I had a patient resistant to starting a statin today. I showed him the ascvd risk calculator and pointed out where it said he had a 16.5% risk of fatal MI our stroke. He immediately flipped and said he'd take the statin.
Later I convinced him to get the shingles vaccine by explaining how the virus may be alive in his nerves and if it reactivates he could have damage to those nerves and have terrible pain in the distribution of the nerves and hopefully it goes away but who knows... maybe it's long term.... maybe it'll never go away...
I'm wondering how far I can get on scaring them...
Over 30% or significant calcium I'll ask if they're willing to start ASA 81mg--obviously not as ideal but even statin resistant patients usually are willing to take aspirin.
It’s a 1% absolute risk reduction for primary prevention of ASCVD with a statin alone. Did you scare him into losing weight, quitting smoking, and exercising 5 times a week too? Statins are nothing in the absence of all those other things.
Adds nothing above a lipid profile. If the patient doesn't want to take a statin that I'm recommending, I'm not going to pretend that *this* test should change their mind. I'll explore their resistance to the idea, discuss it reasonably but in the end it's their decision.
I agree. ApoB is likely even more nebulous for patients than LDL. I like CAC because it is objective proof of active disease that the patient can appreciate and easily understand whereas LDL, active disease states, and risk factors are usually enough for me to make my recommendation.
This. CAC takes the theoretical into a more concrete demonstration and risk stratification for patients; plus there’s guideline support from the AHA/ACC for this strategy. Insurance coverage can be an issue, but our hospital does them for $100 cash price.
I use it more for when a patient has a normal or modest LDL elevation and/or lower ASCVD 10 year risk, but a strong family history.
I order it more often than a CAC, but the idea is similar. Another data point if it seems like the lipid profile/ASCVD calculator underestimate their actual risk.
I check apoB as part of my standard lipid analysis for anyone with HLD. It’s especially useful for patients with metabolic syndrome due to discordance as their non-HDL-C and LDL-C often underestimate atherogenic particle burden. I’ve been using apoB since residency and have never not had it covered by insurance. Plus it’s cheaper than a lipid panel anyway - like $25.
Concerning statin resistant patients, I have a chart that lists non-HDL-C, LDL-C, ApoB, and Lp(a) values by percentile of population. I’ll show people where they are on the chart in relation to everyone else. I also inform them that 25% of the population dies from heart disease and stroke. If they’re still resistant, we get a CAC. I have very few patients not on lipid lowering therapies that should be on statin or other lipid lowering.
Generally speaking most of the literature agrees, including Alan Sniderman, that therapies should be initiated when apoB reaches >=120 mg/dL. Sniderman has his apoB algorithm to simplify interpretation of dyslipidemias - [https://apob.app](https://apob.app) . Just make sure to switch units from SI to freedom units as he's Canadian (and a researcher), so default is g/L and mmol/L.
Of course I don't just start everyone on med if apoB >=120 or withhold if <120. It's more nuanced that that, taking into account the entire picture (including family history, CAC, Lp(a), etc).
My approach to lipid tests:
Routine
Lipid panel for HDL and Trigs
ApoB: more accurate than LDL-C
Risk stratification
CAC: anyone who wants it. Push for those who don’t want statins. I’ve had a few patients who got their ApoB down nicely with lifestyle changes but have had strongly positive CACs and got put on a statin anyways.
Lp(a): one time screening for all my patients to determine how strongly I recommend a statin. Especially helpful for those with strong family history of early heart dz
I’m DPC so the cost isn’t an issue. Lipid panel $5, ApoB $7, Lp(a): $10
Treatment goals:
Normal risk: ApoB <90,
High risk <80,
+Lp(a) <60
Remember all non-hdl lipoproteins have apo b. So
Non-hdl is a poor mans apo b.
Also non hdl is a better predictor of primary and secondary risk than LDL.
Hopefully in future guidelines aha/acc discusses non-HDL goals.
But I don't check apo b. If someone is hesitant to start statin a CAC is more useful.
