David Y. Gaitonde, MD, FACP Endocrinology DDEAMC, Fort Gordon

David Y. Gaitonde, MD, FACP Endocrinology DDEAMC, Fort Gordon

I have no actual or potential conflicts of interest in relation to this program or presentation.

Raphael School of Athens, 1509-1511

Apply guidelines in a systematic manner to enhance clinical judgment and improve patient-provider collaboration Understand the role and value of additional risk factors in determining who may benefit from statin therapy Manage patients at high risk for cardiovascular events who are on statins at the maximum tolerated dose

Genetics Diet Insulin Resistance Metabolic Syndrome Glucose intolerance Dyslipidemia Hypertension Waist Cigarette smoking, sedentary lifestyle, unhealthy eating Obesity Visceral adiposity Cardiometabolic Risk Dyslipidemia LDL TGs HDL Apo-B Age, family history, ethnicity, gender Inflammation hscrp High blood pressure Adapted from Brunzell JD Diabetes Care 2008;31(4) 811-822

Seeks recommendations for her elevated cholesterol Total cholesterol: 238mg/dL LDL-C: 168mg/dL TG: 139mg/dL HDL-C: 42mg/dL Concerned because brother died at age 51 from CAD Patient has no history of: Hypertension Type 2 diabetes mellitus Cigarette smoking Carotid artery disease Aortic or Peripheral artery disease Normotensive & TSH, renal panel normal range

60 Year Old Woman with a first degree relative with early CHD Total: 238mg/dL TG: 139mg/dL LDL-C: 168mg/dL HDL-C: 42mg/dL 7% A. Obtain an Apolipoprotein B-100 level 41% B. Lifestyle modifications alone 5% C. Obtain a hscrp and start statin therapy if > 2 mg/l 33% D. Initiate statin based therapy now because she is high risk 15% E. Follow-up in one year and repeat the fasting lipid panel

Invites patient-provider collaboration Clinical judgment takes into account both sides Patient circumstances, preferences, and concerns High Value Care: evidence base, outcomes, quality, cost Expert panel guidelines inform clinical judgment 2013 American Heart Association/American College of Cardiology (AHA/ACC) 2015 National Lipid Association (NLA)

Individuals with clinical ASCVD Age>21 with primary elevations of LDL-C> 190mg/dL Type 1 or 2 diabetes Age 40-75 years LDL-C 70-189mg/dL Age 40-75 years No ASCVD No Diabetes 10-year ASCVD 7.5% 10-year ASCVD<5% Circulation November 12, 2013 DM, 1 or 2, with 0-1 RF for ASCVD LDL>190mg/dL CKD 3 or 4 0-1 RF Low risk >2 RF High or very-high risk conditions? High risk Consider additional factors to inform tx decision making Count major ASCVD RF and classify 1-2 RF Moderate DM, 1 or 2, with 2+ RF for ASCVD Clinical ASCVD 1. Age M>45 F>55 2. Fhx early CHD M<55 F<65 3. Current smoking 4. HTN 5. Low HDL-C M<40mg/dL F<50mg/dL Quantitative Risk Scoring & risk refinement Adapted from Jacobson TA et al Journal of Clinical Lipidology 2015, 1-41

Non-HDL-C mg/dl LDL-C mg/dl Apo-B mg/dl Low <130 >190 <100 >160 <90 Moderate <130 >160 <100 >130 <90 High <130 >130 <100 >100 <90 Very high <100 >100 <70 >70 <80

Individuals with clinical ASCVD Age>21 with primary elevations of LDL-C> 190mg/dL Type 1 or 2 diabetes Age 40-75 years LDL-C 70-189mg/dL Age 40-75 years No ASCVD No Diabetes 10-year ASCVD 7.5% 10-year ASCVD<5% Circulation November 12, 2013 DM, 1 or 2, with 0-1 RF for ASCVD LDL>190mg/dL CKD 3 or 4 0-1 RF Low risk >2 RF High or very-high risk conditions? High risk Consider additional factors to inform tx decision making Count major ASCVD RF and classify 1-2 RF Moderate DM, 1 or 2, with 2+ RF for ASCVD Clinical ASCVD 1. Age M>45 F>55 2. Fhx early CHD M<55 F<65 3. Current smoking 4. HTN 5. Low HDL-C M<40mg/dL F<50mg/dL Quantitative Risk Scoring & risk refinement Adapted from Jacobson TA et al Journal of Clinical Lipidology 2015, 1-41

http://my.americanheart.org/professional/statementsguidelines/preventionguidelines/prevention- Guidelines_UCM_457698_SubHomePage.jsp or http://my.americanheart.org/cvriskcalculator

