This is a continuation in our series of MD Tech Tips — Technology tips to help physicians improve their craft and work more efficiently.
A 55 year-old African American male with a past medical history of hypertension, hyperlipidemia and tobacco use presents for his annual exam. The patient is already on three blood pressure medications and his systolic is 130 mm Hg and his most recent labs demonstrate an A1C of 5.5, total cholesterol of 230, HDL of 35 and LDL of 165 and Trig of 150 mg/dl. He has no personal or family history of ASCVD or diabetes. Should this patient take a statin?
How to use ACC’s LDL-C Manager app to determine care for this patient
Recently we favorably reviewed the American College of Cardiology’s (ACC) latest app called LDL-C Manager. Using the ASCVD calculator in LDL-C manager, we can calculate this patient’s risk using the ACC’s pooled equations calculator. By inputting the above data, the patient’s 10-year ASCVD risk score is quite high at 21.4% and his lifetime risk score is also extremely high at 69%. Both of these scores could be as low as 4.9% and 5% respectively if his risk factors were optimized. Since his score exceeds, 7.5% (per ACC guidelines) as well as exceeds 10% per USPSTF guidelines, this patient should be prescribed a moderate to high intensity statin. The app includes recommendations of medications and dosages that would fulfill this recommendation such as atorvastatin 20-80mg daily.
The patient is agreeable to a trial of atorvastatin 20mg daily, but refuses to stop smoking despite your recommendation for nicotine replacement therapy and cognitive behavioral therapy. The patient agrees to return in 3 months to discuss his progress on lifestyle modifications.
The patient returns in 6 months instead of 3 months as your nurse tells you the patient suffered a cardiac arrest 3 months ago and underwent emergency angioplasty with 2 stents placed. He is now on 80mg of atorvastatin and both aspirin and clopidgrel for dual anti-platelet therapy. His cardiologist requests you recheck his lipids since taking the higher dose of lipitor.
His repeat lipids on the higher dose are virtually unchanged with a total cholesterol of 220, HDL of 40, LDL of 155 and triglycerides of 130. What would you do now?
Using LDL-C Manager’s section on LDL-C Lowering Therapy, you input the above data. The app calculates the patient’s response to the high intensity atorvastatin was suboptimal (only a 6.6% reduction compared to the recommended > 50% reduction). The app recommends a target LDL (yep, targets are back using the 2016 expert consensus guideline) of 70 mg/dl. The app provides discussion points to have with the patient regarding use of non-statin therapy including risks/benefits and patient preferences. After discussing the above with the patient, he agrees to a trial of ezetimibe 10mg daily.
The patient sees his cardiologist the following week and his medications are changed from atorvastatin 80mg to rosuvastatin 20mg and he is told to continue the ezetimibe.
He follows up with you 2 weeks later complaining of diffuse muscle pains since changing from atorvastatin to rosuvastatin. What would you do now?
Using the 3rd section of the LDL-C Manager app called Statin Intolerance, you input the above information and review labs you obtain that day including a creatine kinase level of 50 which is essentially normal. The patient denies muscle tingling/twitching and complains more of muscle aches and weakness bilaterally. Reviewing the information in the LDL-C Manager app with the patient, you agree to stop the statin until the symptoms resolve, then restart the atorvastatin 80mg (you could also use the 20mg dose of rosuvastatin).
The patient follows-up in 3 months and has been tolerating the 80mg of atorvastatin and 10mg of ezetimibe. His repeat lipids now show the > 50% reduction of LDL down to 75 mg/dl. He is not quite at the target dose per the ACC, but has also stopped smoking. Both you and his cardiologist are much happier with his progress. He plans to follow-up with you in 6 months after completing his cardiac rehab.
Evidence based medicine
Please read our full review to learn more about the evidence behind the LDL-C Manager medical app — we did have some issues with some of the recommendations!
Disclaimer: The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.