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Despite new guidelines, CVD prevention barriers remain for some patients
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CHICAGO — Updated guidelines provide clear CVD prevention strategies for most patients, but barriers to optimal treatment in some patients remain, including issues related to sex, age, inflammation and adequate testing, according to a speaker.
Roger S. Blumenthal, MD, FACC, FAHA, Kenneth Jay Pollin Professor of Cardiology, director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease and editor of the Cardiology Today Prevention section, who was a member of the writing committee for the2018 Guideline on the Management of Blood Cholesterol, addressed some of these barriers in a presentation at the Cardiometabolic Health Congress.
Issues specific to women
Blumenthal said when clinicians discuss lifestyle and the potential for statin benefit in their female patients, they should also consider factors such as premature menopause (younger than 40 years) as well as other pregnancy-related disorders such as high BP, preeclampsia, gestational diabetes, small for gestational age infants and preterm deliveries.
“Keep in mind, women of childbearing age who are treated with a statin should be using a reliable contraception,” Blumenthal said during his presentation. “Women who are planning to become pregnant should stop the statin 1 to 2 months before attempting pregnancy. We want to try to minimize medications during that time.”
Primary prevention in the elderly
Highlighting a study published in The Lancet, Blumenthal said patients older than 75 years who do not already have occlusive vascular disease may not experience the same degree of benefit of statin therapy for the prevention of atherosclerotic CVD due to competing risks for cancer deaths.
“When you look at those individuals who are above the age of 75 and don’t have any occlusive vascular disease, the trend is still there for benefit, but it is not quite statistically significant,” Blumenthal said. “However, I usually say that [if] the patient is young enough to go to the cath lab or the coronary care unit, they’re probably young enough for me to aggressively treat their risk factors and try to avoid those high-cost procedures.”
Inflammatory disorders and HIV
In patients aged 40 to 75 years with LDL between 70 mg/dL and 189 mg/dL as well as a 10-year ASCVD risk of more than 7.5%, chronic inflammatory disorders and HIV should be considered risk-enhancing factors for CVD. Blumenthal said clinicians should favor moderate-intensity statins for this subgroup.
Men who are positive for HIV have a greater incidence of the presence of noncalcified coronary artery plaque on CT angiography, according to research published in Annals of Internal Medicine:
- any plaque present (adjusted prevalence ratio [aPR] = 1.13; 95% CI, 1.04-1.23);
- noncalcified plaque present (aPR = 1.25; 95% CI, 1.1-1.43);
- mixed plaque present (aPR = 1.22; 95% CI, 0.98-1.52); and
- calcified plaque present (aPR = 1.02; 95% CI, 0.84-1.23).
“The approach to cardiac risk factor modification has changed in patients with HIV,” Blumenthal said during his presentation. “We classified HIV as a risk-enhancing factor, and that would favor the initiation of a moderate-intensity statin. We also said that individuals with rheumatoid arthritis may actually have their lipid levels go up when treated with disease-modifying therapy. Therefore, it’s important to repeat those lipid measurements once the inflammatory condition is stabilized.”
Barriers to testing
Lastly, Blumenthal said, despite apparent absence of coronary artery calcification, patients with diabetes, ASCVD, current smoking or HIV may continue to have higher long-term risk.
Blumenthal said high-sensitivity C-reactive protein and lipoprotein(a) testing are also risk-enhancing factors, and elevated levels are a rationale for more aggressive lipid management and lifestyle improvements.
“The guidelines say that the absence of coronary artery calcium may not provide the same reassurance in persons with diabetes, a strong family history of heart disease, smokers and HIV,” Blumenthal said during his presentation. “In my mind, the right test depends on the right patient to guide his or her therapy of choice.” – by Scott Buzby
References:
Blumenthal RS. Guideline and Gaps in Lipid Management. Presented at: Cardiometabolic Health Congress; Oct. 10-13, 2019; Chicago.
Cholesterol Treatment Trialists’ Collaboration. Lancet. 2019;doi:10.1016/S0140-6736(18)31942-1.
Grundy SM, et al. J Am Coll Cardiol. 2018;doi:10.1016/j.jacc.2018.11.003.
Post WS, et al. Ann Intern Med. 2019;doi:10.7326/M13-1754.
Disclosure: Blumenthal reports no relevant financial disclosures.