Transcript

Lee Tetreault:

Welcome to Frequently Asked Questions from today's sessions, updates from the 2018 ACC scientific sessions, and Ask the Experts Cardiology. We are joined by Dr. Gluckman. Before we begin with the questions, doctor, would you be able to reiterate a few key pointers from today's sessions to our audience?

Dr. Gluckman:  

Absolutely, we had a couple of really good sessions today focused on a range of different topics. We first delved into the role of dietary supplements in cardiovascular prevention, highlighting in particular that the vast majority of cardiovascular supplements or supplements taken for cardiovascular disease, don't convey cardiovascular protective benefits. We then touched on briefly the role for screening for atrial fibrillation and increasing availability of devices that consumers may purchase, whether through their watches or other devices that may allow us to understand whether they have atrial fibrillation and what to do with that data. In the last two sessions, we focused on recent updates to guidelines related to the blood cholesterol guidelines and the high blood pressure guidelines and how we apply those new recommendations into practice.

Lee Tetreault:

Great, let's get into some of these frequently asked questions. First, for patients on statin therapy, what's the best way to evaluate musculoskeletal complaints to see if they're related to the statin?

Dr. Gluckman:  

It's a great question and something that we deal with all the time. So, a new term that was coined and introduced more fully in the 2018 blood cholesterol guideline, is SAMS, SAMS, or statin-associated muscle symptoms. And it's a catch-all for a range of different presentations, manifestations of statin-related muscle problems from myalgias on the low end of severity of the spectrum, up to rhabdomyolysis on the severe end with a number of other conditions in-between. So, I think one of the frequent challenges we have as care providers is that there are a lot of patients who will have musculoskeletal complaints, there are a lot of patients who are appropriate for statin therapy and the challenge is, are they true, true and unrelated or is that they are truly related overall? So we touched on some of the things is in a history is really important related to this. Symptoms involving muscle groups, particularly proximal muscle groups involving their thighs or their proximal portions of their arms that are symmetric, bilateral, may be more suggestive of those symptoms related to statins in contrast, those that don't involve muscles, involve the joints.

Involve more distal locations or asymmetric are less commonly associated with statins. And most commonly, not always these symptoms are temporally related to the initiation of statins that they'll develop days or weeks after initiation of statin therapy and when you withdraw the statin those should resolve within days or weeks. So none of these are absolute, but I think a thorough history, some of it's of key importance. We also touched on the fact that for those individuals in whom you're fairly convinced that they have statin-associated muscle symptoms, you can obviously withdraw the statin, see if the symptoms resolve and by reintroducing the statin if they recur, can confirm your suspicion. And then we spent more time going into what do you do if you've confirmed it now, do you in fact re-initiate an alternative statin? Do you start them back at a lower dose of the original statin? Do you change the frequency of the statin, whereby you might take it every other day, a couple of times per week? And all of these are reasonable options for individuals who have anything short of rhabdomyolysis in which case you would not wanna re-challenge them with the statin.

Any of these other manifestation, myaligias, myopathy, can be things in which you actually withdraw the statin and then look to alternatives. And finally I would add that we have a number of statins, in the statin drug class. The vast majority of them are generic some will range in be what we referred to as more hydrophilic drugs like Rosuvastatin, Pravastatin, some be more hydrophobic like atorvastatin, simvastatin. And therefore, just because one individual doesn't tolerate one statin, doesn't mean that they'll not tolerate the whole drug class. So we really covered a broad range of different approaches that can be taken in those individuals with suspected symptoms potentially related to their statin.

Lee Tetreault:

Should patients with Brief episodes of atrial fibrillation, be treated with anti-thrombotic therapy similar to those with longer episodes or permanent atrial fibrillation?

Dr. Gluckman:  

It's a great question and it's one that we get an awful lot overall. So the burden of atrial fibrillation can range from people who have intermittent or infrequent episodes that can be on the shorter side to people who have atrial fibrillation, all the time. They're in chronic or so-called permanent atrial fibrillation. For people that clearly have a diagnosis of atrial fibrillation, the frequency of symptomatic events, the presence of symptoms alone, symptomatic or asymptomatic and whether they're all the time or intermittent, should not influence your choice of anti-thrombotic therapy as it relates to reducing their risk of stroke or systemic embolism. So again just to reiterate, whether they have it intermittently for brief periods, all the time, it's present, you should still use most commonly the chadsvasc score to assess their risk of stroke or systemic embolism and initiate appropriate anti-robotic therapy based on that risk overall.

Lee Tetreault:

What's the rationale for lowering the blood pressure goal to under 130 over 80, particularly among older individuals?

Dr. Gluckman:  

So this is a challenging issue, because for quite a long period of time our norm for blood pressure goals were to get people less than 140 over 90. And prior blood pressure guidelines would define subsets of individuals in whom more intensive lower blood pressure targets, were sought. In 2017, the American College of Cardiology, and American Heart Association, amongst other professional societies came out with new guidelines that define high blood pressure as the presence of a blood pressure on two or more occasions greater than or equal to 130, for the systolic blood pressure, greater than or equal to 80 for the diastolic blood pressure with associated goals of getting people below that level overall.

