2a) This is the next instalment of @cardiomet_CE‘s 10-part #tweetorial foundational series on #lipid management! It is accredited for #CME/CE and intended for #physicians #physicianassociates #nurses #nursepractitioners #pharmacists.#FOAMed @MedTweetorials #cardiotwitter
— cardio-met (@cardiomet_CE) August 2, 2022
3) Let’s start with a poll exploring the impact of intensive lowering of #LDL_C levels with statin therapy and the risk of major cardiovascular (#CV) events.
— cardio-met (@cardiomet_CE) August 2, 2022
For every 1mmol/L reduction in LDL-C, there is an annual reduction in coronary death of:
5) #Cholesterol has many key functions in the human body; it is an essential component of cell membranes and is required to produce steroid-based hormones such as #testosterone & #VitaminD
— cardio-met (@cardiomet_CE) August 2, 2022
7) There is a clear & established relationship between LDL-C and the risk of major CV events. Regardless of how it is achieved, lower LDL-C levels correlate with a lower CV risk!
— cardio-met (@cardiomet_CE) August 2, 2022
See 🔓https://t.co/z2l8eRyv5K pic.twitter.com/IJsfUGmyqE
9) Perhaps we are underestimating the #CV risk of some of our patients in #primarycare? pic.twitter.com/lWCawSZQfD
— cardio-met (@cardiomet_CE) August 2, 2022
10b) Lipid profile reveals an #LDL_C of 3.0mmol/L (116mg/dL). She is on #atorvastatin 40mg (in addition to several other medications) which she assures us she is taking regularly
— cardio-met (@cardiomet_CE) August 2, 2022
Poll – what is your target LDL-C for this patient?
12) Updated 2019 ESC/EAS guidelines for the management of #dyslipidaemias now recommend a #LDL_C goal for very-high risk individuals of <1.4mmol/L (55mg/dL) and a >50% reduction from baseline LDL-C level pic.twitter.com/iaqE1Jcp7Q
— cardio-met (@cardiomet_CE) August 2, 2022
14) As you can see, we are now in an era of much lower #LDL_C goals.
— cardio-met (@cardiomet_CE) August 2, 2022
Unsurprisingly, around 80% of individuals living with #ASCVD on moderate-high intensity #statins failed to achieve their LDL-C goal of <1.8mmol/L
🔓https://t.co/0nRdU8KGPo
15b) The authors concluded that even those on optimised doses of #statins will require additional non-statin lipid-lowering therapies #LLT to achieve these tighter LDL-C goals
— cardio-met (@cardiomet_CE) August 2, 2022
16b) So, how are we going to get our 70♀️ down to her #LDL_C target of <1.4mmol/L?
— cardio-met (@cardiomet_CE) August 2, 2022
Let’s have another poll. What would you do next for her lipid-lowering regimen?
a. Double her atorvastatin to 80mg
b. Switch to rosuvastatin 20mg
c. Add ezetimibe 10mg
d. Add bempedoic acid 180mg
18) WELCOME BACK! I am @drkevinfernando & we are talking about management of #hyperlipidemia in #primarycarewhilst YOU earn 🆓0.5h CE/#CME!
— cardio-met (@cardiomet_CE) August 3, 2022
We left you with a quiz (16b). There may be more than 1⃣ tx approach in this setting, but data ➡️ C–add ezetimibe. Let’s explore this.
19b) As a rule of thumb, doubling the dose of statin above the minimal effective dose, further reduces #LDL_C levels by just an additional 6⃣%
— cardio-met (@cardiomet_CE) August 3, 2022
The maximal reduction in LDL-C levels seen with statin treatment ranges from 24–60%. pic.twitter.com/HYmpIt8bLw
21) In the #IMPROVE_IT CV outcomes study, led by @cardiomet_ce author @cpcannon (🔓https://t.co/9jnjHx1oWJ), #ezetimibe ⬇️ LDL-C by a further 24% when added to #statins ➡️absolute risk ⬇️ of 2% in the primary composite endpoint of #CV mortality, major CV event or non-fatal stroke pic.twitter.com/2cu5YjFMrt
— cardio-met (@cardiomet_CE) August 3, 2022
23) I appreciate this is only a modest treatment benefit given the large sample size (circa 18k participants) and long follow-up period (6 years), but #ezetimibe does do exactly what it says on the tin and significantly ⬇️#LDL_C levels pic.twitter.com/gSYBTpJClz
— cardio-met (@cardiomet_CE) August 3, 2022
24b) These include:
— cardio-met (@cardiomet_CE) August 3, 2022
🫀 Type 2 diabetes #T2D
🫀 Chronic kidney disease #CKD
🫀 #Hypothyroidism
🫀 Medications including steroids, betablockers, diuretics, antipsychotics & retinoids
🫀 Obesity
🫀 Excessive alcohol consumption 🍸
26) #Bempedoic_acid is a new lipid-lowering option in our primary care toolbox to reduce #LDL_C levels.
— cardio-met (@cardiomet_CE) August 3, 2022
Bempedoic acid lowers LDL-C by inhibiting cholesterol synthesis in the liver but via inhibition of a different enzyme to that of statins.
28a) So, does bempedoic acid do exactly what it says on the tin?#Bempedoic_acid has been extensively studied in the phase 3 #CLEAR trial programme which explored its efficacy at lowering #LDL_C as well as its safety profile
— cardio-met (@cardiomet_CE) August 3, 2022
28c) A combination of bempedoic acid and ezetimibe resulted in a 38% reduction in LDL-C from baseline at 12 weeks (on top of maximally tolerated statin (35% were not on a statin)).
— cardio-met (@cardiomet_CE) August 3, 2022
See 🔓https://t.co/92I5jO3DRL
What about clinical outcomes? pic.twitter.com/pHiAp35CLt
30) With regards to safety, most adverse effects with bempedoic acid were mild or moderate in intensity. The most commonly reported adverse effects were hyperuricaemia (#gout in 1.4% of patients on bempedoic acid vs 0.4% treated with placebo), pain in extremities, & anaemia. pic.twitter.com/f8s1ijQUDd
— cardio-met (@cardiomet_CE) August 3, 2022
32) I would add in #ezetimibe 10mg and recheck #LDL_C levels after 2-3 months. If still above target, I would add in #bempedoic_acid 180mg (it is available as a combination product with ezetimibe which can help reduce pill burden)
— cardio-met (@cardiomet_CE) August 3, 2022
33b)
— cardio-met (@cardiomet_CE) August 3, 2022
🔑To achieve these tighter targets, we need to use combination #LLT rather than statins alone
🗝️Consider using more ezetimibe (this has been a big change in practice for me over the past year) – it does exactly what is says on the tin & significantly ⬇️LDL-C levels
(cont)
34) And that’s it! You just earned 0.5h 🆓CE/#CME 🇺🇸🇬🇧🇨🇦🇪🇺! Go claim your certificate at https://t.co/XMQACcVBhx and FOLLOW US here at @cardiomet_ce for more expert-led #accredited education! I am @drkevinfernando. Thanks for joining us!#FOAMed #Cardiotwitter #MedTwitter
— cardio-met (@cardiomet_CE) August 3, 2022