My students Mohit Soni and Chandan Kumar had presented this topic in our 22nd Student Scientific Society Conference in the department of Propaedeutic of Internal Diseases No.2

1. Dyslipidemia and CVS
MOHIT SONI
5TH YEAR STUDENT

2. Case
Dyslipidemia in primary prevention: To prescribe or not????
-

3. Learning objectives
1. What is the role of ASCVD risk estimator in guiding the treatment
of dyslipidemia?
2. What are the additional investigations done for patients who are
low-moderate risk?
3. What are the factors included in clinical-patient risk discussion?
4. What does the guideline say about South Asian ancestry group?

4. Case
• Mr. x is a 57 year-old male executive officer with no significant past medical
history is seen in follow up.
• The patient states he has been adherent to maximal lifestyle modifications
and exercise.
• He has had elevated blood pressures >130/80 on two prior clinic visits. There
is no family history of premature coronary artery disease
• Social History
He has never used any tobacco products.
Denies alcohol use

5. Vitals:
• His blood pressure and pulse at the office visit are 142/80 mm Hg and 70
beats per minute, respectively.
• He weighs 80 kg with a BMI of 24 kg/m2.

6. Lab Values
• Total cholesterol: 190 mg/dl ( n : 150 – 250 )
• Triglycerides: 140 mg/dl ( n : 10 – 90 )
• High-density lipoprotein-cholesterol (HDL-C): 42 mg/dl ( n :<50)
• Low-density lipoprotein-cholesterol (LDL-C) (calculated): 120 mg/dl (<160)
• Hb A1c: 5.1%
• Serum creatinine: 0.8 md/dL ( N : 0.6-1.4 mg/dl )

7. ASCVD calculator: 10 year ASCVD risk
• It is 10.8 %.
https://www.mdcalc.com/ascvd-atherosclerotic-cardiovascular-disease-2013-risk-
calculator-aha-acc

8. Guideline recommendations: ACC 2018
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a
report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73;3168-3209.

9. ACC guideline recommendations in
intermediate risk individuals
 In adults at intermediate-risk, statin therapy reduces risk of ASCVD, and in the context of a
risk discussion, if a decision is made for statin therapy, a moderate-intensity statin should be
recommended. Class 1 A
 In intermediate-risk patients, LDL-C levels should be reduced by 30% or more, and for
optimal ASCVD risk reduction, especially in high-risk patients, levels should be reduced by
50% or more. Class 1 A
 Clinicians and patients should engage in a risk discussion that considers risk factors,
adherence to healthy lifestyle, the potential for ASCVD risk-reduction benefits, and the
potential for adverse effects and drug–drug interactions, as well as patient preferences, for
an individualized treatment decision. Class 1 B-NR
 In intermediate-risk adults, risk-enhancing factors favor initiation or intensification of statin
therapy. Class 2A
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American
College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73;3168-3209.

10. Risk-Enhancing Factors for Clinician–
Patient Risk Discussion
• Patient does not have traditional risk factors or risk enhancers.
• Family history of premature ASCVD (males, age <55 y; females, age <65 y)
• Primary hypercholesterolemia (LDL-C, 160–189 mg/dL [4.1–4.8 mmol/L); non–HDL-C
190–219 mg/dL [4.9–5.6 mmol/L])
• Metabolic syndrome
• Chronic kidney disease (eGFR 15–59 mL/min/1.73 m2 with or without albuminuria; not
treated with dialysis or kidney transplantation)
• Chronic inflammatory conditions such as psoriasis, RA, or HIV/AIDS
• Lipid/biomarkers: Associated with increased ASCVD risk:
- Persistently elevated, primary hypertriglyceridemia (≥ 175 mg/dL)

11. Addressing the concerns of patient:
 The patient is still very concerned.
 Patient inquires if he needs a statin at
the given risk.
 He has heard multiple positives
especially in hypertensives and
negatives with respect to muscle pain
with long-term statin use.

