NEW 2013 ACC/AHA GUIDELINES ON TREATMENT OF CARDIOVASCULAR RISK IN ADULTS

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NEW 2013 ACC/AHA GUIDELINES ON TREATMENT OF

BLOOD CHOLESTEROL TO REDUCE ATHEROSCLEROTIC

CARDIOVASCULAR RISK IN ADULTS

MINI-LECTURE

PEJMAN SOLAIMANI, PGY-2

FEB 2014

OBJECTIVES

I.

INTRODUCTION TO NEW GUIDELINES ON LIPID MANAGEMENT

II.

COMPARISON WITH ATP III GUIDELINES

III.

CURRENT STATIN TREATMENT RECOMMENDATIONS

IV. CURRENT STATIN SAFETY RECOMMENDATIONS

OVERVIEW

• GOAL: TREATMENT OF BLOOD CHOLESTEROL TO REDUCE ATHEROSCLEROTIC

CARDIOVASCULAR RISK IN ADULTS, CURRENTLY THE LEADING CAUSE OF DEATH AND

DISABILITY IN AMERICA

WHAT HAS CHANGED COMPARED TO ATP3

GUIDELINE?

• INITIATE EITHER MODERATE-INTENSITY OR HIGH-INTENSITY STATIN THERAPY FOR PATIENTS WHO FALL

INTO THE FOUR CATEGORIES

• UNLIKE ATP-III, DO NOT TITRATE TO A SPECIFIC LDL CHOLESTEROL TARGET

• MEASURE LIPIDS DURING FOLLOW-UPS TO ASSESS ADHERENCE TO TREATMENT, NOT TO ACHIEVE A

SPECIFIC LDL TARGET

FOUR MAJOR STATIN BENEFIT GROUPS

1) INDIVIDUALS WITH CLINICAL ASCVD

2) INDIVIDUALS WITH LDL >190

3) INDIVIDUALS WITH DM, 40-75 YO WITH LDL 70-189 AND WITHOUT CLINICAL ASCVD

4) INDIVIDUALS WITHOUT CLINICAL ASCVD OR DM WITH LDL 70-189 AND ESTIMATED 10-YEAR

ASCVD RISK >7.5%

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

NO RECOMMENDATIONS ON STATIN THERAPY FOR PTS WITH NYHA CLASS II-IV

OR ESRD ON DIALYSIS (GRADE N RECOOMENDATIONS)

INTENSITY OF STATIN THERAPY IN PRIMARY AND

SECONDARY PREVENTION

STATIN SAFETY RECOMMENDATIONS

• SELECT THE APPROPRIATE DOSE

• KEEP POTENTIAL SIDE EFFECTS AND DRUG-DRUG INTERACTION IN MIND (GRADE A)

• IF HIGH OR MODERATE INTENSITY STATIN NOT TOLERATED, USE THE MAXIMUM TOLERATED

DOSE INSTEAD

STATIN SAFETY RECOMMENDATIONS

• CONDITIONS THAT COULD PREDISPOSE PTs TO STATIN SIDE EFFECT: o IMPAIRED RENAL OR HEPATIC FUNCTION o HISTORY OF PREVIOUS STATIN INTOLERANCE OR MUSCLE DISORDER o AGE >75 o UNEXPLAINED ALT ELEVATION > 3X ULN o HISTORY OF HEMORRHAGIC STROKE o ASIAN ANCESTRY

STATIN SAFETY RECOMMENDATIONS

• CHECK BASELINE ALT PRIOR INITIATING THE STATIN (GRADE B)

• CHECK LFTS IF PATIENT DEVELOPS SYMPTOMS OF HEPATIC DYSFUNCTION (GRADE E)

• IF 2 CONSECUTIVE LDL <40, CONSIDER DECREASING THE STATIN DOSE (GRADE C, WEAK

RECOMMENDATION)

