Sanofi US and Regeneron provided funding and suggested topics to
Cardiosource WorldNews. Drs. Bhatt and Shah received no payment
for their participation in this discussion.
CONVERSATIONS with EXPERTS
Identifying Patients
with Clinical
Atherosclerotic CVD and
Heterozygous Familial
Hypercholesterolemia
With Deepak L. Bhatt, MD, MPH, and Prediman K. Shah, MD
Proprotein convertase subtilisin/kexin
Type 9 (PCSK9), a recently discovered
protein, has led to increased interest in
better defining patients with clinical ASCVD and HeFH who have uncontrolled
LDL-C. Prediman K. Shah, MD, and
Deepak L. Bhatt, MD, MPH, discussed
these patient types.
Deepak L. Bhatt,
MD, MPH
Deepak L. Bhatt, MD, MPH: The
ACC/AHA has provided a definition
for clinical atherosclerotic disease
(ASCVD). In this context and in your
experience, can you tell us which patients you would identify as meeting
the definition of clinical ASCVD?
Prediman K. Shah, MD: One category of patients would have clinical
manifestations of coronary heart
disease, such as stable or unstable
angina, prior history of myocardial
Prediman K.
infarction or sudden cardiac death
Shah, MD
attributed to coronary artery disease. The other category might include patients
with symptomatic manifestations of peripheral
arterial disease, such as claudication or ischemic
foot, and ischemic stroke. So those are the two
broad categories encompassing coronary disease,
peripheral vascular disease, and cerebrovascular
disease.
Dr. Bhatt: What about somebody who has chest
pain that is totally atypical but, for whatever
reason, he/she has gotten a stress test—probably
a false-positive—undergoes catheterization, and
has a 30% lesion in their proximal left anterior
descending coronary artery. Would that be someone who you would consider as having athero-
sclerotic cardiovascular disease or not?
Dr. Shah: I would certainly consider them as
having it, but I would consider that as asymptomatic or subclinical, because the symptoms do
not match the anatomy very well. So if there is
a clear separation of symptoms from anatomy, it
would still be coronary heart disease but subclinical or asymptomatic, so slightly different than
the symptomatic population.
Dr. Bhatt: And what about somebody with a
very high coronary calcium score?
Dr. Shah: Absolutely, a very high-risk, asymptomatic or subclinical atherosclerosis. So, if we
want to be very strict, then the symptomatic
patients would be the ones who would have clinical atherosclerotic cardiovascular disease, and
the asymptomatic ones would be the one with
subclinical atherosclerosis.
Dr. Bhatt: So how would you then G