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Mini-lecture Pejman Solaimani, PGY-2 Feb 2014

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. Introduction to new guidelines on lipid management Comparison with atp III guidelines

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Mini-lecture Pejman Solaimani, PGY-2 Feb 2014

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  1. 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

  2. objectives • Introduction to new guidelines on lipid management • Comparison with atp III guidelines • Current statin treatment recommendations • Current statin safety recommendations

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

  4. 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 nottitrate to a specific LDL cholesterol target • Measure lipids during follow-ups to assess adherence to treatment, not to achieve a specific LDL target

  5. Four Major Statin Benefit Groups • Individuals with clinicalASCVD • Individuals with LDL >190 • Individuals with dm, 40-75 yowith LDL 70-189 and without clinical ASCVD • Individuals without clinical ASCVD or dm with LDL 70-189 and estimated 10-year ASCVD risk >7.5%

  6. http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

  7. NO RECOMMENDATIONS ON STATIN THERAPY FOR PTS WITH NYHA CLASS II-IV OR ESRD ON DIALYSIS (GRADE N RECOOMENDATIONS)

  8. Intensity of Statin Therapy in primary and secondary prevention

  9. 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

  10. STATIN Safety recommendations • conditions that could predispose pts to statin side effect: • Impaired renal or hepatic function • History of previous statin intolerance or muscle disorder • Age >75 • Unexplained ALT elevation > 3x ULN • History of hemorrhagic stroke • Asian ancestry

  11. 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)

  12. 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%

  13. Moderate to high intensity statin

  14. Case 2 50 year old white female • Total cholesterol 180 • HDL: 50 • SBP: 130 • taking anti-hTN meds • +diabetic • +smoker • Calculated 10 yrASCVD: 9.8%

  15. high intensity statin

  16. 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%

  17. Moderate intensity statin

  18. Case 4 22 yo white male • LDL: 195 • SBP: 120 • Not taking anti-hTN meds • Non-diabetic • Non-smoker

  19. High intensity statin

  20. 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 %

  21. Statin therapy NOT recommended

  22. Take Home Message • Rather than LDL–C or non-HDL– C targets, new guideline uses the intensity of statin therapy as the goal of treatment. • Know the 4 Statin Benefit Groups: • Individuals with clinical ASCVD • Individuals with primary elevations of LDL–C ≥190 mg/dL • Individuals 40 to 75 years of age with diabetes and LDL–C 70 to189 mg/dL without clinical ASCVD • 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)

  23. http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

  24. References: • Stone Nj, Robinson J, Lichtenstein Ah, BaireyMerzCn, Lioyd-jones Dm, Blum Cb, Mcbride P, eckel Rh, Schwartz Js, Goldberg Ac, Shero St, Gordon D, Smith ScJr, 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 CollCardiol. 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

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