• IT MAY BE HARMFUL TO INITIATE SIMVASTATIN 80MG, OR INCREASE THE DOSE OF SIMVASTATIN TO

80MG (GRADE B)

CASE 1

62 YEAR OLD AA MALE

• TOTAL CHOLESTEROL: 140

• LOW HDL: 35

• SBP: 130 MMHG

• NOT TAKING ANTI-HYPERTENSIVE MEDICATIONS

• NON-DIABETIC

• NON-SMOKER

• CALCULATED 10 YR RISK OF ASCVD : 9.1%

• MODERATE TO HIGH INTENSITY STATIN

50 YEAR OLD WHITE FEMALE

• TOTAL CHOLESTEROL 180

• HDL: 50

• SBP: 130

• TAKING ANTI-HTN MEDS

• +DIABETIC

• +SMOKER

• CALCULATED 10 YR ASCVD: 9.8%

CASE 2

• HIGH INTENSITY STATIN

48 YO WHITE FEMALE

• TOTAL CHOLESTEROL 180

• HDL: 55

• SBP: 130

• NOT TAKING ANTI-HTN MEDS

• +DIABETIC

• NON-SMOKER

• CALCULATED 10 YR RISK ASCVD : 1.8%

CASE 3

• MODERATE INTENSITY STATIN

22 YO WHITE MALE

• LDL: 195

• SBP: 120

• NOT TAKING ANTI-HTN MEDS

• NON-DIABETIC

• NON-SMOKER

CASE 4

• HIGH INTENSITY STATIN

66 YO WHITE FEMALE

• HIGH TOTAL CHOLESTEROL: 230

• HDL: 55

• SBP: 150

• TAKING ANTI-HTN MEDS

• NON-DIABETIC

• NON-SMOKER

• CALCULATED 10 YR RISK OF ASCVD : 2.0 %

CASE 5

• STATIN THERAPY NOT RECOMMENDED

TAKE HOME MESSAGE

1.

RATHER THAN LDL–C OR NON-HDL– C TARGETS, NEW GUIDELINE USES THE INTENSITY OF STATIN

THERAPY AS THE GOAL OF TREATMENT.

2.

KNOW THE 4 STATIN BENEFIT GROUPS:

I.

II.

INDIVIDUALS WITH CLINICAL ASCVD

INDIVIDUALS WITH PRIMARY ELEVATIONS OF LDL–C ≥190 MG/DL

III.

INDIVIDUALS 40 TO 75 YEARS OF AGE WITH DIABETES AND LDL–C 70 TO189 MG/DL WITHOUT CLINICAL

ASCVD

IV.

INDIVIDUALS WITHOUT CLINICAL ASCVD OR DIABETES WHO ARE 40 TO 75 YEARS OF AGE WITH LDL–C 70 TO

189 MG/DL AND HAVE AN ESTIMATED 10-YEAR ASCVD RISK OF 7.5% OR HIGHER. ( USING THE POOLED

COHORT EQUATIONS FOR ASCVD RISK PREDICTION )

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

REFERENCES:

• Stone Nj, Robinson J, Lichtenstein Ah, Bairey Merz Cn, Lioyd-jones Dm, Blum Cb, Mcbride P, eckel Rh, Schwartz Js, Goldberg Ac,

Shero St, Gordon D, Smith Sc Jr, Levy D, Watson K, Wilson Pw. 2013 ACC/AHA Guideline On The Treatment Of Blood Cholesterol

To Reduce Atherosclerotic Cardiovascular Risk In Adults: A Report Of The American College Of Cardiology/American Heart

Association Task Force On Practice Guidelines.

J Am Coll Cardiol.

2013 Nov 7. Pii: S0735-1097

• John F. Keaney, Jr., M.D., Gregory D. Curfman, M.D., And John A. Jarcho, M.D. A Pragmatic View Of The New Cholesterol Treatment

Guidelines. N Engl J Med 2014; 370:275-278

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