Statin intensity replaces treat-to-goal paradigm Data from fixed-dose statin RCTs drive guidelines Statin benefit groups replace risk categories New Pooled Cohort Equation: estimation of 10-year risk Most controversial component Considered to overestimate risk by 75-150% Risk threshold for primary prevention=7.5% (versus 10-15%) Martin and Blumenthal Annals Internal Medicine 2014 160(5):356-357

FRS-CVD (2008) ACC/AHA (2013) Pooled from 5 large cohorts designed to predict a ten year risk of CV events More racially diverse But, cohorts are from previous decades Multicenter Ethnic Study Atherosclerosis (MESA) Multiethnic, contemporary prospective cohort followed for 10 years 4227 men and women, aged 5-74 years CV and DM disease free at study Observed events: 3% men; 5.1% women (versus 7.5% and 10% predicted) ATPIII-FRS-CHD(2001) white male dominated geographically limited cohort prior generation Coronary events only Reynolds Risk Score (2007) includes parental history of CHD and CRP DeFilippis AP Ann Intern Med 2015;162:266-275

140 Percentage Discordance 120 100 Net discordance 80 60 40 20 0-20 Ridker PM & Cook NR Ann Intern Med 2015;162:313-314

Recalibrate algorithm to reflect geographic and contemporary population Accept that more patients will be treated with drug class shown to reduce CV disease even in lower risk populations Calculate multiple risk scores DeFilippis AP Ann Intern Med 2015;162:266-275

http://statindecisionaid.mayoclinic.org/

Total cholesterol: 238mg/dL HDL-C: 42mg/dL Triglycerides: 139mg/dL LDL-C: 168mg/dL A. Obtain an Apolipoprotein B-100 level B. Lifestyle modification C. Obtain a hscrp and start statin therapy if > 2 mg/l D. Initiate statin based therapy now because she is high risk E. Follow-up in one year and repeat the fasting lipid panel

Adhering to a heart healthy diet Diet Obesity Genetics Visceral adiposity Insulin Resistance Metabolic Syndrome Glucose intolerance Dyslipidemia Hypertension Waist Cigarette smoking, sedentary lifestyle, unhealthy eating Maintenance of healthy weight Cardiometabolic Risk Avoidance of tobacco products Regular exercise habits High blood pressure Dyslipidemia LDL TGs HDL Apo-B Age, family history, ethnicity, gender Inflammation hscrp Adapted from Brunzell JD Diabetes Care 2008;31(4) 811-822

Total cholesterol: 238mg/dL HDL-C: 42mg/dL Triglycerides: 139mg/dL LDL-C: 168mg/dL A. Obtain an Apolipoprotein B-100 level B. Lifestyle modification C. Obtain a hscrp and start statin therapy if > 2 mg/l D. Initiate statin based therapy now because she is high risk E. Follow-up in one year and repeat the fasting lipid panel

A. It should be obtained in the fasting state B. It is less expensive than measuring LDL particle size C. All atherogenic lipoproteins contain Apo B- 100 D. It is a widely available and standardized test E. It has greater value in the management of secondary CHD prevention versus primary prevention 7% 16% 11% 56% 11%

Fewer LDL Particles More LDL Particles LDL-C 130mg/dL Apolipoprotein B Less CV Risk More CV Risk Mayo Clin Proc. 2010 May; 85(5): 440 445

Non-HDL cholesterol Cholesterol content of all atherogenic lipoproteins LDL, lipoprotein(a) or Lp(a), VLDL, IDL Apolipoprotein B-100 (apob) Total number of circulating atherogenic particles Nuclear Magnetic Resonance: LDL particle size Lp(a) Cromwell WC et al. J Clin Lipidol 2007 December 1;1(6) 583-592