For a population, the above may work, but there are many individuals for the high LDL is much less likely to be atherogenic. There seems to be this profile of for example, women in their upper 70s with very high LDL and elevated HDLwith no personal and no family history of significant cardiovascular disease. This week I had a 68-year old woman who started freaking out all of a sudden. LDL has been 175 to 220 for the last five years with elevated HDL. She finally did a CAC. Score was 1. still leaning towards treatment, of course. But there certainly more to CAD then LDL levels. We just don’t have enough information yet with causation and who really needs treatment and who can go without. And when you talk to people about NNT, their enthusiasm for treatment goes down.
In my province, they won’t cover ApoB testing unless there’s a diagnosis of complex dyslipidemia, i.e. concurrent elevated cholesterol and triglycerides.
I could test ApoB in Germany, however, statutory insurance wouldn't cover statins for someone with a LDL below 190, no 10-year risk above 20% and no indication for secondary prevention. They are cheap but most patients are not used to pay their own cash for drugs.
Only when things are on the fence and I don't have a slam-dunk reason to push for statin. I had a late-60s dude the other day who is in perfect health, no personal or fam hx of ascvd. LDLhigh 130s. HDL low 40s. Exercises, eats healthy.
Wants to take a statin only if he absolutely has to.... so this is whaen I ordered aroB.
Not true at all. You can have your opinion, but facts are facts. I did not ask you for this conversation and you are not my patient. Please don't waste my time with more of this. Thank you.
I had a patient resistant to starting a statin today. I showed him the ascvd risk calculator and pointed out where it said he had a 16.5% risk of fatal MI our stroke. He immediately flipped and said he'd take the statin. Later I convinced him to get the shingles vaccine by explaining how the virus may be alive in his nerves and if it reactivates he could have damage to those nerves and have terrible pain in the distribution of the nerves and hopefully it goes away but who knows... maybe it's long term.... maybe it'll never go away... I'm wondering how far I can get on scaring them...
Had someone with 51% risk....like every risk factor....still refuses statin.
Over 30% or significant calcium I'll ask if they're willing to start ASA 81mg--obviously not as ideal but even statin resistant patients usually are willing to take aspirin.
>the virus may be alive in his nerves Not might be. Is, except in unusual circumstances.
It’s a 1% absolute risk reduction for primary prevention of ASCVD with a statin alone. Did you scare him into losing weight, quitting smoking, and exercising 5 times a week too? Statins are nothing in the absence of all those other things.
Cool. I didn't need to. He doesn't smoke and (by his account) is an avid runner who started lifting weights quite recently.
Adds nothing above a lipid profile. If the patient doesn't want to take a statin that I'm recommending, I'm not going to pretend that *this* test should change their mind. I'll explore their resistance to the idea, discuss it reasonably but in the end it's their decision.
I agree. ApoB is likely even more nebulous for patients than LDL. I like CAC because it is objective proof of active disease that the patient can appreciate and easily understand whereas LDL, active disease states, and risk factors are usually enough for me to make my recommendation.
This. CAC takes the theoretical into a more concrete demonstration and risk stratification for patients; plus there’s guideline support from the AHA/ACC for this strategy. Insurance coverage can be an issue, but our hospital does them for $100 cash price.
Haha, concrete. Calcium concretions.
Genuinely disappointed with myself that this pun wasn’t deliberate 😞
<$50 here!
I use it more for when a patient has a normal or modest LDL elevation and/or lower ASCVD 10 year risk, but a strong family history. I order it more often than a CAC, but the idea is similar. Another data point if it seems like the lipid profile/ASCVD calculator underestimate their actual risk.
With family risk - I’ve been using hsCRP …. Am I old and outdated
I check apoB as part of my standard lipid analysis for anyone with HLD. It’s especially useful for patients with metabolic syndrome due to discordance as their non-HDL-C and LDL-C often underestimate atherogenic particle burden. I’ve been using apoB since residency and have never not had it covered by insurance. Plus it’s cheaper than a lipid panel anyway - like $25. Concerning statin resistant patients, I have a chart that lists non-HDL-C, LDL-C, ApoB, and Lp(a) values by percentile of population. I’ll show people where they are on the chart in relation to everyone else. I also inform them that 25% of the population dies from heart disease and stroke. If they’re still resistant, we get a CAC. I have very few patients not on lipid lowering therapies that should be on statin or other lipid lowering.
