Cards question

[BruceBanner]

Probably a dumb question for you guys---

 

Would you put a 35 y/o male, with no fhx of early CVD, CVA, with last lipids of TC 235, TG 196, HDL 44, LDL 152, on a statin? He's a healthy guy, no other risk factors. He's had high lipids his whole (adult) life, per him.

 

I told him putting him on a statin now would only lower his risk of CVD by about 1% in the next 10 years, and he should revisit this at 45, or when his CV risk is >10%, whichever comes first. 

 

Is this valid?

 

 

 

[ventana]

use an online calculator to determine risk... then read their rec's

 

 

this is the one i use

 

http://tools.acc.org/ASCVD-Risk-Estimator/

 

 

 

 

NOT framingham (old)

 

 

Make sure the newest one....

[Joelseff]

Calculate his Framingham score. If his BP is NL and he has no smoking hx etc I roughly calculated his risk score at 4%. +7.5% is the current guideline for statin depending on authority. I would recommend lifestyle/diet, omega 3s low carb etc.

 

Edit: Oops I just saw ventana's post. I thought Framingham was current...

 

Using ventana's calculator pts under 40 don't register

 

Sent from my SAMSUNG-SM-G891A using Tapatalk

[GetMeOuttaThisMess]

AHA calc over estimates risk. At these values it's pt. option, as is option of coronary calcium index/coronary CT. Any LDL >190 is a "polite arm twist" to initiate therapy.

[cbrsmurf]

His 1% decrease is an ABSOLUTE decrease, not relative

 

Any LDL > 125, should have a serious discussion about pharmaceutical treatment

 

10 year f/u is a bit long, but it's up to the patient if he wants diet, exercise, lose wt etc.  If he isn't motivated, 10 years would be fine with me.

[Reality Check 2]

http://circ.ahajournals.org/content/circulationaha/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf

 

UNBELIEVABLY wordy but helpful. Several good charts about age and risk.

 

I would also want to know if his TSH is normal. Suboptimal TSH can elevate LDL.

[BruceBanner]

Thanks all. Good to know on absolute vs relative.

 

The AHA/ACC risk calc puts him at 0.9% 10 year risk. It doesnt look like there is any indication for primary prevention.

 

I think I'll advise we revist his risk at 40, unless he really wants to start a statin now. I dont see a huge benefit for a 35 y/o guy with no other RF.

[GetMeOuttaThisMess]

BTW, conservative mgmt estimated to provide max decrease in LDL of 15% (I've seen more but that's what THEY say, and you know how THEY are).

[HMtoPA]

I don't even consider a statin until a patient is ≥40-years-old, and then only if the patient has an ASCVD 10-year risk score of ≥7.5%. I guess there is some indication if LDL is very high as well (>190), but even then I would wait until age 40.

[Reality Check 2]

Family history plays a big role in some of my patients.

 

If the patient's Mom or Dad had an MI at a young age - ie. Dad died of a massive MI at age 42- then I am more proactive and ask cardiology for assistance as well while the patient is in his/her late 20's or 30's. The sense of  mortality requires a bit more finesse and reassurance - positive personal changes, etc.

 

I still have one firefighter with a horrid family history who refuses ALL treatment for his HTN and LDL of 198 and takes $400 worth of supplements a month that DO NOTHING - his LDL is exactly the same 3 months later. He won't be a firefighter much longer - he won't pass his exam for that. Hope he doesn't have an MI on the ladder.....

 

It seems that things are going full circle - the LDL cutoff used to be 130, then 100 for diabetics only, then 100 for everyone, then 70 for CAD - now we are back to some folks having an acceptable LDL of up to 120-130, etc.

 

Just when I think I have it - they change it up again.....................

[LKPAC]

I love threads like this on the forum!  Thank you! :-)

[ventana]

I don't even consider a statin until a patient is ≥40-years-old, and then only if the patient has an ASCVD 10-year risk score of ≥7.5%. I guess there is some indication if LDL is very high as well (>190), but even then I would wait until age 40.

 

 

what about someone who's has parents and older siblings with AMI in their 40's?

 

try not to say never....

 

35 yr old with + FMH of 1rst degree relatives with AMI < 40 - likely should be on a statin... (with out getting into specifics.)

[GetMeOuttaThisMess]

Family history plays a big role in some of my patients.

 

If the patient's Mom or Dad had an MI at a young age - ie. Dad died of a massive MI at age 42- then I am more proactive and ask cardiology for assistance as well while the patient is in his/her late 20's or 30's. The sense of mortality requires a bit more finesse and reassurance - positive personal changes, etc.

 

I still have one firefighter with a horrid family history who refuses ALL treatment for his HTN and LDL of 198 and takes $400 worth of supplements a month that DO NOTHING - his LDL is exactly the same 3 months later. He won't be a firefighter much longer - he won't pass his exam for that. Hope he doesn't have an MI on the ladder.....

 

It seems that things are going full circle - the LDL cutoff used to be 130, then 100 for diabetics only, then 100 for everyone, then 70 for CAD - now we are back to some folks having an acceptable LDL of up to 120-130, etc.

 

Just when I think I have it - they change it up again.....................

They (FF) tend to die young with CV disease due to chemical work exposures anyway. "Premature CV death" is defined as <55 yo males, <65 yo females. Don't forget to ask this during school/camp PEs for first degree relatives! One has to remember that there is a BIG difference in primary prevention NNT versus those with CVD hx. or risk equivalent disease process.

 

There is also reported increased risk of DM development in FEMALES on statins.

 

Treatment now is less intensive. They're either high dose or low dose dependent on risk level and the key is to have them on it and no longer chase their lipid values.

[newton9686]

35 is a little young.Although I absolutely would start considering it in his 40s.

[BruceBanner]

They (FF) tend to die young with CV disease due to chemical work exposures anyway. 

 

My dad is a FF (chief for many years) and I've noticed a lot of retired FF do tend to have CV events at a relatively young age. I'm sure there are other factors, most modern FF arent putting out fires everyday. Lifestyle and FHx play into it a lot as FF tend to be generational.

[GetMeOuttaThisMess]

My dad is a FF (chief for many years) and I've noticed a lot of retired FF do tend to have CV events at a relatively young age. I'm sure there are other factors, most modern FF arent putting out fires everyday. Lifestyle and FHx play into it a lot as FF tend to be generational.

And older generation, smokers.