by Tim Gieseke, MD, CMD 

Last November, the long-awaited guidelines for reducing the risk of atherosclerotic events through optimal lipid management were released (see link below).  With the advent of multiple generic statin drugs and with the evidence for their efficacy for reducing events when given in high dose (>50% reduction in LDL) or moderate dose (30-50% LDL reduction), the new guidelines emphasize who should be treated with statins and dividing patients into 4 statin-responsive classes of patients, and then a 5th class of discretionary situations.  With these guidelines, the key issues are identifying atherosclerotic risk and then matching statin intervention with the identified risk.  

Whereas the previous guidelines have estimated numerical LDL and non-HDL targets, the new guidelines recommend their use mainly for assessing compliance with statin therapy or for identifying patients who may only be partial responders to statin therapy.  A new cardiovascular event risk calculator which includes stroke risk was developed (Pooled Cohort Equations CardiovascularRisk Calculator) and is available at http://my.americanheart.org/cvriskcalculator .  An app is available from iTunes or Google Play.

In the LTC setting, many of our patients are over 75 y/o where the evidence for the efficacy of statin therapy is poorly developed.  In addition, our older patients may be more sensitive to the myalgia and other side effects of statins.  This may be more common in patients with Vitamin D deficiency.  Our patients also have increased risk for statin overdose due to the higher incidence of polypharmacy, and stage 4-5 CKD / ESRD.  The guidelines also acknowledge there isn’t evidence of benefit for statin use in CHF NYHA Class 2-4 CHF or in ESRD, which are a sizeable portion of our patients.

The AMDA “Choose Wisely” 5th recommendation counsels against the use of statin drugs in those with limited life expectancy. (See link below.)   Perhaps this may be another situation where pharmacologically, “Less is More” for our patients.

A helpful source of practical information to sort out this complex area of medicine can be found at www.prescribersletter.com.  This commercial monthly newsletter is reasonably priced and has a wealth of reliable and practical pharmaceutical information.  The devil truly is in the details  and they have summarized them in a concise and understandable package.

With you, I’m hoping for more research specific to LTC that improves our management of cardiovascular risk.

Links mentioned in this article:

ACC/AHA Guidelines for treatment of Cholesterol November 2013 Circulation

Click here for the AMDAChoosing Wisely 5 Things Physicians and Patients Should Question

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