12. What will be the next risk enhancer you will
check for, if feasible?
1. High-sensitivity C-reactive protein (The
hs-CRP test can be used to determine
your risk of developing coronary artery
disease, a condition in which the arteries
of your heart are narrowed. Coronary
artery disease can lead to a heart attack)
2. Lp(a)
3. ApoB
4. ABI
5. None

13. Not suitable for the given patient profile
Lp(a): A relative indication for its measurement is family history of premature
ASCVD. An Lp(a) ≥ 50 mg/dL or ≥ 125 nmol/L constitutes a risk-enhancing
factor especially at higher levels of Lp(a).
ApoB analysis: A relative indication for its measurement would be triglyceride
≥200 mg/dL. A level ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and
constitutes a risk-enhancing factor

14. If measured:
1. High-sensitivity C-reactive protein
4. ABI
Are feasible, but are they reliable?

15. Lab Value
hsCRP = 3 mg/dL
The inflammatory biomarker high-sensitivity C-reactive protein (hsCRP) adds
prognostic information on cardiovascular risk
Values <1 indicate lower relative cardiovascular risk
1 to 3 indicate average
≥3 mg/l indicate higher
Paul M Ridker. J Am Coll Cardiol. 2016 Feb, 67 (6) 712-723.

16. Paul M Ridker. J Am Coll Cardiol. 2016 Feb, 67 (6) 712-723.

17. Paul M Ridker. J Am Coll Cardiol. 2016 Feb, 67 (6) 712-723.
Limitations of hsCRP:
 There has been concern that hsCRP measurement is not specific for vascular disease.
 There has been a long-standing controversy regarding whether CRP is itself a causal
factor in atherothrombosis
 Risk-based statin treatment without hsCRP testing could be more cost effective than
hsCRP screening
 Initial interventions for patients with elevated hsCRP should be diet, exercise, and
smoking cessation

18. Paul M Ridker. J Am Coll Cardiol. 2016 Feb, 67 (6) 712-723.
Jupiter Trial
JUPITER trial data demonstrate that statins reduce by 47% the rate of first myocardial
infarction, stroke, or confirmed cardiovascular death when given to patients with low-density
lipoprotein-C levels of <130 mg/dl and hsCRP of >2 mg/l (hazard ratio: 0.53; 95% confidence
interval: 0.40 to 0.69; p < 0.00001)

19. Ankle- Brachial
index in given
patient
• 1.1

20. Screening for PAD and CVD Risk With ABI: USPSTF
Recommendation
• Patients with PAD are at increased risk for CVD events. This likely represents the
systemic nature of atherosclerosis.
• The ACC and AHA have released a joint practice guideline recommending ABI
screening among high-risk patients, including patients 65+ years of age, patients 50+
years of age with other atherosclerotic risk factors or a family history of PAD, and
adults <50 years of age with diabetes and at least one other atherosclerotic risk factor.
• Not a strong predictor in our given patient
Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment With the Ankle-
Brachial Index: US Preventive Services Task Force Recommendation Statement. JAMA 2018;320:177-
183.

21. Clinician-patient risk discussion continues…
Should we prescribe a moderate intensity statin given he is an intermediate
risk patient, of Asian race and presence of mild elevation of hsCRP, LDL-c
and Blood pressure?
Or
Should we use a tie-breaker?

22. Guideline recommendations: ACC 2018
In intermediate-risk or selected borderline-risk adults, if the decision about statin use
remains uncertain, it is reasonable to use a CAC score in the decision to withhold,
postpone or initiate statin therapy. IIa B-NR
In intermediate-risk adults or selected borderline-risk adults in whom a CAC score is
measured for the purpose of making a treatment decision,

23. Performing a Coronary artery calcium (CAC)
scoring
Coronary artery calcium (CAC) is a highly specific feature of coronary atherosclerosis
220 Ag units
A CAC score >100 is associated with a risk of events similar to patients with previous CAD; however, low
CAC scores do not exclude obstructive CAD
Shaw, L.J.; Giambrone, A.E.; Blaha, M.J.; Knapper, J.T.; Berman, D.S.; Bellam, N.; Quyyumi,
A.; Budoff, M.J.; Callister, T.Q.; Min, J.K. Long-Term Prognosis After Coronary Artery
Calcification Testing in Asymptomatic Patients: A Cohort Study. Ann. Intern. Med. 2015, 163,
Youssef, G.; Kalia, N.; Darabian, S.; Budoff, M.J. Coronary Calcium: New
Insights, Recent Data, and Clinical Role. Curr. Cardiol. Rep. 2013, 15, 325

