Risk-Benefit Ratios of LDL-Lowering Strategies and the Doctor/Patient Relationship

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The MD Magazine Peer Exchange “Amassing the Clinical Evidence for Optimized Dyslipidemia Management: Vitamin D, Long-Term Statin Outcomes, and PCSK9 Inhibition” features expert insight and analysis of the latest information on managing hypertension and hyperlipidemia, and in-depth discussion on the use of PCSK9 inhibitors in practice.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Christie Ballantyne, MD, Co-director of the Lipid Metabolism and Atherosclerosis Clinic at The Methodist Hospital, Director of the Center for Cardiovascular Disease Prevention at the Methodist DeBakey Heart Center, and the Chief of Cardiology at Baylor College of Medicine
• Keith C. Ferdinand, MD, Immediate Past Chair of the National Forum for Heart Disease and Stroke Prevention, and Professor of Clinical Medicine at the Heart and Vascular Institute at Tulane University School of Medicine
• Jennifer G. Robinson, MD, MPH, Professor in the Departments of Epidemiology & Medicine and Director of the Prevention Intervention Center, Department of Epidemiology at the College of Public Health, University of Iowa
• Karol E. Watson, MD, PhD, Professor of Medicine and Cardiology, Co-director of the UCLA Program in Preventive Cardiology, and Director of the UCLA Barbra Streisand Women’s Heart Health Program

Lowering LDL lowers cardiovascular risk, but all LDL-lowering therapies are associated with some kind of toxicity. In ODYSSEY Alternative, the discontinuation rates due to statin myopathy were about the same for atorvastatin, alirocumab, and ezetimibe, and the discontinuation rate for myalgias was 50% in the placebo arm, said Watson. This myopathy discontinuation rate went down to 0 during the open-label alirocumab phase of the trial, said Robinson.

Because there is such an obvious cognitive component to the myopathy reporting, Robinson said, it is important to let the patients’ concerns be heard without interruption before presenting the reasons why they should be treated with a statin. Ferdinand agreed that the doctor/patient relationship is the best predictor of success. Ballantyne said patients need their doctors to believe that the problem is not just in their head.