Train-the-Trainer Cases *Developed by Saudi Arabian, Chinese, Colombian and Brazilian faculty [ Insert Presenter Name and Credentials Here ]

Case #1: Statin Intolerance Teaching Point In patients with statin-associated muscle symptoms, try 2-3 different statins, including one at the lowest approved dose, before consideration of non-statin therapy Learning Objective Select best management for patients with possible statin-associated muscle symptoms

Case #1: Statin Intolerance A 74-year-old man who underwent coronary stent placement 6 months ago presents to clinic for follow up. He was initially started on atorvastatin 40mg daily, but he developed muscle pain and proximal muscle weakness within 2 weeks. Symptoms resolved with discontinuation.

Case #1: History Patient’s past medical history: HTN and Diabetes Current medications: Aspirin 100 mg daily, metoprolol 50 mg twice a day, metformin 500 mg twice a day Physical Exam: 46 kg (101 lbs.), BP 130/80 mmHG, HR 65 bpm Labs: Total cholesterol today is 6.1 mmol/L (236 mg/dL) and LDL-C is 3.7 mmol/L (143 mg/dL), Thyroid stimulating hormone 1.0 U/L No muscle tenderness to palpation. Good strength in all limb muscles. No other significant findings.

What is the Next Best Management Strategy for the Patient’s Muscle Pain and Elevated Lipid Levels? Change to rosuvastatin 40 mg daily Recommend use of red yeast rice preparation and coenzyme Q10 Patient is statin intolerant. Begin therapy with ezetimibe 10 mg daily Patient is statin intolerant. Begin therapy with PCSK9 inhibitor

Case #2: High Risk Patients with Primary ASCVD Prevention Teaching Point Consider the use of non-statin therapy in patients with heterozygous FH after initial treatment with maximally tolerated statin dose. Learning Objective Differentiate between various secondary treatment choices for patients with heterozygous FH

Case #2: High Risk Patients with Primary ASCVD Prevention 30-year-old man with a long history of elevated cholesterol numbers. He was found to have LDL-C 270 mg/dL (7.0 mmol/L) when he was 25 years old. He started simvastatin 20 mg daily at that time. One year ago, on simvastatin therapy his LDL-C was 275 mg/dL (7.1mmol/L). He was then changed to atorvastatin 40 mg daily. Today, his LDL is 200 mg/dL (5.2mmol/L).

Case #2: History Patient’s family history: both father (age 53) and paternal uncle (age 49) had heart attacks and severe hypercholesterolemia Patient Evaluation: Patient’s BMI is 30 kg/m2, BP is 150/90 mmHg and HR 90 bpm. Normal cardiac physical exam, abdomen is obese, subtle xanthomas Achilles tendons joints

What would be the next best initial strategy to manage this patient’s elevated LDL-C and reduce risk of cardiovascular events? Continue atorvastatin 40 mg daily Change to rosuvastatin 40 mg daily Continue atorvastatin 80 mg daily and add ezetimibe 10 mg daily Stop atorvastatin and begin therapy with PCSK9 inhibitor

Case #3: Recurrent ASCVD Patient Teaching Point Initiate non-statin therapy in a patient with recurrent ASCVD patients already on statins Learning Objective Select the appropriate non-statin therapy for patients with recurrent ASCVD

Case #3: Recurrent ASCVD Patient 55-year-old man with known peripheral artery disease presents to the hospital complaining of chest pain and is found to have non-ST segment elevation myocardial infarction (NSTEMI). He is treated with coronary stenting. He initially stated on atorvastatin 40 mg 2 years ago when he was first diagnosed with PAD. At the time of his NSTEMI, his total cholesterol was 200 mg/dL (5.2 mmol/L) and LDL was 120 mg/dL (3.1 mmol/L). Ezetimibe 10 mg daily was added. Follow-up lipid panel in 3 months showed LDL-C 90 mg/dL (2.3 mmol/L).

Case #3: History Patient’s past medical history: PAD with a left iliac artery stent Family History: father died at age 60 years from a myocardial infarction Current medications: aspirin 100 mg daily, atorvastatin 40 mg daily, ezetimibe 10 mg daily, clopidogrel 75 mg daily, metoprolol 50 mg twice a day.

What is the best next step in the management of this patient’s hyperlipidemia in the setting of his recent NSTEMI? Continue atorvastatin 80 mg daily and ezetimibe 10 mg daily Change atorvastatin to rosuvastatin 20 mg daily and continue ezetimibe 10 mg daily Stop atorvastatin, continue ezetimibe 10 mg daily, and begin therapy with PCSK9 inhibitor Continue atorvastatin 80 mg and ezetimibe 10 mg daily and add PCSK9 inhibitor

Select appropriate lipid therapy for patients with known ASCVD Case #4: VERY High-risk ASCVD Patient: Multiple Myocardial Infarctions and Recent Acute Coronary Syndrome Teaching Point Use high-intensity statin for initial treatment of patients with known ASCVD Learning Objective Select appropriate lipid therapy for patients with known ASCVD

Case #4: History 60-year-old man presents to the hospital with 30 minutes of increasing chest pain and sweating. He has a known history of prior LAD stent for new onset angina.

Case #4: History Current medicine: Atorvastatin 40 mg daily, Lisinopril 5 mg daily, metformin 500 mg twice a day Past Medical History: HTN, diabetes, tobacco (current smoker) Family History: father died from MI at age 50. Mother currently has diabetes Social History: blue collar worker Current BP: 120/80 mmHg, HR is 95 bpm, cardiac exam is normal ECG: v1-v3 ST elevation Emergent left heart catherization shows occlusion in RCA (treated with stent), 30% stenosis of prior RCA stent Patient’s total cholesterol on atorvastatin 40 mg daily is 5.2 mmol/L (201 mg/dL), LDL 3.4 mmol/L (131 mg/dL). Ezetimibe 10 mg daily is added. Repeat lipid panel in 3 months shows LDL-C 100 mg/dL (2.6 mmol/L).

According to the 2018 ACC/AHA Blood Cholesterol Guideline which of the following is the correct ASCVD risk category for this patient? Very high risk High risk Low risk 

What is the goal LDL according to the Chinese Society of Cardiology guidelines? < 70 mg/dl (<1.8 mmol/L) >50% reduction in LDL-C >50% reduction in LDL-C and LDL<70  mg/dL (<1.8 mmol/L)

What is the best management strategy to manage this patient’s cholesterol? Change to simvastatin 40 mg daily and ezetimibe 10 mg daily Continue current therapy Discontinue ezetimibe and add PCSK9 inhibitor Continue atorvastatin 40 mg daily and ezetimibe 10 mg daily. Add PCSK9 inhibitor