This is a part of iMedicalApps.com's MD Tech Tips -- Technology tips to help physicians improve their craft and work more efficiently.
Clinical Scenario
A 55-year-old African American male with a past medical history of hypertension, hyperlipidemia, and tobacco use presents for his annual exam. The patient is already on three blood pressure medications, and his systolic is 130 mm Hg. His most recent labs demonstrate an A1C of 5.5%, total cholesterol of 230 mg/dL, HDL of 35 and LDL of 165 mg/dL and triglycerides of 150 mg/dL. He has no personal or family history of atherosclerotic cardiovascular disease (ASCVD) or diabetes. Should this patient take a statin?
Using ACC's LDL-C Manager
Recently we favorably reviewed the American College of Cardiology's (ACC) latest app called LDL-C Manager. Using the ASCVD calculator in LDL-C manager, we can calculate this patient's risk using the ACC's pooled equations calculator. By inputting the above data, the patient's 10-year ASCVD risk score is quite high at 21.4% and his lifetime risk score is also extremely high at 69%. Both of these scores could be as low as 4.9% and 5% respectively if his risk factors were optimized. Since his score exceeds 7.5% (per ACC guidelines) as well as exceeds 10% per USPSTF guidelines, this patient should be prescribed a moderate to a high-intensity statin.
The app includes recommendations of medications and dosages that would fulfill this recommendation such as atorvastatin 20-80 mg daily. The patient is agreeable to a trial of atorvastatin 20 mg daily but refuses to stop smoking despite your recommendation for nicotine replacement therapy and cognitive behavioral therapy. The patient agrees to return in three months to discuss his progress on lifestyle modifications. The patient returns in six months instead of three months as your nurse tells you the patient suffered a cardiac arrest three months ago and underwent emergency angioplasty with two stents placed. He is now on 80 mg of atorvastatin and both aspirin and clopidogrel for dual antiplatelet therapy. His cardiologist requests you recheck his lipids since taking the higher dose of Lipitor.
His repeat lipids on the higher dose are virtually unchanged with a total cholesterol of 220, HDL of 40, LDL of 155 and triglycerides of 130. What would you do now?
Using LDL-C Manager's section on LDL-C Lowering Therapy, you input the above data. The app calculates that the patient's response to the high-intensity atorvastatin was suboptimal (only a 6.6% reduction compared to the recommended 50% reduction). The app recommends a target LDL (yep, targets are back to using the 2016 expert consensus guideline) of 70 mg/dL. The app provides discussion points to have with the patient regarding use of non-statin therapy including risks/benefits and patient preferences. After discussing the above with the patient, he agrees to a trial of ezetimibe 10 mg daily. The patient sees his cardiologist the following week, and his medications are changed from atorvastatin 80 mg to rosuvastatin 20 mg. He is told to continue the ezetimibe.
He follows-up with you two weeks later complaining of diffuse muscle pains since changing from atorvastatin to rosuvastatin. What would you do now?
Using the third section of the LDL-C Manager app called Statin Intolerance, you input the above information and review labs you obtain that day including a creatine kinase level of 50 which is essentially normal. The patient denies muscle tingling/twitching and complains more of muscle aches and weakness bilaterally. Reviewing the information in the LDL-C Manager app with the patient, you agree to stop the statin until the symptoms resolve, then restart the atorvastatin 80 mg (you could also use the 20 mg dose of rosuvastatin). The patient follows up in three months and has been tolerating the 80 mg of atorvastatin and 10 mg of ezetimibe. His repeat lipids now show the 50% reduction of LDL down to 75 mg/dl. He is not quite at the target dose per the ACC but has also stopped smoking. Both you and his cardiologist are much happier with his progress. He plans to follow-up with you in six months after completing his cardiac rehab.
Evidence-based medicine
Please read our full review to learn more about the evidence behind the LDL-C Manager medical app -- we had issues with some of the recommendations!
Available on iOS (iTunes) and Android (Google Play)
Disclaimer: The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.