Coronary artery disease: Primary care and prevention – 5

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Statin for primary prevention

Very high lipid levels of the order of LDL cholesterol above 190 mg/dL calls for usage of statins for primary prevention. High intensity statins can be considered in this scenario as in acute coronary syndrome. When the LDL cholesterol level is between 70-189 mg/dL, primary prevention with moderate intensity statin may be considered if they are diabetic and have significant other risk factors for CAD. It is reasonable to measure SGPT/ALT levels before initiating statins and while on treatment so that values above 3 times the upper limit are not reached. Caution is advised in those above 75 years while initiating statin therapy. Screening for new onset diabetes mellitus while on statins is reasonable, though in those with high risk of CAD, new onset diabetes mellitus will not be a reason to discontinue statins. In those with CAD, statins will be continued and diabetes mellitus treated concomitantly.

High vs moderate intensity statin

High intensity statin therapy would mean atorvastatin in the dosage of 40-80 mg/d or rosuvastatin 20-40 mg/d in order to reduce LDL cholesterol by 50% or more. Moderate intensity statin could be simvastatin 20-40 mg/d, atorvastatin 10-20 mg/d or rosuvastatin 5-10 mg/d with an aim to reduce LDL cholesterol 30-50% from the baseline level at initiation of therapy.

Obesity

Obesity is diagnosed when the body mass index (BMI) is 30 Kg/sq m or more. Diets for weight loss, lifestyle interventions and counseling are the mainstay of long term management of obesity. Morbidly obese individuals may be considered for bariatric surgery in selected cases.

Summary

To summarise, fast action is needed in cases of acute coronary syndromes. In a peripheral clinic setting or small hospital, initial management and rapid transfer to a higher center is preferred. Primary PCI is the best reperfusion option for STEMI if logistics permit. Alternate option is early thrombolysis and transfer for PCI at the earliest. Cardiogenic shock or severe pulmonary edema needs early transfer to a PCI capable center.

Risk factor modification is important for all three levels of prevention – primordial, primary and secondary. Promote healthy lifestyle in the community at large and specifically in those with CAD. Statins for control of dyslipidemia have a role in primary and secondary prevention.