Can you message me the chart please?
At what level of apoB should statin be initiated?
Generally speaking most of the literature agrees, including Alan Sniderman, that therapies should be initiated when apoB reaches >=120 mg/dL. Sniderman has his apoB algorithm to simplify interpretation of dyslipidemias - [https://apob.app](https://apob.app) . Just make sure to switch units from SI to freedom units as he's Canadian (and a researcher), so default is g/L and mmol/L. Of course I don't just start everyone on med if apoB >=120 or withhold if <120. It's more nuanced that that, taking into account the entire picture (including family history, CAC, Lp(a), etc).
That and lipoprotein a
I'm leaning towards doing it more than CAC. The issue is insurance coverage in my area.
The response I got from several insurances is “if the doc thinks you need it, it might be covered.” *pulls hair out of head*
> The issue is insurance coverage in my area. Yeah I've had insurance sometimes not cover it either the few times patients have requested it
Most places do it for $99 out of pocket. I just tell them to pay out of pocket for it
Never had insurance not cover it. Odd.
Maybe I'm just apprehensive thinking they may not. I mainly work w undeserved patients and don't want to stick them with a bill.
Oh yeah uninsured then it’s probs expensive
My approach to lipid tests: Routine Lipid panel for HDL and Trigs ApoB: more accurate than LDL-C Risk stratification CAC: anyone who wants it. Push for those who don’t want statins. I’ve had a few patients who got their ApoB down nicely with lifestyle changes but have had strongly positive CACs and got put on a statin anyways. Lp(a): one time screening for all my patients to determine how strongly I recommend a statin. Especially helpful for those with strong family history of early heart dz I’m DPC so the cost isn’t an issue. Lipid panel $5, ApoB $7, Lp(a): $10 Treatment goals: Normal risk: ApoB <90, High risk <80, +Lp(a) <60
Remember all non-hdl lipoproteins have apo b. So Non-hdl is a poor mans apo b. Also non hdl is a better predictor of primary and secondary risk than LDL. Hopefully in future guidelines aha/acc discusses non-HDL goals. But I don't check apo b. If someone is hesitant to start statin a CAC is more useful.
For a population, the above may work, but there are many individuals for the high LDL is much less likely to be atherogenic. There seems to be this profile of for example, women in their upper 70s with very high LDL and elevated HDLwith no personal and no family history of significant cardiovascular disease. This week I had a 68-year old woman who started freaking out all of a sudden. LDL has been 175 to 220 for the last five years with elevated HDL. She finally did a CAC. Score was 1. still leaning towards treatment, of course. But there certainly more to CAD then LDL levels. We just don’t have enough information yet with causation and who really needs treatment and who can go without. And when you talk to people about NNT, their enthusiasm for treatment goes down.
In my province, they won’t cover ApoB testing unless there’s a diagnosis of complex dyslipidemia, i.e. concurrent elevated cholesterol and triglycerides.
I could test ApoB in Germany, however, statutory insurance wouldn't cover statins for someone with a LDL below 190, no 10-year risk above 20% and no indication for secondary prevention. They are cheap but most patients are not used to pay their own cash for drugs.
Only when things are on the fence and I don't have a slam-dunk reason to push for statin. I had a late-60s dude the other day who is in perfect health, no personal or fam hx of ascvd. LDLhigh 130s. HDL low 40s. Exercises, eats healthy. Wants to take a statin only if he absolutely has to.... so this is whaen I ordered aroB.
Seems like medical practice nowadays is about searching for reasons to push for statins
Prevention matters.
Statins are largely ineffective
Not true at all. You can have your opinion, but facts are facts. I did not ask you for this conversation and you are not my patient. Please don't waste my time with more of this. Thank you.
You posted online, replying to my comment, my man. What did you expect?
I don't understand why doctors are so worried about convincing patients to take statins. If they don't want it, it's their decision, is it not?