Lipid management 2013 acc-aha guidelines

I. Introduction to new guidelines on lipid management II. Comparison with atp III guidelinesIII. Current statin treatment recommendationsIV. Current statin safety recommendations

Goal: treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults, currently the leading cause of death and disability in America

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

1) Individuals with clinical ASCVD2) Individuals with LDL >1903) Individuals with dm, 40-75 yo with LDL 70-189 and without

clinical ASCVD4) 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)

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

conditions that could predispose pts to statin side effect:o Impaired renal or hepatic functiono History of previous statin intolerance or muscle disordero Age >75o Unexplained ALT elevation > 3x ULNo History of hemorrhagic strokeo Asian ancestry

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)

62 year old AA male Total cholesterol: 140Low HDL: 35SBP: 130 mmHgNot taking anti-hypertensive medicationsNon-diabeticNon-smokerCalculated 10 yr risk of ASCVD : 9.1%

Moderate to high intensity statin

50 year old white femaleTotal cholesterol 180HDL: 50SBP: 130taking anti-hTN meds+diabetic+smokerCalculated 10 yr ASCVD: 9.8%

high intensity statin

48 yo white femaleTotal cholesterol 180HDL: 55SBP: 130Not taking anti-hTN meds+diabeticNon-smokerCalculated 10 yr risk ASCVD : 1.8%

Moderate intensity statin

22 yo white maleLDL: 195SBP: 120Not taking anti-hTN medsNon-diabeticNon-smoker

High intensity statin

66 yo white female High Total cholesterol: 230HDL: 55SBP: 150taking anti-hTN medsNon-diabeticNon-smokerCalculated 10 yr risk of ASCVD : 2.0 %

Statin therapy NOT recommended

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:1. Individuals with clinical ASCVD2. Individuals with primary elevations of LDL–C ≥190 mg/dL 3. Individuals 40 to 75 years of age with diabetes and LDL–C 70 to189 mg/dL

without clinical ASCVD4. 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