5 Steps to prevent Heart Disease

Tuesday, May 31, 2016

Determine Lifetime risk of patient to determine if low dose statin needed

My approach is to
 implement multiplier effect  to treat lifetime risk



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This is a case with high HDLc 60 and CAC zero. 

Subsequently most people would not treat this patient with statins. 

                MESA calculator:
The estimated 10-year risk of a CHD event for a person with this risk factor profile including coronary calcium is 3.9%. The estimated 10-year risk of a CHD event for a person with this risk factor profile if we did not factor in their coronary calcium score would be 8.7%

 Pooled co-hort calculator:

Lifetime risk of atherosclerotic cardiovascular disease Question:
69%
(95% CI 62% to 73%)
Lifetime risk for a 50-year-old with optimal risk factors Question:
5%
(95% CI 0% to 12%)






 
I would want the patient to get an LDLp or apo B and a Lp(a).

Discordance between particles numbers and non-HDLc is possible in a diabetic.

Treatment to Goals over Long term with Low dose Combination treatment:
1-Atorvastain 10 mg/d
2- Wax matrix niacin 1,000 mg/d
3- If still not to goal add one half ezetimibe a day

4- Still not to goal, now is time to go to maximum statin dose. 

My philosophy is to avoid the maximum doses for lifelong treatments to avoid unforeseen side-effects and improve efficacy with multiple actions of multiple drugs at low doses. 

Goals:

LDLp  750 to 1,000

Non-HDL cholesterol  80 to 100


An option is to repeat CAC in 10 years or get CIMT now and serially.
It is generally accepted that lowering LDLp will initially raise CAC calcium score. 

However, in 10 years a complex atheroma may develop which has a residual risk that a high dose statin cannot resolve while early treatment can prevent.

Thus the idea behind the multiplier effect is to prevent the plaque from growing to that complex state which carries a build-in residual risk (30%) that statins have not been able to treat. 

For example:
Treating a 40 year old diabetic man with CAC 50 and his LDLp has been kept around 800. 
However his CIMT shows his atheroma is getting thicker.
This is a good candidate to treat more aggressively and keep his:

LDLp below 750 always.

or

non-HDLc below 80 always.

Naturally, this is assuming his other risk factors are kept under control.






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