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

CASE 2

50 YEAR OLD WHITE FEMALE

• TOTAL CHOLESTEROL 180

• HDL: 50

• SBP: 130

• TAKING ANTI-HTN MEDS

• +DIABETIC

• +SMOKER

• CALCULATED 10 YR ASCVD: 9.8%

• HIGH INTENSITY STATIN

CASE 3

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%

• MODERATE INTENSITY STATIN

CASE 4

22 YO WHITE MALE

• LDL: 195

• SBP: 120

• NOT TAKING ANTI-HTN MEDS

• NON-DIABETIC

• NON-SMOKER

• HIGH INTENSITY STATIN

CASE 5

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 %

• 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. INDIVIDUALS WITH CLINICAL ASCVD

II. 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