Statins: Can there be too much of a good thing?

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1 Statins: Can there be too much of a good thing?

2 Spoiler alert No Oh Contraire Haaaaiiiiiiile No! Frequently under prescribing statin therapy!

3 Typical Case 68 YO Smoker ACS Multiple prior PCI s Multiple LE Interventions/Bypass Extensive carotid atherosclerosis Bilateral renal artery stenosis Pravachol 40mg

4 2013 American College of Cardiology American Heart Association Guidelines for Use of Statin Therapy in Patients at Increased Cardiovascular Risk. Keaney JF Jr et al. N Engl J Med 2014;370:

5 High Intensity Statin Therapy 40 or 80 mg Atorvastatin 20 or 40mg Rosuvastatin Not Pravachol Simvastatin Lovastatin

6 High Intensity Statin Therapy Atorvastatin 80mg

7 From: Underutilization of High-Intensity Statin Therapy After Hospitalization for Coronary Heart Disease J Am Coll Cardiol. 2015;65(3): doi: /j.jacc Figure Legend: Change in Statin Intensity Pre- and Post-Hospitalization for Acute Coronary Syndrome Despite experiencing an acute coronary syndrome (ACS), the majority of Medicare beneficiaries do not fill high-intensity statin prescriptions after hospitalization for their event. LDL-C = low-density lipoprotein cholesterol; MI = myocardial infarction. Date of download: 2/22/2015 Copyright The American College of Cardiology. All rights reserved.

8 Clinical Vascular Disease PCI CABG Carotid Endarterectomy Peripheral intervention or Bypass MI Atorvastatin 80mg CVA Abdominal Aortic Aneurysm CT calcification of coronaries

9 Intensive versus Moderate Lipid Lowering with Statins after Acute Coronary Syndromes Christopher P. Cannon, M.D., Eugene Braunwald, M.D., Carolyn H. McCabe, B.S., Daniel J. Rader, M.D., Jean L. Rouleau, M.D., Rene Belder, M.D., Steven V. Joyal, M.D., Karen A. Hill, B.A., Marc A. Pfeffer, M.D., Ph.D., Allan M. Skene, Ph.D. and the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators N Engl J Med Volume 350;15: April 8, 2004

10 Base-Line Characteristics of the Patients Cannon, C. et al. N Engl J Med 2004;350:

11 Median Low-Density Lipoprotein (LDL) Cholesterol Levels during the Study Cannon, C. et al. N Engl J Med 2004;350:

12 Kaplan-Meier Estimates of the Incidence of the Primary End Point of Death from Any Cause or a Major Cardiovascular Event Cannon, C. et al. N Engl J Med 2004;350:

13 Hazard Ratio for the the Primary End Point of Death from Any Cause or a Major Cardiovascular Event at 30, 90, and 180 Days and at the End of Follow-up in the High-Dose Atorvastatin Group, as Compared with the Standard-Dose Pravastatin Group Cannon, C. et al. N Engl J Med 2004;350:

14 ARMYDA-ACS Randomized Trial J Am Coll Cardiol. 2007;49(12): Date of download: 2/7/2015

15 ARMYDA-ACS Randomized Trial J Am Coll Cardiol. 2007;49(12): ARMYDA-ACS Survival Curves Actuarial curves of 30-day major adverse cardiac event (MACE)-free survival in the 2 arms. PCI = percutaneous coronary intervention. Date of download: 2/7/2015 Copyright The American College of Cardiology. All rights reserved.

16 ARMYDA-ACS Randomized Trial J Am Coll Cardiol. 2007;49(12): Date of download: 2/7/2015 Copyright The American College of Cardiology. All rights reserved.

17 45 YO with chest pain: Cardiac Catheterization Cardiac catheterization report Impression Mild non-obstructive CAD Normal LV function Recommendations Investigate non-cardiac sources of chest pain

18 Non-obstructive CAD

19 3/7/2015 2:50 PM Interventional Cardiology University of Florida

20 3/7/2015 2:50 PM A B A B C C

21 REVERSAL 3/7/2015 2:50 PM Nissen et al JAMA March 2004

22 SATURN

23 SATURN

24 65 YO with carotid bruit: Carotid Duplex Carotid Duplex Report <50% Stenosis of the Internal Carotid Arteries Mild to Moderate atherosclerosis of Left and Right Internal Carotid Arteries

25 Moderate Atherosclerosis?

26 75 YO with leg discomfort: Vascular studies Vascular Report Normal ABI s 1.0 Moderate atherosclerosis of Left and Right Superficial Femoral Arteries

27 75 YO with leg discomfort: Vascular studies

28 2013 American College of Cardiology American Heart Association Guidelines for Use of Statin Therapy in Patients at Increased Cardiovascular Risk. Keaney JF Jr et al. N Engl J Med 2014;370:

29 Conclusion Recognize Clinical Atherosclerosis Initiate intensive statin therapy Prevent cardiovascular events Induce regression Simplify your practice!

30 ARMYDA-ACS Randomized Trial J Am Coll Cardiol. 2007;49(12): Date of download: 2/7/2015 Copyright The American College of Cardiology. All rights reserved.

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