You'll hear buzz about the new cholesterol guidelines that bring back some emphasis on LDL and promote even more individualization.
LDL will guide use of non-statins...but ONLY for the highest-risk patients with CV disease, such as those with multiple CV events OR additional CV risks (diabetes, smoking, etc).
Experts have landed on 70 mg/dL as the threshold to consider adding a non-statin...AFTER verifying adherence to statins and lifestyle changes. The change is based on more data that "lower is better" in these patients.
Continue to recommend a high-intensity statin (atorvastatin 80 mg, etc) for very high-risk patients. Then use a stepped approach if needed.
Suggest adding ezetimibe first. It prevents one CV event for every 50 acute coronary syndrome patients treated for about 7 years...is well tolerated...and the generic costs about $360/yr.
If LDL is still above 70 mg/dL, weigh pros and cons of injectable Praluent (alirocumab) or Repatha (evolocumab). Adding one of these PCSK9 inhibitors to a statin in patients with CV disease and other CV risks prevents about one CV event for every 70 patients treated for 2 to 3 yrs.
But Repatha costs about $4,150/yr...Praluent about $13,400/yr. Payer contracts may result in similar costs for either med.
Don't routinely suggest adding ezetimibe or a PCSK9 inhibitor for lower-risk CV disease patients. Help them stick to their statin instead.
And don't suggest a bile acid sequestrant, fibrate, or niacin...these aren't shown to improve CV outcomes when added to a statin.
Individualization will be a bigger focus...for patients ages 40 to 75 who DON'T have CV disease. Use the Am Coll of Cardiology/Am Heart Assn CV risk estimator as a starting point to discuss if a statin is needed.
Advise using a high-intensity statin if 10-year CV risk is 20% or higher, since this level of risk is similar to having CV disease.
If CV risk is 7.5% to 19.9%, statin use will now be guided by "risk enhancers"...family history, kidney disease, etc. If patients have risks, generally suggest a moderate-intensity statin (atorvastatin 20 mg, etc).
- J Am Coll Cardiol Published online Nov 8, 2018; doi:10.1016/j.jacc.2018.11.003
- J Am Coll Cardiol Published online Nov 3, 2018; doi:10.1016/j.jacc.2018.11.004
- J Am Coll Cardiol Published online Nov 3, 2018; doi:10.1016/j.jacc.2018.11.005
- Medication pricing by Elsevier, accessed Dec 2018