What is the best approach to manage cardiac risks in high-risk patients?

From the Guidelines

The best approach to manage cardiac risks in high-risk patients involves a comprehensive strategy combining lifestyle modifications, medication therapy, and regular monitoring, with a focus on upfront lipid-lowering combination therapy, as recommended by the 2024 International Lipid Expert Panel (ILEP) position paper 1.

Key Components of Cardiac Risk Management

• Lifestyle modifications: heart-healthy diet, moderate exercise (150 minutes weekly), healthy weight, smoking cessation, and limited alcohol consumption
• Medication therapy: statins (e.g., atorvastatin 20-80mg daily or rosuvastatin 10-40mg daily) to lower LDL cholesterol below 70 mg/dL, antihypertensives to maintain blood pressure below 130/80 mmHg, and antiplatelet therapy (aspirin 81mg daily) for appropriate patients
• Regular monitoring: quarterly blood pressure checks, annual lipid panels, and appropriate cardiac testing based on risk factors

Upfront Lipid-Lowering Combination Therapy

• Recommended for very high-risk secondary prevention patients, with a focus on double or triple therapy for extremely high-CVD-risk patients 1
• Includes statins, ezetimibe, bempedoic acid, and monoclonal antibody/small interference RNA (siRNA) targeting proprotein convertase subtilisin/kexin type 9 (PCSK9) 1

Importance of Adherence and Access to Care

• Regular monitoring and follow-up care are crucial to ensure adherence to therapy and achieve treatment targets 1
• Innovative digital tools and coordinated comprehensive care programs can improve patient education, therapy adherence, and effectiveness 1

Prioritization of High-Risk Patients

• Patients with established coronary heart disease, peripheral artery disease, and cerebrovascular atherosclerotic disease should be prioritized for preventive efforts 1
• Asymptomatic individuals with multiple risk factors or markedly raised levels of single risk factors should also be prioritized for preventive interventions 1

From the FDA Drug Label

Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal

The best approach to manage cardiac risks in high-risk patients includes:

• Comprehensive cardiovascular risk management
• Control of high blood pressure
• Lipid control
• Diabetes management
• Antithrombotic therapy
• Smoking cessation
• Exercise
• Limited sodium intake
• Aggressive treatment to a lower blood pressure goal in patients with higher risk independent of their hypertension, such as those with diabetes or hyperlipidemia 2, 3, 4.

From the Research

Cardiac Risks Management

To manage cardiac risks in high-risk patients, several approaches can be considered:

• The use of statins, such as atorvastatin, has been shown to be effective in reducing low-density lipoprotein cholesterol (LDL-C) levels and subsequently lowering the risk of cardiovascular disease (CVD) events 5, 6, 7.
• High-intensity statins are recommended for patients with atherosclerotic cardiovascular disease (ASCVD) or those at high risk for ASCVD, with a goal of reducing LDL-C levels by 50% or greater 7.
• For patients who cannot tolerate high-intensity statins, a combination of a moderate-intensity statin with ezetimibe may be a reasonable alternative 7.
• Fixed-dose combinations of amlodipine and atorvastatin have been shown to be effective in reducing LDL-C levels and blood pressure in patients with concomitant hypertension and hypercholesterolemia 8.

Patient Selection

When selecting patients for cardiac risk management, the following factors should be considered:

• Patients with a history of CVD or those at high risk for CVD, including those with diabetes, hypertension, or hypercholesterolemia 5, 6, 7.
• Patients with a 10-year CVD risk of 10% or greater, as estimated by risk assessment tools 6, 7.
• Patients with severe hypercholesterolemia or those with a high coronary artery calcium score 7.

Treatment Monitoring

When monitoring patients on cardiac risk management therapy, the following should be considered:

• Regular monitoring of LDL-C levels to ensure that treatment goals are being met 5, 7, 8.
• Monitoring of blood pressure and other CVD risk factors, such as diabetes and smoking status 6, 8.
• Adjustment of treatment as needed to ensure that patients are receiving the most effective therapy for their individual risk profile 7.