CardioSource WorldNews | Page 61

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