A disproportionate portion of that guideline recommendation came from the Sprint trial, overall, that looked at intensive versus less intensive blood pressure lowering, but there is additional accrued data, that informs us seeking out those of lower blood pressure goals. What this means for me practically is not so much the numbers of people that are appropriate for anti-hypertensive therapy. Well, that does go up, it goes up a small amount, but we have a larger number of individuals that may now require either intensification of their current medications or more medication to get people lower on a background of lifestyle interventions to lower a blood pressure overall.

I think the challenge for a lot of individuals is the prevalence of hypertension goes up, as we age, and there may be greater challenges in managing hypertension, as people age. And in potential, there is a chance that as people get older, their susceptibility to being symptomatic from lower blood pressure may be greater as well. They may have orthostatic hypotension, with associated symptoms and other potential related symptoms or side effects. For me, as a clinician, I've adopted the 130 over 80 for my patients across the spectrum, but this is all framed in an understanding of listening to my patients. So if patients are having leaning symptoms, side effects, that precludes them from getting below that goal, I list it to the patients first and foremost, it has introduced a few challenges, but I think it's for the betterment of our patients based on the clinical trial data.

Lee Tetreault:

In light of recent data, what's aspirin's role in primary prevention to reduce the risk of adverse cardiovascular events?

Dr. Gluckman:  

It's a phenomenal question, and we're dealing with this more and more. I will preempt this by saying that the new American College of Cardiology and American Heart Association, convention guidelines are due out in March of 2019. So just about five weeks from now. And as a result of that, we'll see what our professional societies, say about this overall. It is correct, that there are three large trials that have been published in the last few months, that call into question the net clinical benefit of using aspirin in primary prevention, one firmly dedicated a diabetics and others in two different populations. And so, as a cardiologist, I'm beginning to think or pause more before reflexively starting all people on low dose aspirin who may be at increased cardiovascular risk. And this primarily stems from the fact that well, aspirin can convey cardiovascular benefit, the benefit is small and in many cases it's offset by a heightened risk of bleeding, particularly gastrointestinal bleeding. So we'll have more data in the not too long distant future in terms of weight and recommendations with regard to this, but I will say that for people with clear indications for aspirin they should continue it.

Those people who have had prior heart attack, stroke, bypass surgery, angioplasty, for diabetics there appears to be more equipoise between the ischemic benefits that are offset by increased bleeding risk, and for non-diabetics without established atherosclerotic cardiovascular disease, there doesn't seem to be as much benefit as we have thought in the past. It's offset by a higher bleeding risk.

Lee Tetreault:

And lastly, in which patients should I consider ordering a coronary calcium scan?

Dr. Gluckman:  

So this is something that we've been discussing now, perhaps for 20+ years, but it's taken acrued data and incorporation into our guidelines to give us a better perspective on where to go with this. In November of 2018, the American College of Cardiology and American Heart Association, amongst other professional societies, released its 2018 Blood Cholesterol Guidelines. And they do call out specifically the role of coronary calcium scoring in certain individuals to serve sort of as a referee or a tie breaker. So we're not talking about people with atherosclerotic cardiovascular disease clinically who have had a heart attack or strokes. We're not talking about people who have severe hyper-hypercholesterolemia, and those with an LDL cholesterol greater than or equal to 190 milligrams per deciliter. We're not talking about diabetics. So in the group that's not clinical atherosclerotic cardiovascular disease, not severe hypercholesterolemia, not diabetics, we're left with a largely non-diabetic primary prevention population. And in that group, the guidelines previously and currently recommend an estimation of their 10 year risk of having a fatal or non-fatal heart attack or stroke.

For individuals that have a risk greater than are equal to 20%, there's a clear recommendation to use high-intensity statin therapy. In those in whom their risk is less than 5%, re-assurance, lifestyle changes are reinforced overall. For those of a risk of about 5%-7.5%, there likely is a recommendation to use lifestyle changes and you could be justified to doing that alone, but there are a number of what we call risk enhancers. Presence of metabolic syndrome, chronic kidney disease, family history of premature, atherosclerotic cardiovascular disease that may tip you towards a statin. And finally in that seven and a half to 20% range, is a fair number of people and the guidelines currently recommend moderate-intensity statin therapy, but I know that many of the listeners know is, not everybody wants to go on a statin in spite of the recommendations.

And so in that last group with a 10-year predicted risk between essentially seven and a half to 20%, if that is their risk one option is to consider a coronary calcium score and the reason is is because if their estimated risk is 12.2%, we know that the risk estimate is not perfect. And what has been learned through a large trial called the Macy's study, is that if you do a coronary calcium score and their score is zero, it suggests that their risk is lower than what was predicted by the calculator. And so the greatest value of a coronary calcium score, is in ruling out the presence of coronary calcium. A coronary calcium score, of zero. And so if somebody came to me, their predicted risk is 12.2%, we got a coronary calcium score, their score is zero. It's not that their risk is 0%, but their risk is lower than the 12.2% whether it was predicted and may shift them into a group in whom lifestyle reassurance... Reassurance and lifestyle changes are all that's needed.

In contrast if their coronary calcium score is elevated, it's an affirmation of what the guidelines say outright, that they should be on statin therapy overall. So I think we'll begin to start seeing more providers ordering, more payers hopefully covering coronary calcium scores as a one time test for the vast majority of individuals to help refine our risk prediction to better determine who's most likely to benefit from lipid-lowering therapy with a statin.

Lee Tetreault:

This is great information, Doctor. Thank you so much for your time.

Dr. Gluckman:  

My absolute pleasure, thanks for asking the questions.




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