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Identifying Patients for Nonstatin Therapy
Journal article   Open access   Peer reviewed

Identifying Patients for Nonstatin Therapy

Jennifer G Robinson and Karol E Watson
Reviews in cardiovascular medicine, Vol.19(S1), pp.S1-S8
2018
DOI: 10.3909/ricm19S1S0004
PMID: 30207552
url
https://doi.org/10.3909/ricm19S1S0004View
Published (Version of record) Open Access

Abstract

Statins are first-line therapy for reducing atherosclerotic cardiovascular disease (ASCVD) risk. Some patients remain at high ASCVD risk despite maximizing statin therapy. Ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies (mAbs) have been shown to reduce ASCVD events in randomized trials and may be of benefit in selected high-risk patients with cardiovascular disease (CVD) or familial hypercholesterolemia (FH). Number-needed-to-treat (NNT) to prevent one ASCVD event can help identify groups of patients who may gain a net benefit from added nonstatin therapy. Patient groups with NNTs <25 (in whom PCSK9 mAbs may approach cost effectiveness with discounting) include extremely high-risk patients (those with CVD with FH, polyvascular disease, or recurrent ASCVD events) with lowdensity lipoprotein cholesterol (LDL-C) levels ≥70 mg/dL, very high-risk patients (those with CVD with diabetes [and no polyvascular disease], chronic kidney disease, or acute coronary syndromes, or CVD or FH with poorly controlled risk factors) with LDL-C levels ≥100 mg/dL, and high-risk patients (those with CVD or FH with well-controlled risk factors) with LDL-C ≥130 mg/dL. Ezetimibe, which is generic in the United States, is reasonable for patient groups with NNTs <30, the level considered reasonable by most patients. This includes extremely high-risk patients with LDL-C levels ≥130 mg/dL, or very high-risk patients with LDL-C ≥190 mg/dL. All guidelines recommend statin therapy for the prevention of ASCVD.
 Dyslipidemias - drug therapy Ezetimibe - adverse effects Cardiovascular Diseases - prevention & control Humans Risk Factors Treatment Outcome Biomarkers - blood Proprotein Convertase 9 - metabolism Anticholesteremic Agents - adverse effects Patient Selection Serine Proteinase Inhibitors - therapeutic use Dyslipidemias - blood Anticholesteremic Agents - therapeutic use Dyslipidemias - epidemiology Proprotein Convertase 9 - antagonists & inhibitors Serine Proteinase Inhibitors - adverse effects Clinical Decision-Making Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use Cardiovascular Diseases - epidemiology Cholesterol, LDL - blood Ezetimibe - therapeutic use Drug Therapy, Combination Dyslipidemias - diagnosis Cardiovascular Diseases - diagnosis

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