Managing elevated lipids and statins – the good, the bad and the ugly?
General practitioners from about 20 European countries travelled to Barcelona to attend the Annual EPCCS CV Summit for Primary Care. In addition to the lively discussions and interaction between primary care physicians of different corners of Europe, an important objective of this summit is to produce guidance documents specifically aimed at primary care. Sessions were set up in such a way that not only the current evidence on a subject was reviewed, but that specific considerations for primary care were discussed and challenges and gaps in the evidence were identified. These sessions focused on diabetes and vascular care, managing lipids, hypertension and heart failure. Based on the sessions, EPCCS guidance documents will be written.
Prof. Frank Visseren (UMC Utrecht, The Netherlands) referred to the American State of the Union of 2015, in which former President Obama pointed out the opportunities of precision medicine, to emphasize the possibility of applying therapies more efficiently and more effectively, in the right persons, at the right moment. Obama spoke of a desirable system that focuses on prevention and keeping healthy, rather than only curing disease. Both doctors and patients should get more involved to achieve this.
For the clinician, aiming for better personalised medicine poses the challenge of translating the results of large randomized clinical trials to the treatment of an individual. Considering lipid-lowering, it is clear that lipids are among the most important CV risk factors, and the lower the LDL-c level, the lower the CV risk. Lowering LDL-c by 1 mmol/L lowers CV risk by about 21% in persons with a history of vascular disease. This effect has been demonstrated for various lipid-lowering strategies.
The ESC 2016 guidelines on CV prevention in clinical practice distinguish several risk categories, ranging from low- to very high-risk, and different LDL-c treatment goals are recommended for each of the risk categories. Recommendations on pharmacological treatment of hypercholesterolemia start with high-dose statins, which can be combined with other agents if the effect is insufficient.
Based on the Systematic Coronary Risk Evaluation (SCORE) risk charts, all elderly appear to have a very high risk. The risk chart may however not be so accurate at the ends of the age spectrum, in particular at high age, because competing risks are not taken into account. Statins are quite effective in the elderly, but this is mainly driven by individuals with existing vascular disease. A large part of elderly individuals without vascular disease have, however, a low absolute risk of CV events. More research is needed to establish a specific risk score for the elderly, and on the question whether these individuals benefit from statin treatment.
In clinical reality, reaching LDL-c treatment goals is a problem in many patients, as is adherence to statins. Statin intolerance is also a challenging aspect of lipid-lowering therapy, and negative media coverage on statins does not help either. Prof. Visseren referred to an article by Stroes et al. in Eur Heart J (2015; 36:1012-1022), which describes how to manage patients with statin-associated muscle symptoms. Studies have revealed that the incidence of ‘real’ statin-associated muscle symptoms is low. A flow chart in the article illustrates the steps to be taken when a statin-treated patient experiences muscle problems; re-starting a statin after discontinuation due to a statin-related event has been described to be successful in most patients who were rechallenged.
It has been described that following negative news stories on statins, more people discontinue their statin treatment, which impacts the number of CV events. Concerning statins appearing in the media, Visseren noted, however, that both positive news about statins as a supposed cure for Alzheimers’s or cancer, or negative stories stating risks of statins are published. Visseren concludes that clinicians should benefit from the media by ensuring that the actual, undoubted benefits of statin therapy receive most attention.
The last topic Visseren covered was on precision medicine; more studies now focus on the predicted absolute treatment effect, since this is not the same for all patients. The U-Prevent calculator is in development, and will help doctors communicate with an individual patient about how a given therapy may affect their CV risk. This individualized prediction of risk and treatment effects helps translate group-level evidence to individual patients in clinical practice.
We will compose an EPCCS Guidance Document on this topic, based on this session (presentation and discussion) during the EPCCS CV Summit 2018 in Barcelona.