Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Jeremy Chow
Cardiologist, Electrophysiologist
Asian Heart & Vascular Centre
www.ahvc.com.sg
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Managing the Myths in Lipid Management
1. Managing the Myths in Lipid
Management
PRESENTED BY:
DR JEREMY CHO
W
Consultant Cardiologist & Electrophysiologist
Director of Electrophysiology Service
MBBS, MRCP (UK), MRCP (London), M Med (Int Med)
FAMS, FESC, FHRS
Certified Cardiac Device Specialist
Website：www.ahvc.com.sg
Email: drchow.jeremy@asianheart.com.sg
4. Overview
How common is Hyperlipidaemia?
What are the main challenges with statins usage
in Asians?
Statin Myths and your patients
New Cholesterol targets in High Risk Patients
My Management strategies with case examples
9. 50% of patients in Asia are not reaching their
cholesterol targets
Cholesterol goal attainment (percent of patients attaining goal) by risk status in the
overall population and by country/region
➢ REALITY-Asia Study: To evaluate prescribing patterns and cholesterol goal
attainment in the ‘real world’ setting (N=2622)
17. Myth # 1
My total cholesterol is borderline and
don’t need medication
.
Fact: Total Cholesterol is part of a patient’s
risk estimate for coronary artery disease.
Just being within the range may not be good
enough. The important target is the LDL-C
(Bad) and not total cholesterol.
18. What would you do?
50 yo Male, Lawyer
CVRF: Ex-Smoker, Positive family history of IHD
Asymptomatic and did a cholesterol profile
Lipid Profile: TG 1.32 mmol/L, LDL 4.78 mmol/L, HDL 1.38 mmol/L
Would you?
A. Start Medication
B. Lifestyle modification
C. Do a CT Calcium score
20. CT Calcium Score - What it means
In multiple studies the following definitions have been used to
correlate the CAC score and the coronary plaque burden:
0 NORMAL
1 – 99
Mild Disease
100 – 399 Moderate Disease
> 400 Severe Disease
22. Figure 1 Unadjusted Kaplan–Meier cumulative incidence curves for
hard atherosclerotic cardiovascular disease events by ...
23. Figure 2 Unadjusted Kaplan–Meier cumulative incidence curves for
hard atherosclerotic cardiovascular disease events by ...
24. What would you do?
Would you?
A. Start Medication
B. Lifestyle modification
C. Do a CT Calcium score
His CT calcium score is 0
Will anyone start him on statin?
I didn’t but I gave him a supplement (Lipascor) and his LDL
improved to 2.77 mmol/L after 1 month.
25. What did I do?
Trial of supplements
Lipascor 600mg BD
Not all patients need to
start on Statins for primary
prevention.
26.
27. Myth # 2
I can avoid taking medication by
controlling my dietary lifestyle
.
Fact: Cholesterol is both manufactured by
the liver and absorbed by the intestine.
Intensive dietary restriction will only reduce
LDL-C by 35%.
28.
29. Myth # 3
Cholesterol medication has a lot of side
effects and can cause cancer and kidney
failure
.
Fact: All medication has side effects. The
most common reported side effects of
statins is Statin Associated Myopathy
(SAM).
31. David H F et al. Circulation 2015; 131: e389-e391
32. David H F et al. Circulation 2015; 131: e389-e391
33. What is Statin Intolerance?
When a patient is unable to continue to use a
statin, either because of the development of a side
effect or because of evidence on a blood test that
certain markers of liver function or muscle function
(creatine kinase) are sufficiently abnormal to cause
concern.
The intolerance can be either partial (ie, only some
statins at some doses) or complete (ie, all statins at
any dose).
David H F et al. Circulation 2015; 131: e389-e391
34. SAM prevalence
RCT (but lead-in period: withdrawal if SAM)
Myalgia <3%
Myositis <0.1%
Myopathy < 0.01%
Rhabdo very rare (placebo = statin)
Clinical practice: COMMON
PRIMO trial of French GPs (Bruckert et al)
High dose statins
up to 17% SAM
36. Myth # 6
I can stop taking my cholesterol
medication since it is under good
control
.
Fact: Atherosclerosis is a process that
cannot be stopped. Cholesterol treatment
can only reduce the rate of progression and
not reverse the process.
40. Case 1
SC, 21 year old Female university student
Father died of AMI at 40 years old
Family screening and found to have severe
hypercholesterolaemia (LDL=7.09 mmol/l)
She has probable Familial
Hypercholesterolaemia by Dutch Lipid
Clinic Network CRITERIA.
So what should we do?
41.
42. Case 1
Will you proceed with the plan to start
medical treatment or advocate lifestyle
modification?
A. Medical treatment
B. Life style modification first
43. Case 1
If you proceed, what drug and what dosage
level will you use?
A. High potency statin like Crestor 40mg ON
B. Ezetimibe combined with statin
C. PCSK9 inhibitor
44. Case 1
She was previously on generic Ezetimibe 10mg ON and
Rosuvastatin 20mg ON from KKWCH.
I started her on Atozet 10/40 ON. Single Pill Combination
45. Case 2
LVP, 39yo Male
Had CTCA done which showed SVD
PCI with BRS done to LAD
Fasting LDL was 4.1 mmol/L
I started Lipitor 20mg ON but had to reduced to
Vytorin 10/10 ON as he was still having side effects.
He has recurrent statin induced transaminitis with
non specific giddiness.
What other options do we have?
47. Lipascor® – a natural alternative for healthy blood
lipid levels
Lipascor ® is a natural Red Yeast Rice product for use in the
management of healthy blood lipid (cholesterol) levels.
Active ingredients
Each Lipascor® capsule contains the proprietary ingredient
Xuezhikang® 600mg, including metabolic by-products of fermentation
consisting of Monacolins (naturally occurring HMG-CoA reductase
inhibitors 0.8%), natural pigment and unsaturated fatty acids.
