Transcript Lipid Management - 2013 ACC

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