Cardiology Management Challenges in Daily Clinical Practice
Rasha N. Bazari MD Ministrelli Womenâ€™s Heart Center William Beaumont Hospital Royal Oak, Michigan USA GHA10-SHA24 2/13/2013
Case Presentation • Patient is a 49 year old female with no significant past medical history • Fasting lipid profile: -TC 218 -TG 170 -HDL 28 -LDL 158 -TC/HDL ratio 7.8
• She has History of HT and her current BP is 132/85 on therapy • She does not smoke and is not diabetic
What her goal LDL? A. B. C. D.
<190 mg/dL <160 mg/dL <130 mg/dL <100 mg/dL
What would you do next? A. Start her on simvastatin 40 mg nightly, repeat lipid profile and LFTs in 12 weeks. B. Dietary changes and exercise. Repeat labs in 3 months. C. Need more information to treat this patient. D. No need for therapy or life style changes. Repeat labs in one year.
Okâ€Ś. â€˘ You should realize that significant data needed for risk stratification is missing
• You want to risk stratify this patient to see which category she falls into • Very low, low, intermediate, high, or very high risk • You will consequently decide her goal LDL and the pathway you will follow to achieve that goal.
Risk Factor Assessment • Cigarette smoking • Hypertension (HT) (BP≥ 140/90 or on treatment for HT) • Low HDL (<40 mg/dL; 1.03 mmol/L) • Family history of premature CAD (male first degree relatives <55 years, female first degree <65 years) • Age (men ≥45 years, women ≥ 55 years)
Risk Factor Assessment, Cont. â€˘ HDL â‰Ľ 60mg/dL(1.55 mmol/L) counts as a negative risk factor; its presence removes one risk factor
CAD Equivalents • • • • •
DM Symptomatic carotid artery disease Peripheral arterial disease Abdominal aortic aneurysm Multiple risk factors that confer a 10-year risk of CAD >20% • Chronic renal insufficiency (Cr>1.5mg/dL or GFR <60 mL/min per 1.73 m2)
Circulation 2004; 110:227
Risk Stratification Tools • • • •
Framingham risk score ATP III risk stratification Reynolds risk score Other methods of risk assessment
More Information… • It turns out that she has a family history of DM (mother), and 2 of her siblings had CAD; one brother dying at age 30 of MI
• Physical exam revealed elevated BP as mentioned • Waist circumference 40 inches (100cm) • Fasting blood sugar 113
So, whatâ€™s her goal LDL now? A. B. C. D.
<160 mg/dL (< 4 mmol/L) <130 mg/dL (<3.3 mmol/L) <100 mg/dL (<2.6 mmol/L) <70 mg/dL (<2.3 mmol/L)
Risk factors in this patient • Hypertension • Low HDL • Elevated triglycerides, waist circumference >35”, and elevated fasting blood sugar, putting her in the metabolic syndrome category • Family history of premature CAD
Goal LDL • • • •
This patient has multiple risk factors She is a moderate to moderately high risk patient Her 10-year risk is probably in the 10-20% range Her goal LDL per the guidelines is <130 (<3.36mmol/L) • Therapeutic lifestyle changes are indicated • Drug therapy is appropriate and should be considered • The drug of choice should be a statin in absence of contraindications
Risk Factors â€˘ If two or more risk factors other than LDL exist in a patient without CAD or CAD equivalent, the 10 year risk is assessed using the ATP III modification of the Framingham risk tables
Other Risk Factors â€˘ Novel risk factors are to be included in risk assessment and decision making, such as hs-CRP, and coronary artery calcium scoring â€˘ Obesity, physical inactivity, impaired fasting glucose, inflammation markers, abnormalities of thrombosis and endothelial dysfunction have all been suggested by epidemiologic studies as CAD risk factors
â€˘ There is no evidence from controlled trials that targeting these risk factors improves outcomes â€˘ ATP III, however, suggests that these factors can be used to modify clinical judgment
Other Risk Factors â€˘ Total Cholesterol/HDL ratio: -Goal< 6.4 in men and <5.3 in women
Keep in Mind • ATP III may underestimate risk of cardiovascular disease in women and thus physicians need to be aware of this phenomenon • In patients with 0 to 1 risk factors (other than CAD equivalents), 10-year risk of CAD is generally <10% • Clinical judgment is still to be used in deciding care plan
Circulation 2004; 110:227