Presentation made by Dr. Akshay Mehta on the use of statins in Indians.

1. Statins for Primary Prevention
In Indians
Dr. Akshay Mehta
Nanavati Superspeciality Hospital
Asian Heart Institute
Holy Family Hospital

2. If CVD in Indians is a challenge !
• Two to four –fold more prone to MI and CV
death compared to Caucasians
• Increasing incidence…
• < 40 years of age
• Metabolic syndrome and
• Atherogenic dyslipidemia (small dense LDL,
high triglyceride, and low HDL)
• Lipoprotein (a) a potent atherogenic
lipoprotein

3. Statins are an opportunity !
• Cheap & freely available statins-many generics
• Effective at low doses in Indians-higher blood levels
• At young age, small reduction in LDLC, great lifetime
benefit
• Catching them young in their (plaque) formative years
is important !
ARIC study
PCSK9 mutation

4. Mr. Suresh T is a 42 year old executive. He is not
a smoker or a diabetic. Pursues a healthy
lifestyle including diet and exercise. His
grandfather had an MI at age 76.
• TC=220
• HDLC=35
• TG=150
• LDLC=155
• SBP of 130 on
medications.
His question:
“Should I take a statin ?”

5. Number of CVD Risk Scores in the
World……………ABOUT 70
• Examples:
• ACC/AHA
• ATP III/FRS
• INTERHEART
• SCORE
• QRISK2
• JBS3
• Reynolds
• MESA
• WHO………..etc etc

6. Problems with risk scores
• Heavily influenced by age
• Dangers of over treatment-esp >60 yrs age
• Dangers of under treatment-esp the young-very
important in India
• More than half IHD occurs in people at low to
moderate risk
• No randomized prospective studies of statin benefit
from young age (e.g. from age 30)
• No risk prediction models exclusively based on Indian
data or has been validated in Indians

7. CRUCIAL QUESTION: How to select the
high risk Indian?
How to separate wheat from the chaff ?

8. 1. Select a risk score best applicable to
Indians-----JBS3

9. Comparative accuracy of different risk scores in assessing
cardiovascular risk in Indians: A study in patients with first
MI: Indian Heart J. 2014 myocardial infarction
• 149 patients with AMI
• 4r risk assessment models applied to estimate what would
have been their predicted 10-year risk of CV events if they had
presented just prior to suffering the acute MI.
• Framingham Risk score (RiskFRS),
• WHO risk prediction charts (RiskWHO),
• ACC/AHA pooled cohort equations (RiskACC/AHA) and
• 3rd Joint British Societies' risk calculator (RiskJBS)]

10. The estimated 10-year cardiovascular risk divided
into two risk categories as <20% and ≥20%.

11. 2. ApoB
• Nearly 80% of heart disease occurs in developing
countries.
• Nine modifiable risk factors predict 90% of acute MI
• Current smoking and an abnormal ApoB/ApoA-1 ratio
predict 66% of global heart disease.

12. J Am Coll Cardiol 2016; 67:193–201
A multicenter, longitudinal, population-based cohort of
3,036 aged 18 to 30 years at Year 0 (1985 to 1986)with
measurements for apoB at baseline
who also underwent CAC measurement at Year 25
A dose–response association between apoB in young
adults and the presence of midlife CAC independent of
baseline traditional CVD risk factors

13. 3. CAC- The Great Discriminator !
J Am Coll Cardiol. 2015;66(15):1643-1653
10-Year Coronary Heart Disease Risk Prediction Using
CAC and Traditional Risk Factors: MESA

14. CAC--- the power of zero !
A 15-Year Warranty Period for Asymptomatic Individuals
Without CAC: A Prospective Follow-Up of 9,715 Individuals
2015;8(8):900-909.

15. CAC- Cheaper than a life time of
statins !
50 % of statin recommended patients had zero CAC
with low CVD over 10 yrs
Implications of CAC Testing Among Statin Candidates According to ACC/AHA
Cholesterol Management Guidelines: MESA Analysis JACC 2015;66(15):1657-
1668

16. J Am Coll Cardiol 2016;67:630–40)
OBJECTIVES : This study aimed to assess whether statin therapy was associated
with a reduction in major adverse cardiovascular events (MACE) and mortality in
patients with asymptomatic peripheral arterial disease.
After a median duration of 3.6 years, statin therapy was found to cause a
reduction in MACE and all-cause mortality among participants without clinical
CVD and low mean CVD risk, but with asymptomatic peripheral arterial disease.
4. ABI

17. 5. Use Life time risk
score or FRS X 1.8

18. So, what do we tell Suresh T ?
• Choose the risk prediction algorithm most
applicable to Indians- ex JBS3
• Or recalibrate FRS/ATPIII by 1.8
• Or calculate lifetime risk

19. Start a conversation-
risk / benefit- use NNT/NNH

20. If he still wishes better definition of
risk..
Use:
CACS
ABI
ApoB
………………………………………..
hsCRP, CIMT, etc

21. Talking is important !