High-Risk Prevention: Stepped Approach or Statins Therapy

Deepak L. Bhatt, MD, MPH: I’m not talking about secondary prevention now—everyone should start a statin barring the contraindication. I’m talking about primary prevention. Do you guys believe in a stepped approach, as is often recommended? But then there’s the reality if they didn’t actually come back for their 6-month appointment. Or do you just initiate statin right away in the high-risk primary prevention patient? Is it a concurrent approach or a stepped approach?

Michael Miller, MD: Yes, and I think it’s going to differ for men and women, because women who are of childbearing age who may have a relatively high LDL [low-density lipoprotein], you may want to withhold statin therapy until they’re through having their children and breastfeeding and so forth. But by and large, if their LDL is at least 190 mg/dL, based on the new guidelines and they’re diabetic, it is a clear indication to start statins. I do concomitantly recommend lifestyle. And as part of that lifestyle, dietary cholesterol is 1 thing, but there’s that negative regulatory mechanism through cholesterol, through hepatic upregulation of LDL receptors and production. But saturated fat is a big culprit, so I try to recommend reducing animal-based saturated fat. As Steve points out, on average, you get only about a 10% reduction. But I will do that concomitantly and say medication, you need to be on medicine, but you also need to monitor your lifestyle.

Deepak L. Bhatt, MD, MPH: Well, you said diabetes and LDL greater than 190 mg/dL. What about Steve’s patient who had LDL of 150 mg/dL and a bunch of risk factors? There do you go concurrent with diet, or do you do it as step therapy?

Christie M. Ballantyne, MD: I think it’s important. This is where you get into the whole concept of risk assessment. The issue is that most people think the LDL 190 mg/dL is straightforward, 200 mg/dL. But what most people are confused with—say I’ve got borderline blood pressure, and you look at their blood pressure, and it’s consistently 145 mmHg, but it’s borderline. And their HDL is low with it. And they say, “Well, I don’t have diabetes, but they have impaired fasting glucose.”

Steven E. Nissen, MD: And their waist-to-hip ratios.

Christie M. Ballantyne, MD: Yeah, so they’ve got metabolic syndrome, and it turns out, “Well, my parents didn’t, but my uncle had a heart attack.” It’s the clustering of risk factors, a bunch of things that are abnormal. And so they say, “Well, nothing is really that bad,” but it’s multiplicative. If you get 4 of them, it’s 2 to the 4th power, as compared with having 1 thing that’s high. I think the lifestyle part is 1 thing that’s very important. I would start them on a statin. And for those patients, when I see them I say, “We’re going to start you on a statin. Now, it’s very important in terms of your diet and exercise, because it’s important that you don’t get diabetes.”

We know from DPP [Diabetes Prevention Program] that you can reduce onset of diabetes by 60% for that person when they have impaired fasting glucose, and that helps worry the concern. They say, “Well, isn’t this worse than diabetes?” So your lifestyle can make a huge impact. Although it doesn’t do much for cholesterol, it does a lot for diabetes, and it does a lot for blood pressure. It’s the same as a medication for blood pressure. It does a lot for your triglycerides. The lifestyle argument, to me, is I’m going to help control those other risk factors. It will help your cholesterol a little—maybe you use a lower dose for it, but I would not. If you lost 30 pounds and everything was incredible, yeah, we could consider stopping it in the future. But let’s start now and not waste time.

Steven E. Nissen, MD: Let me be provocative for a moment if I can.

Deepak L. Bhatt, MD, MPH: Oh, you’ve already been provocative. This is going to generate so many comments on the web page that you said it doesn’t have to be lifestyle first. But let me just challenge you. I agree with you. A lot of times the patient doesn’t come back for 6 months, lost to follow-up, and they come back with their event. We see that a lot, in particular in cardiology. But what about the flip side though, because you’re telling this couch potato with multiple risk factors to start exercising, and here is your diet and now a statin. And a week later they haven’t exercised, and their thighs hurt. It’s the statin’s fault. I’m going to stop the statin. Isn’t that a risk when you just do everything at once?