Directions For Use
Take one capsule twice daily after meals (morning and evening),
or as directed by the physician
48. 2. Lin CC, et al. Efficacy and safety of Monascuspurpureus Went rice in subjects with Hyperlipidemia. European Journal of Endocrinology (2005)153:679-686
3. Mak KH, et al. A Randomized, Parallel, Double-Blind Study Comparing the Lipid Lowering Effect of Xuezhikang (Lipascor) with Simvastatin n Asymptomatic Patients with
Hyperlipidaemia. ASEAN Heart Journal Vol. 13, No.1, 15-20; January – June 2005
Proven Lipid End Point
Effect on Lipid Profile of Asymptomatic Hyperlipidaemic Patients (n=30)
(National Heart Centre Singapore)
In patients with hyperlipidaemia studied in Singapore, Lipascor improved their lipid profile after 12 weeks
of treatment Xuezhikang® 3
49. 3. Mak KH, et al. A Randomized, Parallel, Double-Blind Study Comparing the Lipid Lowering Effect of Xuezhikang (Lipascor) with Simvastatin n Asymptomatic Patients with
Hyperlipidaemia.
ASEAN Heart Journal Vol. 13, No.1, 15-20; January – June 2005. 5. Li JJ, et al. Impact of Long-term Xuezhikang Therapy on Cardiovascular Events in High-risk Patients with
Non-specific,
Pre-existing Abnormal Liver Tests: A Post-hoc Analysis from Chinese Coronary Secondary Prevention Study (CCSPS). International Journal of Cardiology Vol. 154, Issue 3,
362-365, February 9, 2012.
Proven Safety
No Change in Muscle and Liver Functions at
End of Treatment with Lipascor® (Xuezhikang®)
No Difference in Liver Function between Treatment
Group and Placebo in 4.5-year Follow-Up
No change in muscle and liver functions
between baseline and at 12-weeks (n=30)
ASEAN Heart Journal3
XZK therapy in patients with pre-existing abnormal
LFTs had same outcomes as patients with normal
LFTs, suggesting safety of XZK as long-term
treatment for patients with abnormal LFTs
International Journal of Cardiology5
50. 3. Mak KH, et al. A Randomized, Parallel, Double-Blind Study Comparing the Lipid Lowering Effect of Xuezhikang (Lipascor) with Simvastatin n
Asymptomatic Patients with Hyperlipidaemia.
ASEAN Heart Journal Vol. 13, No.1, 15-20; January – June 2005. 5. Li JJ, et al. Impact of Long-term Xuezhikang Therapy on Cardiovascular Events in
High-risk Patients with Non-specific,
Pre-existing Abnormal Liver Tests: A Post-hoc Analysis from Chinese Coronary Secondary Prevention Study (CCSPS). International Journal of
Cardiology Vol. 154, Issue 3, 362-365, February 9, 2012.
How long before results of Lipascor can be seen?
• Results can be seen with Lipascor in 8 weeks with BID dosing
• For lesser dosage, results and time taken varies from 8 weeks to a few months
FAQ
What are the potential side effects of taking Lipascor?
• Side effects reported during clinical trials were few and mild, most common one being
gastrointestinal upsets which can be alleviated by taking Lipascor after meals.
• Some feedback of ‘heatiness’ from people taking Lipascor which can be relieved by
increasing intake of water
• There are also cases of headache or a feeling of an increase in heartbeat which can be
alleviated by slowly increasing the dosage from 1 capsule to 2.
52. Case 3
TAL, 42 yo Female.
CVRF: Mixed Hyperlipidaemia
Non alcoholic, non smoker
She was admitted for first presentation of
pancreatitis due to high TG in Sep 2019
Referred to me for cardiac assessment
CAC 0
53. Case 3
During her first admission for pancreatitis
Her lipid profile showed:
TC 12.9, TG 20.76, HDL 0.7, Chol/HDL 18.4
What is her LDL???
What is the non-HDL cholesterol level?
12.9-0.70=12.2
56. In April 2020, she was readmitted for recurrent pancreatiti
s
Her serum lipase was 247
2
What will you start her on
?
1.Fibrate
s
2.Fibrates + Ezetro
l
3.Fibrates + Statin +Ezetrol
63. Case 4
ET, 42 yo Male
Only risk factor is family history of IHD and
young stroke.
Routine health screening and found to
have hyperlipidamemia (LDL=5.26 mmol/l)
CTCA showed no CAD and CAC 0.
Possible Hypercholesterolaemia by Dutch
Lipid Clinic Network CRITERIA.
64. Case 4
Tried lifestyle modification plus supplements
LDL dropped to 4.83 mmol/L
For primary prevention, I seldom start statin
in CAC 0.
Patient keen to have a trial of statin
Started Vytorin 10/10 ON
After 1 week, complained of SAM.
CK 506
65. Case 4
For such patients, is there any data for using
PCSK9 inhibitor?
69. Take Home Message.
Lipid treatment needs to be individualised
CAC is a useful tool to aid in ASCVD risk
profiling.
High risks patients will need lower LDL
targets.
PCSK9i can play a role in non FH patients
as statin intolerance in high risk CAD
patients are more common.
70. Thank You and
Stay Safe
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71. Case 5
TH, 38 yo, Male
CVRF: Hyperlipidaemia (LDL 4.66 mmol/L)
Hx of Childhood AML s/p Chemo and RT
Positive family hx of hyperlipidaemia ? FH
First presented with lacunae infarct in 2018, Unable
to tolerate statins and defaulted medication.
Had another episode of posterior circulation stroke
in 2019.
CAD s/p PCI with BRS (Magmaris) in 2019
