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Lipid Lollapalooza at AHA 2018

The information presented on the first day of the American Heart Association (AHA) Scientific Sessions 2018 has proven we are…

The information presented on the first day of the American Heart Association (AHA) Scientific Sessions 2018 has proven we are finally getting somewhere with regard to lipid management. The mighty coronary artery calcium score, so long a bridesmaid but rarely a bride, got some love in the new American College of Cardiology / AHA cholesterol management guidelines, albeit as a recommended “tie breaker” test rather than a screening tool. [1] The power of the calcium score was brought to the forefront for patients who do not smoke and do not have diabetes or a history of coronary events. A 90-year-old patient with supraventricular tachycardia with a calcium score of 0, for example, can finally stop his statin and win his ongoing argument with his prescriber.

Recognition for Women

In these new guidelines, women were validated as worthy targets of lipid management, with recommendations for screening of pregnancy-associated conditions, including preeclampsia, gestational hypertension and diabetes, low birth weight, and premature delivery. [1


Firm recommendations were made to stop statins 1 to 2 months prior to planned pregnancy. Det var bestemt retning at diskutere behovet for effektiv fødselsstyring i statin-behandlede kvinder af barnslebende alder og til stop statiner på tidspunktet for en uplanlagt graviditet er kjent.

In contrast to most cardiovascular trials, women made up a whopping 74% of the Japanese EWTOPIA trial looking at ezetimibe monotherapy. [2] This study included an elderly cohort (≥75 years) with an average low-density lipoprotein cholesterol (LDL-C) or 160 mg / dL and at least one of seven conditions: diabetes, hypertension, low high density lipoprotein cholesterol (HDL-C), elevated triglycerides, smoking, prior cerebrovascular accident, and peripheral artery disease (but no history of coronary artery disease). It found that ezetimibe lowered both LDL-C and non-HDL-C, resulting in a reduction of atherosclerotic cardiovascular events. This lop-sided number of women is probably due to longer life expectancy in women, but it was interesting to see the outcomes.

No Fasting Required

We can forget the need to order a “fasting” status for lipid levels. Det er ikke meningen at vi ikke trenger å retest personer med meget forhøjede triglyceridniveauer, men som vice-chair of the cholesterol-guideline committee, Neil Stone, MD, udtalte i pressekonferencen, at vi kan “undgå disse lange linjer på lab at 7:30 am “and send our patients down the hall to the lab no matter their fasting status. [19659000] Undetected Diabetes

Although the presence of diabetes is a key decision point for the addition of statin therapy, we are not doing a very good job of diagnosing the condition. Ifølge de Centers for Disease Control and Prevention 1.5 million new cases of diabetes were diagnosed in 2015; bijna 1 op 4 volwassenen leven met diabetes, waaronder 7,2 miljoen Amerikanen die het niet weten. [3] Ik ben vaak de eerste die het voor een patiënt dat een eerder gedocumenteerde maar gemiste of genegeerde verhoogde bloedglucosegehalte of abnormal hemoglobin A1c shows they have diabetes. Many more have never been screened.

Though a majority of AHA attendees polled just before the DECLARE trial presentation expressed confidence in treating their high-risk diabetic patients with dapagliflozin (a sodium glucose cotransporter-2 inhibitor), we can not treat a condition if we don [4] Det er tid for kardiologer at dele ejerskab med primærplejeleverandører i diagnostik og behandling af diabetes.

Er nogle anbefalinger praktiske?

Recommendations for conversations regarding lifestyle management were prominent in the new cholesterol guidelines, but is that a practical goal for the hamster wheel of today’s office medicine? Physicians barely have time to do a physical exam, review meds and office labs, and hear new or ongoing concerns. Med den RVU-politien, som er fast knyttet til ryggen fra næsten alle leverandører, som virkelig har tid til en passende samtale om livsstilsadministrasjon? It should be a number 1 priority, but instead it’s rarely an afterthought. After today, reimbursement patterns should shift towards better equalization for the time it takes for that conversation compared to the time it takes to obtain an angiogram, for example.

Do the Guidelines Need an Instant Update?

Fish oils are not mentioned in the cholesterol guidelines; maybe they should be. The REDUCE-IT trial demonstrated that 2 g twice daily of icosapent ethyl-a highly purified fish oil-reduced cardiovascular events by 25% in patients with elevated triglycerides. [5] The similar STRENGTH trial testing 4 g of a mixed fish oil is due to be completed late 2019. If it is also positive, proprotein convertase subtilisin / kexin type 9 inhibition may be pushed farther down the ladder of recommendations.

I’d like to thank the guidelines writers and other trialists for their diligent work. De frukter af deres arbejde vil holde os langt ud over vores livstid, men kun hvis vi anvender dem i vores daglige praksis.

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