Heart Failure with Preserved Ejection Fraction - Managing Comorbidities

Heart failure (HF) is a complex condition characterized by signs of volume overload or symptoms such as dyspnea, exercise intolerance, and fatigue. Being a syndrome, HF is not explained by one unifying pathophysiologic cause.  Rather, various mechanisms lead to the deficit between the amount of blood delivered and the amount of blood that needs to be delivered through the body to maintain homeostasis.  HF is defined as the previously mentioned signs or symptoms being caused by structural or functional cardiac abnormalities plus either 1) elevated natriuretic peptides (e.g., BNP) or 2) objective evidence of

Update on niacin - Results from the HPS2-THRIVE study

In a previous blog post, niacin for dyslipidemia, we discussed the concerns regarding niacin's lack of improvement of clinically meaningful endpoints in addition to some of its adverse effects and how to deal with them.  Recently, final results of the HPS2-THRIVE study have been published.  Here are a few highlights of the results of this study.

Dealing with statin-induced myopathy

Let’s start with a patient case.  An 82 year old female patient presents to clinic with complaints of weakness in her lower extremities. She describes her weakness as symmetrical heaviness and identifies some stiffness and cramping. Other causes of her complaints are ruled out except for her medications. Her hyperlipidemia is currently being managed with simvastatin 40 mg orally daily and niacin ER 1 g orally daily. What are our options for dealing with suspected statin-induced myopathy?

Statins in liver disease?

A middle-aged patient arrives to his regularly scheduled clinic appointment looking for refills of his medication. His PMH includes HTN, hyperlipidemia, diabetes mellitus, obesity, and cirrhosis secondary to nonalcoholic fatty liver disease. His medications include antihypertensive and antihyperglycemic drugs in addition to atorvastatin 80 mg by mouth daily. At this time, you recall that statins have a risk for hepatotoxicity and are concerned whether it should be refilled at this time. What are the considerations for continuing statin therapy in this patient with known liver disease?

Elevation of liver enzymes is a well-known risk of statin therapy. Since the first statin was approved by the FDA in 1987, regular monitoring of liver enzymes to screen for elevations was routine practice. However, in 2012, the FDA revised the prescribing information for all statins to recommend serum aminotransferases be measured at baseline and then only thereafter if clinically indicated. There were primarily two reasons for this change:

Niacin for dyslipidemia

Niacin is one of our options for managing cholesterol in patients with dyslipidemia.  The benefits of high doses of niacin are well established in reducing triglycerides by 20-50%, reducing LDL by 10-25%, and increasing HDL by 10-30%.  What is not well established, however, are the clinically beneficial endpoints of niacin.