastatin dosed 40 to 80 milligrams per day and resume statin dose 20 to 40 milligrams per day moderate

Intensity statin means reducing the ldl by 30 to 49 percent and you have several options there for moderate intensity statin therapy including atorvastatin resuve statin simvastatin and pravastatin that the dose is indicated i want to point out that the statins that have an asterisk next to them have a longer half-life and what that means is that you can actually

Administer them at any time of day so for patients who are struggling to take their statin at night it may be easier for them to take it in the morning with the rest of their medications so those with the asterisk can be administered in the morning now let’s review appropriate intensity statin therapy for our three high-risk groups starting with our patients

Who have clinical ascbd this group is actually fairly straightforward so for people aged 75 and younger it is clearly recommended and there’s strong evidence that these people should be treated with a high intensity statin for people over the age of 75 you can consider it a moderate or high intensity statin and you want to think through their risk factors and

Their functional status and have a conversation with your patients before you decide which intensity to pursue we all have many patients in this age group who actually have a pretty significant life expectancy may be expected to live more than 10 years and for those people it’s definitely worth considering a high intensity statin on the other hand if you have a

Patient who is frail or could potentially struggle with multiple drug drug interactions in those folks perhaps a moderate intensity statin may be more appropriate one thing that is new about the 2018 guideline is that it addresses heart failure patients so for patients who have clinical ascbd and they have heart failure due to ischemic ascvd and they also have

A life expectancy of three or more years consider using a moderate intensity statin the takeaway really is that for most of our patients with clinical ascbd they should be on a high intensity statin now moving on to patients who have a very elevated ldlc of greater than or equal to 190 milligrams per deciliter this is also a very straightforward group for all

Of these people they should be on a high intensity statin or if they’re unable to tolerate it they should be on their maximally tolerated statin i do have a couple notes here about additional treatments in the case where you’re not seeing the expected ldl reduction so this is a group of people in which you may consider using a zeta mibe or you may consider using

A pcsk9 inhibitor if they’re not experiencing the expected ldl reduction but the focus of this project is really on appropriate statin use and for all of these people who are able to tolerate it you want to be using a high intensity statin our third high risk group are people who have diabetes and do not fall into those previous two groups so this is primary

Prevention in people who have diabetes and an ldlc of 70 to 189 milligrams per deciliter for adults ages 40 to 75 you want to start a moderate intensity statin regardless of their 10-year ascvd risk however if they do have multiple ascvd risk factors you can consider using a high-intensity statin in those people for people who are over the age of 75 and who

Are already on a statin it’s reasonable to continue that statin and for those who are over 75 but not already on a statin you can consider starting one after having that risk benefit discussion with your patient and again i just want to remind people that many of our patients over the age of 75 still have a significant life expectancy and for those people i

Would strongly encourage considering statin use the guideline also talks about adults who are under the age of 40 so adults ages 20 to 39 who have diabetes for those people you may consider starting a statin if they have a long duration of their diabetes so 10 years or more or if they already have evidence of microvascular disease i did want to put in a quick

Note about interactions most of the interactions that you may encounter with statins can result in increasing statin exposure this could theoretically increase a person’s chances of experiencing adverse effects but for the most part it’s fine to use statins and in some cases you can choose a statin that is less likely to have an interaction i do want to point

Out that etorvastatin can increase digoxin levels and that several stents can increase in inr for people on warfarin but that doesn’t mean that you should avoid statins and people on warfarin in fact they are almost certainly indicated but you do want to make sure that you monitor that patient’s inr after you’ve initiated statin therapy you need to follow up

With your patients and check their lipid panel for patients who have just started a statin you want to check a lipid panel four to twelve weeks later and then after that you’re checking every 3 to 12 months as indicated statins produce a pretty predictable response in ldl so the main reason to check an ldl level after a patient has started a statin is to check

For medication adherence so if you don’t see the expected reduction in ldl after initiating a statin the first conversation that you want to have is about medication adherence before you think about adjusting that statin dose one important piece in the guideline is that you don’t need to routinely monitor transaminases in fact you don’t even need to check baseline

Transaminases before initiating statins i actually say the new baseline that you should be checking is having a conversation with your patient about muscle symptoms and documenting any muscle symptoms before you start statins because you may need that later on if your patient comes back experiencing potential side effects so i just covered a lot in a few minutes and

I’m sure you’re all thinking how do i remember all of this i recommend you take advantage of the american college of cardiology’s ldlc manager tools the link is included on this slide you can use these tools to determine the initial management group of your patient and how to initiate treatment you can also use these tools to determine if your patient’s responding

Appropriately to a statin as well as a tool on how to deal with statin associated side effects also the journal of the american college of cardiology has a great guideline summary that’s an excellent quick reference tool and those are the key highlights from the 2018 acc aha cholesterol management guideline now you’re ready to initiate appropriate intensity statin

Therapy for the three high-risk groups as well as monitor responses to treatment

Transcribed from video
Statin Therapy for High-Risk Groups Summary Video By NACHC