Statins for Primary Prevention In Indians

Dr. Akshay MehtaNanavati Superspeciality Hospital

Asian Heart InstituteHoly Family Hospital

If CVD in Indians is a challenge !• Two to four –fold more prone to MI and CV

death compared to Caucasians• Increasing incidence…• < 40 years of age• Metabolic syndrome and• Atherogenic dyslipidemia (small dense LDL,

high triglyceride, and low HDL)• Lipoprotein (a) a potent atherogenic

lipoprotein

Statins are an opportunity !

• Cheap & freely available statins-many generics• Effective at low doses in Indians-higher blood levels• At young age, small reduction in LDLC, great lifetime benefit

• Catching them young in their (plaque) formative years is important !

ARIC study PCSK9 mutation

Mr. Suresh T is a 42 year old executive. He is not a smoker or a diabetic. Pursues a healthy lifestyle including diet and exercise. His grandfather had an MI at age 76.

• TC=220• HDLC=35• TG=150• LDLC=155• SBP of 130 on

medications.

His question:

“Should I take a statin ?”

Number of CVD Risk Scores in the World……………ABOUT 70

• Examples:• ACC/AHA• ATP III/FRS• INTERHEART• SCORE• QRISK2• JBS3• Reynolds• MESA• WHO………..etc etc

Problems with risk scores• Heavily influenced by age • Dangers of over treatment-esp >60 yrs age• Dangers of under treatment-esp the young-very

important in India • More than half IHD occurs in people at low to

moderate risk• No randomized prospective studies of statin benefit

from young age (e.g. from age 30)• No risk prediction models exclusively based on Indian

data or has been validated in Indians

CRUCIAL QUESTION: How to select the high risk Indian?How to separate wheat from the chaff ?

1. Select a risk score best applicable to Indians-----JBS3

Comparative accuracy of different risk scores in assessing cardiovascular risk in Indians: A study in patients with first

MI: Indian Heart J. 2014 myocardial infarction

• 149 patients with AMI

• 4r risk assessment models applied to estimate what would have been their predicted 10-year risk of CV events if they had presented just prior to suffering the acute MI.

• Framingham Risk score (RiskFRS), • WHO risk prediction charts (RiskWHO), • ACC/AHA pooled cohort equations (RiskACC/AHA) and • 3rd Joint British Societies' risk calculator (RiskJBS)]

The estimated 10-year cardiovascular risk divided into two risk categories as <20% and ≥20%.

2. ApoB

• Nearly 80% of heart disease occurs in developing countries.

• Nine modifiable risk factors predict 90% of acute MI• Current smoking and an abnormal ApoB/ApoA-1 ratio

predict 66% of global heart disease.

J Am Coll Cardiol 2016; 67:193–201

A multicenter, longitudinal, population-based cohort of 3,036 aged 18 to 30 years at Year 0 (1985 to 1986)with measurements for apoB at baseline who also underwent CAC measurement at Year 25

A dose–response association between apoB in young adults and the presence of midlife CAC independent of baseline traditional CVD risk factors

3. CAC- The Great Discriminator !

J Am Coll Cardiol. 2015;66(15):1643-1653

10-Year Coronary Heart Disease Risk Prediction Using CAC and Traditional Risk Factors: MESA

CAC--- the power of zero !A 15-Year Warranty Period for Asymptomatic Individuals Without CAC: A Prospective Follow-Up of 9,715 Individuals

2015;8(8):900-909.

CAC- Cheaper than a life time of statins !

50 % of statin recommended patients had zero CAC with low CVD over 10 yrs

Implications of CAC Testing Among Statin Candidates According to ACC/AHA Cholesterol Management Guidelines: MESA Analysis JACC 2015;66(15):1657-1668

J Am Coll Cardiol 2016;67:630–40)OBJECTIVES : This study aimed to assess whether statin therapy was associated with a reduction in major adverse cardiovascular events (MACE) and mortality in patients with asymptomatic peripheral arterial disease.

After a median duration of 3.6 years, statin therapy was found to cause a reduction in MACE and all-cause mortality among participants without clinical CVD and low mean CVD risk, but with asymptomatic peripheral arterial disease.

4. ABI

5. Use Life time risk score or FRS X 1.8

So, what do we tell Suresh T ?

• Choose the risk prediction algorithm most applicable to Indians- ex JBS3

• Or recalibrate FRS/ATPIII by 1.8

• Or calculate lifetime risk

Start a conversation- risk / benefit- use NNT/NNH

If he still wishes better definition of risk..

Use:

CACSABIApoB………………………………………..hsCRP, CIMT, etc

Talking is important !