Transcript

Lee Tetreault:

Hello and welcome to Frequently Asked Questions from the session 'Medical Literature Updates: Cardiology Highlights from 2018 to 2019'. We are joined today by Dr. Ty Gluckman. Doctor, let's start with some questions. What about aspirin in patients older than 75 years? 

Dr. Gluckman:  

Yeah, so it's a great question. And historically, we used to decide on the use of aspirin in primary prevention based upon the presence of other risk factors, and in particular, what their 10-year risk was for fatal or non-fatal cardiovascular events. More recent data within the last year, and even more recently, the new prevention guidelines focused on primary prevention that came out from the American College of Cardiology and the American Heart Association in March of 2019, now provide strong support that most patients in primary prevention, in particular, over the age of 70 years of age, do not benefit from aspirin in so far as either the benefits afforded by the agent are offset by an increased risk of bleeding, or there's no net benefit at all. This does extend to an even younger population, but most of the studies had taken an older primary prevention population to ask this question. And the bottom line is, for most individuals, even at higher risk without established cardiovascular disease, including diabetics, regular use of low-dose aspirin is not warranted.

Lee Tetreault:

That's good. What is the ideal time to recheck a lipid profile after starting statin therapy? 

Dr. Gluckman:  

A couple of things are related to this. The American College of Cardiology, American Heart Association guidelines recommend that for all individuals, who have new initiation of therapy or a change in their drug therapy, that a lipid panel be checked four to 12 weeks later, and for those individuals on a stable regimen, a lipid panel be checked every three to 12 months. The first approach, primarily revolves around wanting to make sure that people achieve the desired response. And you don't know unless you recheck. We're used to looking at a mean treatment effect, but some individuals may not have an average effect, they may have a less than average, or in some cases, an exaggerated more than average effect. The rationale for testing every three to 12 months, and for me, personally, usually on an annual basis is to assess for adherence to therapy overall.

Lee Tetreault:

Can you comment on using fish oil for hypertriglyceridemia.

Dr. Gluckman:  

Yeah, so it's a great question. We have known for a long time that omega-3 fatty acids aka fish oil can be an effective strategy to lower triglycerides, particularly for people with high and very high levels, primarily to mitigate the risk of pancreatitis, which goes up for those individuals with triglyceride levels greater than or equal to 500. First and foremost, it's important to call out that there are some reversible causes of hypertriglyceridemia related to certain medications, poor blood sugar control in diabetics, and those things should be addressed first.

Omega 3 fatty acids have been studied more recently at a high dose in a purified form as pure EPA or eicosapentaenoic acid in a REDUCE-IT trial, and even for individuals that have normal or modest elevations in triglycerides have also been associated with cardiovascular risk reduction. I think we're beginning to learn even more about the role for omega-3 fatty acids. They can be an effective therapy to lower triglycerides, but also can have a cardiovascular risk-reducing effect independent or above and beyond their impact on triglycerides.

Lee Tetreault:

What type of follow-up AFib screening would you recommend for a patient coming in reporting an abnormal rhythm on a wearable device? 

Dr. Gluckman:  

As part of our discussion, we recognize the fact that now, consumer-driven wearables, most notably that's received the most attention, the Apple Watch, have the ability to detect abnormalities in the heart rhythm overall. The Apple heart study that was presented at the American College of Cardiology this past March of 2019 highlighted the fact that for those individuals who end up having an alert on their wearable device, in this case, the Apple Watch, that a large portion of those individuals, in excess of 80%, who ultimately underwent additional monitoring to definitively evaluate whether they had AFib, actually had AFib. The current recommendation is, if someone has a wearable that raises a concern of a rhythm, like atrial fibrillation, is to confirm that with, most commonly, a Holter monitor, usually an extended Holter monitor beyond the 48-hour period, and if, in fact, it establishes a diagnose of atrial fibrillation, then appropriate therapy, even if asymptomatic based on their stroke risk or systemic embolism risk, should be initiated with appropriate antithrombotic therapy.

Lee Tetreault:

Would you treat LDL over 190 after attempting behavioral modifications, regardless of age? 

Dr. Gluckman:  

The question that often comes up is, "What does an LDL cholesterol greater than or equal to 190 mean?" And it's for those individuals that don't otherwise have clinical atherosclerotic cardiovascular disease, they haven't had a heart attack, or stroke, bypass surgery, angioplasty. The next question is, "Do they have severe hypercholesterolemia?" And for those individuals who have levels greater than or equal to 190, a sizable portion of those individuals will have what's called familial hypercholesterolemia or a genetic predisposition to high cholesterol. The first thing to do is to exclude secondary causes: Hypothyroidism, nephrotic syndrome cholestasis or some drugs that can raise LDL cholesterol. Absent having those findings, individuals with LDL cholesterol levels greater than or equal to 190, who don't otherwise have clinical atherosclerotic cardiovascular disease, merit treatment, I would argue, independent of age, to get their LDL cholesterol below 100 milligrams per deciliter. I'd even extend that further that we're finding out that in individuals in the pediatric population, who are appropriately screened, pre-preteen years with a lipid panel if they're identified to have LDL cholesterol levels in this range on a background of lifestyle intervention, pharmacotherapy, starting first with statins, is appropriate.

Lee Tetreault:

And lastly, what are your thoughts on CoQ10 use? 

Dr. Gluckman:  

Coenzyme Q10 is available in supplement form and has been evaluated in very limited degrees to determine its effectiveness in addressing statin-associated muscle symptoms. The more common term that's used today is SAMS, or statin-associated muscle symptoms which is the spectrum of potential muscle-related complications that can occur in small percentages of people on statin therapy. Right now, the prevailing theory is that in those individuals on a statin who otherwise do not have any muscle-related symptoms, Coenzyme Q10 has really no place whatsoever.

The data is mixed, in so far as whether or not it provides any symptomatic improvement in those individuals with statin-associated muscle symptoms. Some very small studies have suggested benefit, some other studies have suggested a lack thereof. In those circumstances, if a patient wants to try it and they get relief, I have no objection to them using it. If they try it and they don't get relief, then it doesn't make sense to be on it. It's important, though, to undergo a formal algorithmic approach to evaluating people with statin-associated muscle symptoms. That's probably beyond the scope of this discussion, but definitely take a good history, review their current medications, look for other co-morbid conditions, evaluate whether it's symmetric or asymmetric, does it involve proximal muscle groups as opposed to their joints? These are all things that can be helpful in sorting out whether the symptoms are due to the statin or not.

Lee Tetreault:

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



 

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