Steven E. Nissen, MD: It is a risk, OK. Let me be even more provocative here, OK?

Deepak L. Bhatt, MD, MPH: Uh-oh.

Steven E. Nissen, MD: Somebody comes to see you; they’re 50 years old. They don’t have a lot of other risk factors except maybe a family history, and their LDL is 150 mg/dL and their HDL is 32 mg/dL. They’re overweight. For 100 people like that whom you tell to lose weight, exercise, and do that, I’d be interested in knowing what fraction of them do you guys think are successful at doing so. And are you going to somebody at an LDL of 150 mg/dL? I know from our IVUS [intravascular ultrasound] studies that they’ve already got tons of plaque in their coronaries. Most of them will have. If you were to put an IVUS probe down their coronaries, we know they’re going to have plaques there. We know that half the population is going to die of cardiovascular disease. You calculate their ACC [American College of Cardiology]—AHA [American Heart Association] risk score, and they’re going to be under 5%. Are you willing to leave them where they are?

Deepak L. Bhatt, MD, MPH: Well, why not do not an intravascular ultrasound but a CT [computed tomography angiogram]? I think you will like those tests, so why not just order 1 of those?

Steven E. Nissen, MD: Well, I hate them.

Deepak L. Bhatt, MD, MPH: I just prodded it.

Steven E. Nissen, MD: Your provocateur. I don’t think making people glow in the dark from radiation in order to decide whether to use a $3-a-month drug makes a lot of sense.

Deepak L. Bhatt, MD, MPH: All right. How about CT angiograms? What do you think, coronary calcium scans or CT angiograms?

James A. Underberg, MD, MS: I don’t order a lot of CT angiograms. I don’t even order a lot of coronary calcium scans. I use them sometimes but not frequently. I would tell you, for this patient who you’re talking about, Steve, I agree and I disagree.

Deepak L. Bhatt, MD, MPH: Oh, you’re so diplomatic.

James A. Underberg, MD, MS: What I agree about is the response to diet and lifestyle. What I disagree about is how we measure response. And we measure response numerically: Did the blood pressure go down? Did the glycated hemoglobin A1C go down? Did the cholesterol go down? What we have to think about with diet and lifestyle is that it’s like adding an aspirin. It’s maybe like adding some other preventive cardiovascular agents that we’re going to talk more about today. I intervene with diet and lifestyle and say, in addition to this, we’re also going to start you on a statin because the diet and the lifestyle isn’t going to fix your cholesterol of 150 mg/dL because cholesterol of 150 mg/dL is not something you do to yourself. It’s something your parents did to you, because it’s inherently probably a SNP [single nucleotide polymorphism] in 1 of the multiple genes that control the LDL receptor. It’s function. It’s a combination of both. And I agree, you can’t fix it with diet and lifestyle, but you should do it anyway.

Steven E. Nissen, MD: I completely agree, and that’s what I do. I say, “Look, change your lifestyle, do these things, and here is an entry dose,” and I start people at a low dose, 5 mg of rosuva [rosuvastatin] or 10 mg or atorva [atorvastatin], which generally is well tolerated; you don’t see a lot of muscle complaints. I know I’m going to get a 35%, 40% reduction in their LDL. I’m going to sleep better at night knowing that I have not left that patient. Here’s where the problem is. I may not see that patient again. You don’t know what their future holds, and 10 years from now they may still have an LDL of 150 or 160 mg/dL, and nobody has done anything.

Michael Miller, MD: That’s fine and good if you have those patients who are willing to go on a statin. The problem is, I get referrals for patients who are vehemently opposed to starting a statin, either because they had a relative who had an adverse effect or they read on the internet that there were some issues. Under no circumstances will they try a statin. That becomes an issue. We will try to give them Metamucil or some soluble fiber to take and then consider, will you take ezetimibe? Sometimes you have to have an approach with a patient in which you might do a coronary calcium if it’s a tie-breaker. Will you go on a statin if we can show that you have coronary calcium? Some will say yes; others will say no. But that’s kind of the practice or the art of medicine to determine.

Transcript edited for clarity.