|Case Four: Secondary Prevention Lipid Management|
|Mr Johnson is a 58 year old white male living in Stamford, Connecticut. He is here to see you for a follow up 1 month after discharge to the hospital, where he was treated for an ST-segment elevation myocardial infarction (STEMI). Prior to discharge he was initiated on a high-intensity statin, atorvastatin 80 mg daily.
Mr. Johnson admits to you that he stopped his statin about 2 weeks ago, because he’s heard that it can cause liver damage on the radio. He feels he needs more time on his diet and exercise. He also wants to try garlic supplements, fish oils, and Chinese herbs to help his cholesterol first. He does not report any side effects of atorvastatin, and he does not have comorbidities or predisposing factors that could influence statin safety. How would you approach Mr. Johnson?
Evidence based guidelines from the ACC/AHA in 2013 for treatment of cholesterol to reduce ASCVD risk include guidelines for patients with established ASCVD. Evidence-based therapy for Mr. Johnson’s cholesterol should focus on which of the following?
The correct answer is 3. For patients with established ASCVD such as Mr. Johnson with a recent STEMI, the evidenced-based best cholesterol treatment is high-intensity statin therapy. Specific cholesterol level treatment goals are not based on RCT evidence and are not a part of 2013 ACC/AHA guidelines (options a and b are incorrect); there is also no evidence that non-statin therapy of any intensity will lower risk in this patient (option d is incorrect).
The four groups recommended for statin therapy according to the 2013 guidelines are:
Which one of the following includes the determinants used in 2013 ACC/AHA risk calculator to assess 10-year risk for ASCVD?
The correct answer is 1:
You also explain to Mr. Goodman that the new (2013) guidelines have shifted the approach to using statins and that they have generated controversy. You tell him that, in fact, statin treatment would not be recommended under the old guidelines.
You tell him that you want more time to consider the 2013 guidelines, and the two of you agree to meet again in 2 weeks. Stephen, with his hand on the doorknob, says, “Doc, I really want to know what you would do.”
What treatment strategies for hyperlipidemia should be offered to Mr. Goodman? Which of the options below you recommend, based on your review of the 2013 ACC/AHA guideline.
The true answer is that there are several ways to treat him; all of these are potential recommendations and you may see all used at your practice site. In a poll of NEJM readers of this article, 56% chose option a; 26% chose option b; 16% chose option c.
Click on each option below to read how three NEJM commentators defend each of these approaches in response to the vingette which appeared April, 2014 in NEJM.
Rationale for option a: do not begin statin therapy, by Dr. Benjamin J. Ansell, M.D
Rationale for option b, begin statin therapy and monitor LDL level, by Dr. Samia Mora, M.D., M.H.S
Rationale for option c: begin statin therapy and do not monitor LDL level, by Dr. Harlan M. Krumholz, M.D
A visual aid
The Mayo Clinic has produced a web-based visual tool to use with patients in your office to help them understand their cardiovascular risk, and how interventions (tobacco cessation, blood pressure lowering, aspirin, and/or statin therapy) can have on their risk. Here is what you could show Mr. Goodman about the effect of starting a statin on his CV risk: