2013 ACC/AHA Guidelines: Blood Cholesterol And Assessment of Cardiovascular Risk

1. 2013 ACC/AHA Guidelines:Blood Cholesterol AndAssessment of Cardiovascular Risk Elena Kuklina, MD, Ph.D. Senior Service Fellow State Grantee Webinar, Hypertension, Cholesterol and Sodium Guidelines: Implications for Cardiovascular Health February 12, 2014 National Center for Chronic Disease Prevention and Health Promotion Division for Heart Disease and Stroke Prevention

2. Background • ACC/AHA published new cholesterol and cardiovascular risk assessment guidelines in 2013.1 • This is an overview of the 2013 ACC/AHA guidelines and a comparison to preceding guidelines. 1. Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print November 12 2013]. Circulation. 2013. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98.citation. Accessed February 3, 2014.

3. ATP III Lipid and Lipoprotein Classification (The “Old Familiar Classification”) LDL Cholesterol (mg/dL) <100 Optimal 100–129 Near optimal/above optimal 130–159 Borderline high 160–189 High 190 Very high

4. Old vs. New: Lifestyle Modification New guidelines: Diet: healthy pattern DASH, USDA , AHA Diet Calorie requirements, personal and cultural preferences, and nutrition therapy for other medical conditions • Old guidelines: • Diet: low fat and low cholesterol • regular exercise habits • avoidance of tobacco products • maintenance of a healthy weight

5. Old vs. New: Statin Eligibility New Old

6. Determining Risk for the 4thGroup New Pooled Cohort Equations to estimate 10-year risk • Adults 20-79 years of age who are free from ASCVD • 4 racially and geographically diverse cohorts • ASCVD risk: heart disease and stroke • Calculated from sex, age, race, total cholesterol, HDL cholesterol, systolic blood pressure, and whether on treatment for high blood pressure, has diabetes, or is a smoker See Flowchart (addendum)

7. New: Classification of Statin Intensity Intensity of statin therapy: is defined as a daily dose that lowers LDL-C by • High-intensity: by 50% • Moderate-intensity: by 30% to <50%

8. New: Intensity Instead of Levels

9. What about the Rest? • There are people who may benefit from statin therapy who do not fall into one of the four groups. • As with other guidelines, clinicians may use their judgment in considering other factors such as: • family history of ASCVD. • biomarkers such as C - reactive protein. • ankle-brachial index, etc.

10. Summary • Statin is the first line therapy. • Statin eligible groups based on benefit, not only on the LDL-C measurement. • Treatment is based on statin intensity instead of specific treatment goals for blood cholesterol. • New global risk assessment tool.

11. Healthy Dietary Patterns (servings per day unless specified) (2000 kcal)

12. Implications • High cholesterol is a major and controllable risk factor for heart attacks and strokes. • One goal of the ACC/AHA guidelines is to better identify and focus statin therapy on those who are most at risk for (or have) ASCVD.

13. Implications • We have much room for improvement for increasing the level of healthy lifestyles and statin therapy even among those most at risk. • We can use the guidelines to identify those who do not yet know they are at risk, and increase healthy lifestyle choices and statin therapy for those who are.

14. Program Considerations • New performance measures for cholesterol are in the development phase. Right now, we can: • Increase adaptation of healthy lifestyle and levels statin therapy for those who do know they are at risk. • Help them adhere to that therapy for the rest of their longer lives.

15. Sources Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print November 12 2013]. Circulation. 2013. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98.citation. Accessed February 3, 2014. Stone NJ, Robinson J, Lichtenstein AH, et al. 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 [published online ahead of print November 12 2013]. Circulation. 2013. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.citation. Accessed February 3, 2014. Journal of American College of Cardiology. 2013. http://www.sciencedirect.com/science/article/pii/S0735109713060282. Accessed February 3, 2014

16. Education materials for patients • “Getting Healthy” by AHA: https://www.heart.org/HEARTORG/GettingHealthy/GettingHealthy_UCM_001078_SubHomePage.jsp • “Chose my plate” by USDA: http://www.choosemyplate.gov/ • “Lowering your blood pressure with DASH” by NIH” https://www.nhlbi.nih.gov/health/health-topics/topics/dash/

17. Thank you! For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion Division for Heart Disease and Stroke Prevention