Nov 16, 2018

Risk management

The story

Seasons change, and so do lipid guidelines. Here's what's new since 2013.

Get personal

It's not the soundtrack from A Star is Born, but new statin guidelines tend to make a splash. Among the top 10 takeaways from this year's ACC/AHA Guideline on the Management of Blood Cholesterol was an emphasis on personalized care. Beyond traditional ASCVD risk factors like smoking, blood pressure, and LDL cholesterol, family history, chronic health conditions like the metabolic syndrome and CKD, and additional biomarkers are now part of risk assessment in your primary (page 20 if you're on your phone) and secondary (page 15) decision trees.

Start early

Since atherosclerosis occurs over a lifetime, the panel recommends screening children once for high cholesterol, including a single screening between age 9 and 11 for most children and screening for very high-risk children as early as age 2. No one is saying to put kids on Lipitor – instead, the guidelines encourage early lifestyle changes to avoid danger later on.

Find value

A new Value Statement encourages physicians to consider cost of care in what amounts to an implicit swipe at PCSK9 inhibitors, the much-hyped but expensive antibodies that cut cholesterol below levels seen with high-dose statins. As if on cue, newly released ODYSSEY OUTCOMES results found the first all-cause mortality benefit for this class of medications. Over 3-year follow-up, alirocumab reduced CV endpoints compared to placebo (9.5% vs. 11%) and improved mortality (3.5% vs. 4.1%) in 20,000 patients with an ACS event in the past year on high-intensity statin therapy. Physicians targeted an LDL-cholesterol in the 25 - 50 mg/dL range for these extremely high-risk patients.  

The takeaway

If 2013 is any guide, it may take a while for some of these changes to catch on and for physicians to catch up to their complexity. In the meantime, use PCSK9 inhibitors in high-risk patients who don't meet LDL goals on statins alone.

Say it on rounds

When your patient on 7HS is again refusing medication

She may have a point. Sparing long-term drug toxicity is an important goal in the era of modern antiretroviral therapy (ART). The Phase 3 GEMINI trials compared a 2-drug regimen of dolutegravir and lamivudine with a traditional 3-drug regimen of dolutegravir, tenofovir, and emtricitabine in ART-naive patients without baseline drug resistance. The 2-drug regimen met non-inferiority criteria after 48 weeks, and 90% of patients achieved viral loads of < 50 copies / mL in all groups. Fewer patients in the 2-drug group (18% vs. 24%) reported drug-related adverse events.

When a busy gen med list makes it hard to keep track of clinic

You could use an extra hand. A trial of 500 older adults (mean age 75) in Quebec found that community pharmacists played a strong role in discontinuing inappropriate medications. After identifying inappropriate scripts, pharmacists in the intervention group sent patients a deprescribing brochure and physicians an evidence-based pharmaceutical opinion. The efforts led to medication discontinuation in 43% of patients compared to 12% in a usual care group after 6 months. NSAIDs and sedative-hypnotics (e.g. Ambien) were the most frequently discontinued drugs.

When the wards are filled with flu, but your shoulder's sore from the vaccine

It's all relative. An analysis of first-time myocardial infractions (MIs) in 500,000 patients in the UK Biobank found that while the rate of MI was 3x higher in men than women, women were much more sensitive to key risk factors. Women who smoked heavily had three times the risk of MI compared to women who did not smoke, while men who smoked had only twice the risk compared to non-smokers. Compared to equivalent men, women faced a 40% or greater relative risk increase for diabetes, mild smoking, and hypertension.

Brush up

Get active

About 80% of US adults and adolescents are insufficiently active, says The Department of Health and Human Services in its new Physical Activity Guidelines for Americans. Uncle Sam calls for 150 - 300 minutes of moderate-intensity exercise per week or 75 -150 minutes of vigorous / aerobic activity. HHS also recommends muscle strengthening activities 2 or more days a week. The authors link exercise to benefits ranging from improved sleep to longevity.

What's the evidence

For physical inactivity and disease risk? A 2016 burden of disease analysis estimated that physical inactivity in the US was responsible for 7% of coronary artery disease, 8% of type 2 diabetes, 12% of breast cancer, and 12% of colon cancer. A separate meta-analysis found a dose-response relationship between exercise and risk of coronary artery disease: 150 minutes of weekly exercise decreased CAD risk by 14%, while 300 weekly minutes decreased risk by 20%.  

What your trauma center friends are talking about

Dr. Judy Melinek was among the earliest to rebut the NRA with her now famous tweet on lanes vs. highways. But beyond numerous public appearances and a bevy of social media commentary, she's penned an editorial on the decades long contribution of physicians to public health regulation on matters like seat belts and cigarettes.


Tackle your student debt with surgical precision


Extracting savings from your student debt doesn't require a scalpel – you just need a lower interest rate. Laurel Road helps doctors save $29K on average over the life of their loans when they refinance to a lower rate.1 With Laurel Road's $100/month student loan program for residents,2 it’s never too early to start saving, and readers of The Scope receive a $300 bonus when they refinance.3

Click here to check your rate. 

Spread the word

Share our fresh approach to medical research with friends


We're off next week for Thanksgiving. We hope the call schedule left you off work, but if it didn't, we hope there are plenty of leftovers in the resident lounge.

Sign up at

  1. Average savings calculated based on single loans of DO and MD degree holders refinanced from 9/2013 to 12/2017 where borrowers’ previous rates were disclosed. Assumes same loan terms for previous and refinanced loans, and payments made to maturity with no prepayments. Actual savings for individual loans vary based on loan balance, interest rates, and other factors.
  2. We may agree under certain circumstances to allow a borrower to make $100/month payments immediately after loan disbursement if the borrower is employed fulltime as an intern, resident, fellow, or similar postgraduate trainee at the time of loan disbursement. These payments may not be enough to cover all of the interest that accrues on the loan. Unpaid accrued interest will be added to your loan and monthly payments of principal and interest will begin when the post‐graduate training program ends.
  3. $300 bonus subject to eligibility. Offer cannot be combined with other offers, including the Referral Program.  
Copyright © 2018 Scope Media, LLC. All rights reserved.