Density (g/ml) 1.2 1.1 1.06 1.02 1.006 0.95 VLDL chylomicrons Lp(a) Chylomicron remnants Triglycerides Apolipoprotein B 5 10 20 40 60 80 1000 Diameter (nm) Mayo Clin Proc. 2010 May; 85(5): 440 445

LDL-C; VLDL; IDL; Lp(a): Each particle contains one Apo B-100 molecule Non-fasting; standardized; widely available; inexpensive ACC/AHA: potential future area for statin RCTs NLA: good predictor of ASCVD; optional, 2 0 target Use: marker of residual risk in CHD patients on statins Cromwell WC et al. J Clin Lipidol 2007 December 1;1(6) 583-592

Total cholesterol: 238mg/dL HDL-C: 42mg/dL Triglycerides: 139mg/dL LDL-C: 168mg/dL A. Obtain an Apolipoprotein B-100 level B. Lifestyle modifcations C. Obtain a hscrp and start statin therapy if > 2 mg/l D. Initiate statin based therapy now because she is high risk E. Follow-up in one year and repeat the fasting lipid panel

No ASCVD No diabetes LDL 70-189 mg/dl Age 40-75 Additional factors may be considered to inform treatment decision making Pooled Cohort Equation: ten year risk ASCVD<5% Circulation November 12, 2013

Primary LDL-C > 160mg/dL Family history of premature CHD (M<55, F<65) hscrp 2.0 mg/l Ankle-brachial index <0.9 Coronary artery calcium > 300 Agatston units Increased lifetime risk of ASCVD

STEP 2 STEP 1 STEP 3 Quantitative Risk Scoring & risk refinement Count major ASCVD RF and classify 1-2 RF Moderate risk High or very-high risk conditions? 0-1 RF Low risk >2 RF High risk 1.ATPIII FRS CHD >10% 2. Pooled Cohort >15% 3. FRS CVD >45% DM, 1 or 2, with 0-1 RF for ASCVD LDL>190mg/dL CKD 3 or 4 DM, 1 or 2, with 2+ RF for ASCVD Clinical ASCVD Major RF for ASCVD 1.Age M<45 F<55 2. Fhx early CHD M<55 F<65 3. Current smoking 4. HTN 5. Low HDL-C M<40mg/dL F<50mg/dL Other factors 1.Severe disturbance in a major ASCVD RF 2.Indicators of subclinical disease such as CAC>300 Agatston units 3.hsCRP>2mg/L 4.LDL-C>160 or non-hdl-c>190 5.Lp(a)>50mg/dL 6.Urine albumin:creatinine>30mg/g Adapted from Jacobson TA et al Journal of Clinical Lipidology 2015, 1-41

Randomized, placebo-controlled trial 17,802 healthy men (age>50) and women (age>60) LDL<130mg/dL and highly-sensitive CRP > 2.0 mg/l One-third: 0 ATP III RFs; two-thirds: 1+ ATP III RFs Rosuvastatin 20mg or placebo Combined primary end-point: Myocardial infarction Stroke Arterial revascularization Hospitalization for Unstable Angina Death from cardiovascular causes Ridker, Paul M NEJM 2008 359(12):2195-2207

Median pre-trial LDL-C 108 mg/dl At 12 months: LDL-C 50% lower compared to placebo: 55mg/dL (44-70) hscrp 37% lower compared to placebo Trial terminated early at 1.9 years because of benefit 142 first CV events versus 251 Ridker, Paul M NEJM 2008 359(12):2195-2207

NLA: high risk with goal LDL-C <100mg/dL Not in statin benefit treatment group and low 10 year risk LDL>160mg/dL 1 st degree relative with premature CHD Elevated hscrp ACC/AHA or NLA guidelines serve as valid framework to build collaboration with patient What is the potential for ASCVD risk reduction? What are the adverse effects? What drug-drug interactions may develop? What is the patient s preference? Can the patient afford the treatment?

