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I've been thinking a lot about PCSK9i lately. I have several patients with moderate or even normal LDL and high Lp(a) but no "established clinical atherosclerotic cardiovascular disease " cignaforhcp.cigna.com/public/content…
These patients are either tolerant or intolerant of statin and it does not matter and companies won't approve PCSK9i unless the LDLc is at or near FH levels as it is technically secondary prevention
I've done calcium scans on a few of them and that does not change things no matter how high the CAC. The payers do not see that as established disease. So a few of these patients have discussed paying out of pocket for PCSK9i and I have discouraged them...
Well it turns out that I learned that established ASCVD can be defined as any coronary atherosclerosis as seen on CTA. Whether you agree with that or not this sets up an interesting scenario whereby one can pay out of pocket for a CTA for ~$1200 and thereby save ~$7K/year
It is actually more than just a game. In fact, the information we learn is very useful in helping to guide decisions about medical therapy even more than CAC. With the reduced radiation these days it is one of the most common reasons I do them now (CTAs)
Again this is not for patients with chest pain but really as an aide in guiding choices about medical therapy for patients in what is effectively primary prevention
And the side-benefit is that it is practically the only way to get PCSK9i approved in higher risk non secondary prevention patients with high Lp(a)
It's a holiday weekend so feel free to completely crucify me. I just wanted to throw this out there cuz it's come up half a dozen times recently
