Internal Medicine & Hospital Medicine

Biography

Biography: Ishwarlal Jialal

Abstract

Atherosclerotic Cardiovascular disease (ASCVD) is the leading cause of mortality in patients with diabetes. Whilst there are many potential mechanisms including dyslipidemia, hypertension, inflammation and increased oxidative stress, low density lipoprotein- cholesterol(LDL-cholesterol) ranked as the strongest predictor for future Cardiovascular  events (CVE).

Furthermore numerous trials with statin drugs including HPS-(simvastatin) and CARDS, TNT , PROVE-IT(atorvastatin)have shown a reduction in CV events including ischemic stroke . A meta-analysis of 14 randomized trials showed that statin therapy in diabetics resulted in a 13 % reduction in vascular mortality. Numerous guidelines have been issued with respect to statin therapy. The most recent recommendation of the ADA (2016) is high intensity statin (> 50 % reduction in LDL-C ) for diabetics between ages 40-75 years with ASCVD or ASCVD risk factors(LDL-C>100mg/dl, hypertension, smoking, obesity ,albuminuria  FH of premature ASCVD). In this age range if there is no ASCVD or risk factors moderate intensity statin is recommended(30-50% reduction in LDL-C). In patients > 75 years  with ASCVD the only difference is moderate intensity/high intensity  statin with ASCVD risk factors. Finally in patients <40 years  with no risk factors statin therapy is not recommended whilst moderate/high intensity statin is recommended for patients with ASCVD risk factors  and high intensity statin for patients with ASCVD. The ESC/EASD guidelines recommend targets ie LDL-C < 70mg/dl for diabetics with ASCVD or ASCVD risk factors ( or > 50 % reduction in LDL-C). In the remaining diabetics they recommend a LDL-C goal < 100mg/dl . Neither make a strong recommendation for combination therapy with fibrates and discourage combination with niacin .

In conclusion , statin therapy is the cornerstone in our strategy to lower LDL-C to targets or  by percentage to reduce ASCVD mortality  .