Raphael School of Athens, 1509-1511

Significant past medical history: Type 2 diabetes mellitus (duration unknown) CHD (5 vessel CABG in 2011) Currently taking atorvastatin 20mg daily Previous trial of atorvastatin 40mg: felt weak and achy Refuses rosuvastatin: too new and confangled to my liking. Total cholesterol: 139mg/dL HDL-C: 28mg/dL Triglycerides: 123mg/dL LDL-C: 86mg/dL

A. Start alirocumab (Praluent) 75mg every two weeks B. Add ezetimibe 10mg daily C. Add niacin 500mg and increase to 2000mg as tolerated D. Add fenofibrate E. Change atorvastatin to ezetimibe 10mgsimvastatin 40mg 18% 44% 16% 5% 16%

Population Base LDL/HDL ACCORD LLT 2010 5518 DM2 36% prior CV event simvastatin Treatment fenofibrate 160 v placebo Primary Outcome AIM-HIGH 2011 3414 CV disease + LDL <70 + metab.syndrome Simva+/-ezetim HPS2-THRIVE 2013 25,673 occl. arterial disease 32% DM2 Simva+/-ezetimibe IMPROVE- IT 2015 18,144 ACS 100/38 mg/dl 71/35 mg/dl 63/44 mg/dl 94/42 mg/dl 1 yr: 70 v 54mg/dL Nonfatal MI Nonfatal CVA Death from CV causes niacin 1.5g v placebo Death from CHD Nonfatal MI Ischemic CVA Cor/Cer Revasc. niacin 2g + Laropiprant v placebo Death from CHD Nonfatal MI Stroke Revascularization Duration 4.7 years 3 years, early 5 years 6 years Results No benefit Men, TGs>204 + HDL<34 No efficacy No benefit bleeding Myopathy:Chinese ezetimibe/simvastatin v. Simvastatin CV death, MI USA hospitaliz. Cor. Revasc.1mo. Stroke 6.4% composite 50 pts X7y:prevent 1 event All-cause, CV mortal not Diabetics >benefit

Proprotein Convertase Subtilisin Kexin type 9 Degrades LDL receptors LDL levels Monoclonal antibodies that inhibit PCSK9 Evolocumab (FDA approved August 2015) Alirocumab (Praluent) Reduce LDL receptor degradation

Alirocumab (Praluent): FDA approved July 2015 Fully human monoclonal antibody that binds PCSK9 150mg subcutaneously every two weeks for 78 weeks 99% of study participants on statin; 47% on high intensity Mean LDL-C lowering of 62% compared to placebo Non-HDL-C, APO-B significantly reduced Effect on CV morbidity and mortality not yet assessed Indication: adjunct to diet & maximally tolerated statin therapy Heterozygous familial hypercholesterolemia Clinical atherosclerotic CV disease Robinson JG et al N Engl J Med 2015;372:1489-99

Injection site reactions Myalgias (5.4% versus 2.9%) Neurocognitive disorders (1.2% versus 0.5%) Primarily related to memory Ophthalmologic disorders (2.9% versus 1.9%) Retinal, corneal, and optic nerve No increase: creatinine kinase; LAEs; blood glucose Robinson JG et al N Engl J Med 2015;372:1489-99

Dialogue focused on holistic approach to risk reduction: Patient collaborates on treatment decisions AHA/ACC: Four statin benefit groups Use three risk calculators: Mayo provides visual aid NLA: Low, moderate, high, very-high risk with numerical targets Further refine risk with selective use of additional factors hscrp: cost, incorporated into Reynolds, JUPITER JUPITER, IMPROVE-IT: LDL-C 50mg/dL range with benefit Are new LDL targets forthcoming in future guidelines?

2 0 prevention in high intensity statin-intolerant patients combination of ezetimibe plus simvastatin was better than simvastatin PCSK9 inhibitors: recently approved but no outcomes yet Improved adherence? Injection every two weeks versus daily oral pill Triple therapy for very high risk patients is a future direction Odyssey Outcomes: RCT alirocumab versus placebo Evaluate efficacy of alirocumab on CV events in patients who recently experienced an ACS Start date: October 2012 Anticipated study end: December 2017 Expected enrollment: 18,000

Questions Thank You

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