CME: Considering Statin Eligibility for Older Patients

CME: Considering Statin Eligibility for Older Patients
Author Information (click to view)

Michael D. Miedema, MD, MPH

Preventive Cardiologist, Minneapolis Heart Institute
Minneapolis Heart Institute Foundation

Michael D. Miedema, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

  1. Explain the impact of the recent American College of Cardiology and American Heart Association updated guidelines for treating cholesterol, which shifted the recommendations to allocate statins to those with a high absolute risk for cardiovascular disease.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwaugust1.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria, Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Michael D. Miedema, MD, MPH
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Michael D. Miedema, MD, MPH (click to view)

Michael D. Miedema, MD, MPH

Preventive Cardiologist, Minneapolis Heart Institute
Minneapolis Heart Institute Foundation

Michael D. Miedema, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Guidelines on managing cholesterol recently shifted the treatment paradigm for statin therapy use, basing treatment with these drugs on an individual’s risk for a heart attack or stroke instead of their cholesterol levels. The majority of older patients now qualify for treatment with statins.
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Recently, the American College of Cardiology and American Heart Association (ACC/AHA) updated guidelines in the United States for treating cholesterol, shifting the recommendations to allocate statins to those with a high absolute risk for cardiovascular disease (CVD). “The guidelines recommend using statins for people with CVD, diabetes, or high cholesterol levels,” explains Michael D. Miedema, MD, MPH. “They also advise clinicians to use these medications in patients without these conditions but with a higher than 7.5% risk of heart attack or stroke in the next 10 years based on risk calculator data.”

The updated guidelines represent a paradigm shift from the Adult Treatment Panel (ATP) III recommendations. The ATP III guidelines relied heavily on levels of LDL cholesterol to determine who to treat. The ACC/AHA guidelines recommend using statin therapy on patients who are at highest risk for heart attack and stroke, even if their cholesterol levels are within normal limits.
<h3>Examining the Impact of New Statin Guidelines</h3>
A recent study estimated that the ACC/AHA guidelines will lead to significant increases in statin use, largely because more adults aged 60 and older without CVD or diabetes will be eligible for these medications. Dr. Miedema says it is important to look at the effect that the ACC/AHA guidelines will have on older patients because they may be prone to adverse effects with statin use. “It can be challenging for clinicians to determine whether or not statins should be used in older, healthy patients,” he says.

<a href=”http://dev.physiciansweekly.com/?s=statin” target=”_blank”><img class=”aligncenter wp-image-31949 size-full” src=”http://dev.physiciansweekly.com/wp-content/uploads/2015/04/Statin-Eligibility-Older-Patient-Callout.png” alt=”Statin-Eligibility-Older-Patient-Callout” width=”475″ height=”196″ /></a>

In a research letter published in <em>JAMA Internal Medicine</em>, Dr. Miedema and colleagues analyzed the potential effect of the updated ACC/AHA guidelines and contemporary use of statins in older patients from the Atherosclerosis Risk in Communities (ARIC) study. The cross-sectional analysis involved more than 6,000 African Americans and Caucasian Americans between the ages of 66 and 90. The prevalence of indications for statin therapy was then analyzed according to ACC/AHA guidelines and ATP III guidelines, the latter of which were the most relevant guidelines at the time ARIC participants made their fifth study visit.
<h3>Greater Eligibility for Statin Use</h3>
According to the results, many ARIC participants used medications to lower their lipid levels, but uncontrolled hyperlipidemia was still common according to the ATP III guidelines that were then in place (<a href=”http://dev.physiciansweekly.com/wp-content/uploads/2015/04/Miedema-table1.png”>Table 1</a>). Patients with a high absolute risk for coronary heart disease (CHD)—defined as greater than 20% for 10 years—were the least likely to be at their LDL cholesterol goal. Those with one or zero risk factors for CHD were most likely to be at goal. Full implementation of ATP III guidelines should have resulted in treatment of about 70% of the study sample.

Conversely, using the ACC/AHA guidelines, 97% of ARIC participants aged 75 and younger met one of the four major indications for statin therapy, which included CVD, diabetes, LDL cholesterol levels above 190 mg/dL, and an absolute 10-year CVD risk of 7.5% or higher (<a href=”http://dev.physiciansweekly.com/wp-content/uploads/2015/04/Miedema-table2.png”>Table 2</a>). Among these patients, nearly half were taking a statin, but only 9% were taking a high-intensity statin. “There definitely will be an increase in statin eligibility for patients aged 65 to 75,” Dr. Miedema says. “However, the guidelines make it clear that being eligible for a statin should stimulate a discussion about the risks and benefits of these drugs as opposed to a strict mandate to take them.”

Importantly, the ACC/AHA guidelines do not offer a recommendation for or against statin therapy in people older than 75 because of a lack of evidence in this age group, says Dr. Miedema. “That said, more than half of the study participants in that age group were taking statins,” he says. “We need more data on the safety and efficacy of statins in patients who fall into this age range.”
<h3>Important Implications With CVD Risk Factors</h3>
Older individuals will likely cross the 7.5% threshold based on age alone, even if they have normal cholesterol levels and no other CVD risk factors, according to the study. Dr. Miedema and colleagues noted that the 7.5% CVD risk threshold is aggressive in that it creates a nearly universal recommendation for statin use among patients between the ages of 65 and 75. “Although older people are naturally at higher risk for heart attacks and strokes, it’s still important to assess the risks and benefits of statins in these patients.”

Dr. Miedema says it is encouraging that older patients are taking statins more often than other medications to lower their lipid levels but notes that the optimal role for statin therapy in the elderly must be further explored. “We need more research to help define ideal older candidates for statin therapy,” he says. “This research may enhance our ability to reduce the risk of heart attacks and strokes in older patients while simultaneously avoiding treatment in individuals who are unlikely to benefit from a preventive medication.”

Readings & Resources (click to view)

Miedema MD, Lopez FL, Blaha MJ, et al. Eligibility for statin therapy according to new cholesterol guidelines and prevalent use of medication to lower lipid levels in an older US cohort: the Atherosclerosis Risk in Communities Study cohort. JAMA Intern Med. 2015;175:138-140. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1935930&resultClick=3

Stone NJ, Robinson J, Lichtenstein AH, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;6:2889-2934.

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.

Pencina MJ, Navar-Boggan AM, D’Agostino RB Sr, et al. Application of new cholesterol guidelines to a population-based sample. N Engl J Med. 2014;370:1422-1431.

ARIC Investigators. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives. Am J Epidemiol. 1989;129:687-702.

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