by
Apurva D. Shah, FACC
Northside Heart and Vascular Institute
2013
2001
• ACC/AHA
GUIDELINES ON THE
TREATMENT OF
BLOOD
CHOLESTEROL
• ATP-3
Statin Trials
&
Non Statin Trials
1. “Doc, why would you want to change my cholesterol
medications?”
2. I need a trick to remember the guidelines; I can’t Google it in
front of the patient
3. That wasn’t so bad, lets try it again on the next patient
“Doc, why would you want to change my
cholesterol medications?”
The ATP III guidelines:
1. Assess risk based on the Framingham Risk Score
1. FRS underestimates cardiovascular risk
2. Lots of patients with low FRS have MI’s
2. Sets goal LDL-C levels for therapy
1. Clinical trials didn’t set LDL-C goals
2. No trial was powered for and LDL-C = 70
By using the Framingham Risk Score, we are missing
people who can benefit from statin therapy
10 Year Predicted and Observed Rates of CV Disease and Heart Disease
Mortality Quintiles of Framingham Predicted CV Disease Events
Brindle P M et al. Br J Gen Prac
2005;55:838-845
I need a trick and method to remember the guidelines
that’s not Google!
Place in risk group
Prescribe statin dose based on risk group
Atherosclerotic Disease
LDL-C >190 mg/dl
Diabetes
Everyone Else
A
• Atherosclerotic Disease
L
• LDL > 190 mg/dl
D
• Diabetes
E
• Everyone Else
Place in risk group
Prescribe statin dose based on risk group
High-Intensity
statin therapy
• Lipitor 40-80 mg
• Crestor 20-40 mg
ModerateIntensity statin
therapy
•
•
•
•
No Statin
Therapy
Lipitor 10-20 mg
Crestor 5-10 mg
Zocor 20-40 mg
Pravachol 40-80 mg
• Healthy lifestyle
Atherosclerotic Disease
LDL-C >190 mg/dl
Diabetes
Everyone Else
• High risk for cardiovascular event
• High risk requires High Intensity
•Lipitor 40-80mg
•Crestor 20-40mg
Atherosclerotic Disease  NO
LDL-C >190 mg/dl
Diabetes
Everyone Else
• LDL > 190 confers a high event risk
• High risk requires High intensity
•Lipitor 40-80mg
•Crestor 20-40mg
Atherosclerotic Disease  NO
LDL-C >190 mg/dl  NO
Diabetes
Everyone Else
• Not all Diabetic are created equal
But
• All Diabetics benefit from statin therapy
• Must calculate risk score
• Found at Google Play
Store:
• ASCVD Risk Estimator
• Estimates 10 year risk for
a cardiovascular event
• High risk > 7.5%
Calculate Risk Score
Risk > 7.5%:
Risk < 7.5%:
High Intensity
Statin
Therapy
Moderate
Intensity
Statin
Atherosclerotic Disease  NO
LDL-C >190 mg/dl  NO
Diabetes  NO
Everyone Else
Calculate Risk Score
Risk > 7.5%:
Risk < 7.5%:
High Intensity
Statin Therapy
No Statin
Indicated
Atherosclerotic • High Dose Statin
Disease
LDL-C >190
Diabetes
Everyone Else
• High Dose Statin
• High Dose Statin (Risk>7.5%)
• Moderate Dose Statin (Risk<7.5%)
• High Dose Statin (Risk>7.5%)
• No Statin (Risk<7.5%)
That wasn’t so bad, let’s try it again on the next patient
42 year old Male with a
Coronary Stent
• Total cholesterol, 140
mg/dl
• HDL cholesterol, 35
mg/dl
• LDL cholesterol, 110
mg/dl
• Normal BP
• Not diabetic
• Nonsmoker
What therapy would you
initiate
•
•
•
•
A) Niacin 1000mg daily
B) Lipitor 80mg daily
C) Zocor 10mg daily
D) No therapy
52 year old Male with
Gastric Bypass
• Total cholesterol, 300
mg/dl
• HDL cholesterol, 15
mg/dl
• LDL cholesterol, 210
mg/dl
• Normal BP
• Not diabetic
• Nonsmoker
What therapy would you
initiate
•
•
•
•
A) Niacin 1000mg daily
B) Crestor 40mg daily
C) Lipitor 10mg daily
D) No therapy
What therapy would you
initiate
50 year old with Diabetes
•
•
•
•
•
•
•
Total cholesterol, 210 mg/dl
HDL cholesterol, 50 mg/dl
LDL cholesterol, 180 mg/dl
No ASCVD
Diabetic
Smoker
Calculated 10 year risk of
CHD or stroke, 9.8%
•
•
•
•
A) Vytorin 10/40mg daily
B) Lipitor 80mg daily
C) Pravachol 10mg daily
D) No therapy
What Therapy should be
Initiated
48 year old with Diabetes
• Total cholesterol, 210
mg/dl
• HDL cholesterol, 45 mg/dl
• LDL cholesterol, 165 mg/dl
• No ASCVD
• Diabetic
• Non-Smoker
• Calculated 10 year risk of
CHD or stroke, 2.5%
•
•
•
•
A) Lipitor 80mg
B) Crestor 5mg
C) Vytorin 10/40mg
D) Niacin 1000mg