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Treatment of Blood Cholesterol to Reduce Atherosclerotic Car
Transcript of Treatment of Blood Cholesterol to Reduce Atherosclerotic Car
2013 ACC-AHA guidelines
ACC-AHA expert panel
The 2013 panel included members of the National Heart, Lung, and Blood Institute Adult Treatment Panel (ATP) IV, and the document review included 23 expert reviewers and representatives of federal agencies.
Recommendations arose from careful consideration of an extensive body of higher quality evidence derived from randomized controlled trials (RCTs), and systematic reviews and meta-analyses of RCTs.
Rather than LDL-C or non–HDL-C targets, this guideline used the intensity of statin therapy as the goal of treatment," identifying four groups of individuals "for whom an extensive body" of evidence from randomized controlled trials demonstrated a reduction in atherosclerotic CVD events "with a good margin of safety from moderate- or high-intensity statin therapy,"
Four Statin Benefit Groups
Group 1 :Individuals with clinical ASCVD (acute coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin ) without New York Heart Association (NYHA) class II-IV heart failure or receiving hemodialysis.
Group 2: Individuals with primary elevations of low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dl.
Group 3: Individuals 40-75 years of age with diabetes, and LDL-C 70-189 mg/dl without clinical ASCVD.
Group 4: Individuals without clinical ASCVD or diabetes, who are 40-75 years of age with LDL-C 70-189 mg/dl, and have an estimated 10-year ASCVD risk of 7.5% or higher.
Individuals in the fourth group can be identified by using the new Pooled Cohort Equations for ASCVD risk prediction, developed by the Risk Assessment Work Group.
Pooled Cohort Equation
Stroke now included in ASCVD risk assessment, in addition to myocardial infarction (MI)
Separate equations for nonwhite populations
Guidelines focus on assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, and management of overweight and obesity in adults, in addition to management of blood cholesterol
How to manage cholesterol?
Those with an LDL-C ≥190 mg/dl should receive high-intensity or moderate-intensity statin therapy, if not a candidate for high-intensity statin therapy. Addition of other cholesterol-lowering agents can be considered to further lower LDL-C.
Diabetics with a 10-year ASCVD ≥7.5% should receive high-intensity statins and <7.5% moderate-intensity statin therapy.
Persons 40-75 years with a ≥7.5% 10-year ASCVD risk should receive moderate- to high-intensity statin therapy.
High-intensity statin therapy is defined as a daily dose that lowers LDL-C by ≥50% and moderate-intensity by 30% to <50%.
All patients with ASCVD who are age ≤75 years, as well as patients >75 years, should receive high-intensity statin therapy; or if not a candidate for high-intensity, should receive moderate-intensity statin therapy.
What is high vs moderate intensity statin?
Treatment threshold :7.5%
Lowered from former threshold of 20% risk of MI over 10 years or > 10% with multiple risk factors
What about the intermediate group <7.5?
No recommendations are made to inform treatment decisions in selected individuals who are not included in the four statin benefit groups.
In these individuals whose 10-year risk is <7.5% or when the decision is unclear, other factors including:
family history of premature ASCVD,
LDL-C >160 mg/dl,
high-sensitivity C-reactive protein ≥2 mg/dl,
coronary calcium score ≥300 Agatston units or ≥75th percentile for age, sex, ethnicity, and
ankle-brachial index <0.9, or elevated lifetime risk of ASCVD may be used to enhance the treatment decision making.
The following are no longer considered appropriate strategies: treat to target, lower is best.
The new GL recommends: treat to level of ASCVD risk, based upon estimated 10-year or lifetime risk of ASCVD.
The guidelines provided no recommendations for initiating or discontinuing statins in NYHA class II-IV ischemic systolic heart failure patients or those on maintenance hemodialysis.