Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Satellite Industry Meeting - A veritable PRIMARY PREVENTION- FESTMar 29, 2009 10:47 EDT
Some of the world’s leading Prevention specialists came together tonight from 7:30 pm to 9:30 pm at the Peabody hotel for an outstanding discussion on such issues as hsCRP, calcium scoring, data interpretation and the future direction of risk reduction. The distinguished panel consisted of moderator Christie Ballantyne of Baylor, Roger Blumenthal , Johns Hopkins, Michael Davidson, U of Chicago, and Peter Ganz,, San Francisco General. Though I must advise that this was an INDUSTRY-SPONSORED event, the discussants mentioned every statin on the planet in a favorable light with no real bias projected into any aspect of any discussion. The closest thing that an ""industry critic" would latch onto was a comment made by Michael Davidson regarding" high efficacy statins getting patients to target faster than generics". This was an UN- “bias”-ed statement however as it was grounded in evidence based medicine and a statement of fact . Generics produce approximately 2/3 the benefit of brand statin in the PROVE-IT trial.
It was a 2 hour program packed with information, so I’ll do my best to give you the salient points. Forgive the lengthy diatribe here, but I’d like to do it justice so you can get a flavor of the event. I’ll break it into two or three segments for better readability,
Case study presented by Peter Ganz: : 57 y.o. male with 134/70 bp on Rx with ace and negative FH-. No tobacco . Asymptomatic. 32 inch waist., FBS 93, chol 186, HDL 38, TG 195 and LDL 109.
QUESTION: Would you treat?
I was one of the 58% in the audience who voted “yes”. He went onto explain that the ATP III- FHR was a score of 14 = 16% risk. Then Dr. Ganz added that “the patient reached in his pocket and pulled out a CRP that he forget to tell anyone about” of 4.2 .(audience chuckles). 20 of mg rosuvastatin dropped LDL from 109 to 62 but only decreased CRP to 3.4.
NEXT QUESTION: Would you then increase dose to 40 mg? 1/3 of the audience vote no, 1/3 yes and 1/3 would add another drug. The point: hsCRP is an independent risk factor so we should probably increase the dose.
There was an indepth explanation of why we CANNOT rely upon the ROC curve alone in order to decide treatment thresholds but SHOULD employ the REYNOLD's RISK score which re-classified nearly half of the cohorts in the WOMEN'S HEALTH STUDY. He quoted Nancy Cook who pointed out that adding LDL and HDL levels to age, smoking and BP in the Women’s health study did NOT shift the ROC curve upward the to the left and therefore would have resulted in a significant missed opportunity for risk reduction.
There was then a short discussion of the JUPITER trial which we all know treated healthy elevated hsCRP men greater than 50 y.o and women greater than 60 with low LDL but high hsCRP yielding a 37% reduction in CRP with a NNT of 25 (with <100 being the ideal). He included important criticism of Jupiter asking the rhetorical question “was it CRP or was it age”? He frankly pointed out that if reduction in cancer mortality had been excluded then the mortality benefit would not have been significant, a very important aspect of this trial that deserves sharp focus. Finally, the JUPITER trial was terminated early which left us to draw incomplete conclusions on many endpoints. He also added that his sister- in- law would hopefully be participating a trial in which they would examine whether or not a reduction in the formation of intestinal polyps and gut cancers could be attributed to Rosuvastatin which I think is a logical next step.
Dr. Ganz described himself as an “interventional cardiologist who also believes in prevention therapy”.
I am grateful for that evangelical point and his excellent presentation tonight.
More salient points from the primary prevention gurus: