2) This presentation was originally delivered by @NP_ltl_a at an accredited satellite symposium at @nationallipid's June 2023 congress. She shared the podium there with lipidology & #preventive #cardiology experts @alanbrownmd, @jpenamd, & @lipiddoc.@MedTweetorials
— cardio-met (@cardiomet_CE) September 19, 2023
3b) The symposium itself is available for on-demand viewing and EVEN MORE 🆓CE/#CME at https://t.co/x76rN22q5u. pic.twitter.com/Nu79ugt7wJ
— cardio-met (@cardiomet_CE) September 19, 2023
5) We have progressed, though, from #riskfactors to equations. All started with #Framingham, the launch of which was prompted by #FDR's premature death from #HTN #CVD & #stroke in 1945.
— cardio-met (@cardiomet_CE) September 19, 2023
🔓 https://t.co/dL7ff7GxyB
7) It was recognized that assessing the aggregate burden of #riskfactors is more useful than looking for single RFs, & gradually Risk equations were created based on population-level estimates of #CVD.
— cardio-met (@cardiomet_CE) September 19, 2023
9) This gave us our 1st real primary prevention risk equation. Because it was recognized that ♂️ < 50 & ♀️ < 70 are at “low” short-term risk regardless of RF burden, the potential solution was long-term/lifetime risk estimates & sequential refinement for the individual patient. pic.twitter.com/mpqXvtoxz3
— cardio-met (@cardiomet_CE) September 19, 2023
11a) Suboptimal risk prediction before the 2019 Guidelines and tool yielded suboptimal treatment recommendations, especially for younger patients. See https://t.co/D8uTZBgbDW pic.twitter.com/kPdtBgogLb
— cardio-met (@cardiomet_CE) September 19, 2023
11c) 2018 guideline identified fewer young adults, prob because the 2013 guidelines considered pts with a 10-year ASCVD risk of 5-7.5% as eligible to receive statins, whereas the 2018 guideline only provided a Class IIb indication & only when risk-enhancing factors were present.
— cardio-met (@cardiomet_CE) September 19, 2023
13a) So in 2019 we got a better risk equation and we started using more tools. Example: #CAC. In green (below) – PCE, when added other RF (elevated #CRP, ABI, #FamHx) – very little is added to reclassify risk for coronary events pic.twitter.com/StKU7aFjCL
— cardio-met (@cardiomet_CE) September 19, 2023
14a) These (see 14b) are data in pts reclassified by @MichaelJBlaha et al (🔓https://t.co/0kOIbfBLD1) for #CVD events or proportion of pts who are correctly reclassified into a lower or higher risk group based on presence/absence of risk factors.
— cardio-met (@cardiomet_CE) September 19, 2023
15a) Data from #CAC_Consortium retrospectively evaluated 66,366 asymptomatic adults for mean f/u 12.3 ± 3.9 years for development of #CVD, #CHD, #cancer, & all-cause ☠️.
— cardio-met (@cardiomet_CE) September 19, 2023
15c) Those with scores ≥1000 had multivariable HRs adjusted for conventional #RFs of 5.04, 6.79, 1.55, & 2.89-fold risk of #CVD, #CHD, #cancer, and all-cause ☠️, respectively, compared to those with CAC = 0.
— cardio-met (@cardiomet_CE) September 19, 2023
See original data and 95% CI’s at 🔓https://t.co/hnYgkWINyC
16a) MISCONCEPTION: The primary yield of #CACS comes from identifying pts with subclinical #coronary artery #stenosis. NOT SO, per 🔓https://t.co/oPTSDRmxWL. pic.twitter.com/TjUsf8VUD6
— cardio-met (@cardiomet_CE) September 19, 2023
17) So how does #riskstratification guide primary prevention? Well, we know that ⬆️ #LDL_C is causal for #atherosclerosis and that the benefit of #statins in ⬇️LDL is unquestioned.
— cardio-met (@cardiomet_CE) September 19, 2023
🔓 https://t.co/hdc7jzhJem
🔓 https://t.co/F1BwfgV2yZ
🔓 https://t.co/gImMKV57RU pic.twitter.com/nJLllHMqyJ
19) For #statin-intolerant & statin-resistant pts, consider adding #ezetimibe or #PCSK9i for this very high-risk group. And 🆕 data from #CLEAR_Outcomes (see primary prevention data per @cpcannon at https://t.co/lcgSWzRVxu) add #bempedoic_acid to the 2019 @escardio list.
— cardio-met (@cardiomet_CE) September 19, 2023
21) That #ACC document https://t.co/dePAAkgl6l gave specific guidance for the addition of non-statin therapy: pic.twitter.com/S4yCcPu9dI
— cardio-met (@cardiomet_CE) September 19, 2023
23) Lp(a) levels are genetically predetermined; we need ✔️only once. Lp(a) contributes a small portion of measured #LDL_C, but it cannot be estimated from traditional lipid panel. It must be measured directly!
— cardio-met (@cardiomet_CE) September 19, 2023
This is 🔑because as much as 20% of the population has ⬆️Lp(a)! pic.twitter.com/MfeqHiMOCd
24b) Highest 10yr #ASCVD incidence in #MESA (Multi-Ethnic Study of Atherosclerosis) participants was in Lp(a) quintile 5 + #CAC ≥100 group. Lowest was in Lp(a) quintiles 1 to 4 + CAC = 0 group.
— cardio-met (@cardiomet_CE) September 19, 2023
24d) HUGE: Pts w/ ⬆️Lp(a) + #CAC ≥100 had a nearly 5⃣ X ⬆️increased #ASCVD risk as compared with those with non-elevated Lp(a) and CACS = 0. Notably, the ASCVD hazard was similar across elevated & non-elevated Lp(a) among participants with CAC = 0 and CAC score 1-99 pic.twitter.com/QhNCkpYtt0
— cardio-met (@cardiomet_CE) September 19, 2023
25a) Healthy diet & lifestyle are 1st step to ⬇️#ASCVD risk from ⬆️Lp(a). #Statins do not ⬇️Lp(a) levels. #Niacin can ⬇️Lp(a) levels by 25-40%, as can #PCSK9i. #Apheresis ⬇️Lp(a) levels ~65–75% immed post-procedure & 40–50% on standard schedules, but isn't suitable for all pts.
— cardio-met (@cardiomet_CE) September 19, 2023
26a) So, what have you learned about advances in risk assessment in patients with #hyperlipidemia? Which of the following makes the most substantial contribution to usual risk strat for #ASCVD?
— cardio-met (@cardiomet_CE) September 19, 2023
a. 🚬history
b. #hypertension
c. #CAC score
d. #diabetes
26c) Which of the following statements about Lp(a) is FALSE?
— cardio-met (@cardiomet_CE) September 19, 2023
a. can be measured on "comprehensive" lipid panel
b. independently assoc'd with ⬆️#ASCVD risk
c. risk from ⬆️Lp(a) levels correlates with risk from ⬆️ #CACS
d. ⬆️levels can be ⬇️ w/ niacin & #PCSK9i
27) Great job! You just earned 0.5hr 🆓CE/#CME credit. Claim your certificate NOW at https://t.co/DkaBZ9OsTH. Then click your 🖱️just ONCE MORE and FOLLOW US for more expert-led, always 🆓#MedEd! Thanks to @NP_ltl_a for being today's faculty!
— cardio-met (@cardiomet_CE) September 19, 2023