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I think this person has familial hypercholesterolemia?” Does that knowledge trigger you to alter
your treatment or screening strategy?
Dr. Foody: Well, we have to stay vigilant, and,
in some respects, the success of statins has unfortunately eliminated the need to look at this. We
have to recognize that when individuals are on
a maximally tolerated dose of statin—and I use
“tolerated” because we all know that statins may
not be without side effects—and their numbers
are still above 130 or 160 mg/dL, it may be a
good signal to start looking for presence of familial hypercholesterolemia. The maximal intensive
dose of statins should reduce LDL by about 50%.
You could argue that, if someone’s LDL was above
100 mg/dL on maximal-intensity statins, they
probably, in fact, started in a range that would
signal that they had either heterozygous or homozygous familial hypercholesterolemia.
Dr. Bhatt: As we have seen from epidemiologic
and clinical studies, poorly controlled LDL is linked
with persistent cardiovascular risk.
There has also been some confusion about
lowering LDL in recent years, but I think it is
good to prescribe statins to at-risk patients. That
is probably one of the most important steps in
ensuring that patients have the best outcomes:
being on a statin versus not being on a statin for
patients at appropriate levels of cardiovascular
risk. The second step, then, is making sure that a
patient’s LDL levels are actually reduced. There are
two methods for this: the patient’s adherence to
therapy (because, obviously, if they are not adherent to therapy, their LDL levels are not going to be
reduced by the statin) and making sure that the
patient has the correct intensity and dose of statin.
There is a subset of patients who continue to have
poorly controlled LDL despite treatment with current standard of care.
Dr. Foody: Absolutely, Deepak—that is a critical
point that should be emphasized. The power of
the genetic findings, Mendelian randomization,
and—as you mentioned—the lack of similar findings with HDL, have really further bolstered an
approach focusing on LDL cholesterol.
To your point, there has been significant misunderstanding about the guidelines because they were
interpreted as throwing out cholesterol targets. I
tend to take a more moderate view: yes, they focused
on evidence-based intensity and dosing of statins,
but the trials also required that patients met certain
endpoints for LDL cholesterol. The guidelines have
been very clear to emphasize that LDL remains an
i