24. CAC can be considered a decision aid, rather
than a screening tool.
 CAC score correlates with the total coronary plaque burden and is an independent
predictor for CV events irrespective of ages
 There is robust evidence that CAC adds additional risk stratification to traditional risk
factors in modern cohorts
 CAC was far superior to hsCRP
, ABI and family history in improving the
discriminative ability of the pooled cohort equation (PCE)
 CAC scoring has emerged as a widely available, consistent, and reproducible means
of assessing risk for major cardiovascular outcomes, especially useful in
asymptomatic people for planning primary prevention interventions such as statins
and aspirin.
Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of coronary artery calcium testing among statin candidates according to American College of Cardiology/American
Heart Association cholesterol management guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2015;66:1657-68.

25. Statin recommended

26. The MASALA STUDY in South Asians
 South Asians have the highest ischemic heart disease mortality rate among the top 6 racial/ethnic
groups
 Ten‐year and lifetime cardiovascular risk assessment algorithms have been adopted into
atherosclerotic cardiovascular disease (ASCVD) prevention guidelines, but these prediction models are
not based on South Asian populations and may underestimate the risk in Indians.
Objective: Mediators of Atherosclerosis in South Asians Living in America (MASALA) study
was conducted to evaluate the association between the ASCVD predicted risk (both
10‐year and lifetime) and measures of subclinical atherosclerosis (coronary artery calcium
and carotid intima media thickness) in US South Asians
Kandula NR, Kanaya AM, Liu K, et al. Association of 10-year and lifetime predicted cardiovascular disease risk with subclinical atherosclerosis in South Asians: findings
from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. J Am Heart Assoc. 2014;3:e001117.

27. Results of the MASALA Study
 South Asian men and women with high 10‐year predicted risk had a
significantly greater CAC burden than those with low 10‐year risk.
 South Asians with high lifetime predicted risk had a significantly
increased odds for CAC higher than 0 (odds ratio: men 1.97; 95% CI,
1.2 to 3.2; women 3.14; 95% CI, 1.5, 6.6).
 Associations between risk strata and CIMT were also present
Kandula NR, Kanaya AM, Liu K, et al. Association of 10-year and lifetime predicted cardiovascular disease risk with subclinical atherosclerosis in South Asians: findings
from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. J Am Heart Assoc. 2014;3:e001117.

28.  Individuals from South Asia have increased ASCVD risk.
 Majority of risk in South Asians is explained by known risk factors, especially
those related to insulin resistance
 Pooled cohort equation(PCE) may underestimate ASCVD risk in South Asians.
 Higher rosuvastatin plasma levels are seen in Japanese, Chinese,
Malay, and Asian Indians as compared with whites.
 FDA recommends a lower starting dose (5 mg of rosuvastatin in Asians
versus 10 mg in whites).
Important points about South-Asian race
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American
College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019;73;3168-3209.

29. Labs
• Total cholesterol: 190 mg/dl
• Triglycerides: 140 mg/dl
• High-density lipoprotein-cholesterol (HDL-C): 42 mg/dl
• Low-density lipoprotein-cholesterol (LDL-C) (calculated): 120 mg/dl
• Hb A1c: 5.1%
• Serum creatinine: 0.8 md/dL
What does the ESC recommends?

30. SCORE Cardiovascular
Risk Chart
10-year risk of fatal CVD
3 % risk of fatal CVD in next 10
year and 9 % for fatal + Non-
Fatal
European Heart Journal (2020) 41, 111188 doi:10.1093/eurheartj/ehz455
SCORE

31. Summary
Clinician-patient risk discussion is important aspect in prescribing statin for primary prevention
especially for patients at intermediate risk
CV risk assessment marks the beginning of Clinician-patient risk discussion
We do not have our own risk scoring system for Indians at present
South-Asians are at higher risk of ASCVD
If decision is inconclusive for statin prescription, CAC scoring is recommended by ACC

32. Thank You