Update on Lipid Management in Cardiovascular Disease: How to Understand and Implement the New ACC/AHA Guidelines

Transcription

1 Update on Lipid Management in Cardiovascular Disease: How to Understand and Implement the New ACC/AHA Guidelines Paul Mahoney, MD Sentara Cardiology Specialists

2 Lipid Management in Cardiovascular Disease Hyperlipidemia is critical risk factor in progression of atherosclerotic cardiovascular disease (ASCVD) Treatment of abnormal lipids reduces risk of recurrent events in patients with ASCVD Statins remain the mainstay of therapy New Published Guidelines (November 2013) focus on risk specific, rather than goal specific, therapy and significantly alter approach to treatment of patients with ASCVD and abnormal lipids

3 Coverage of new Guidelines

4 Prevalence of Lipid Abnormalities

5 There is still work to be done: Untreated patients

6 New Guidelines: ACC/AHA November 2013 What s New What s Controversial

7 Consensus Document 1. The 2013 ACC/AHA Expert Panel included all 16 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. The expert panel 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.

8 Non-Pharmacologic Treatment Lifestyle modification (i.e., adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight) remains a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol-lowering drug therapies.

9 Smoking Cessation: Patient and Community

10 Diet: DASH vs TLC

11 Benefits of Lifestyle Modification on LDL-C and Total Cholesterol in Women

12 Physical Activity: Strong Evidence

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14 Role of Pharmacologic Therapy: statins

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18 STATIN USE: Meta-Analysis Impact on Vascular Events and Mortality NEJM.org may 10, 2012

19 Statins -- Risk of Diabetes: 13 Trials; 91, 140 Non-Diabetic patients Treatment of 225 patients with statins for 4 years resulted in one extra case of diabetes

20 Big Changes in 2013 Guidelines 1. There is no evidence to support continued use of specific LDL-C and/or non high-density lipoprotein cholesterol (non HDL-C) treatment targets. 2. The appropriate intensity of statin therapy should be used to reduce risk in those most likely to benefit. Certain high risk groups will not benefit. 3. Nonstatin therapies, whether alone or in addition to statins, do not provide acceptable ASCVD risk reduction benefits compared to their potential for adverse effects in the routine prevention of ASCVD.

21 Pharmacologic Therapy: Statins

22 Four Statin Benefit Groups (1) : 1. Individuals with clinical ASCVD (acute coronary syndromes, or a history of myocardial infarction, 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. 2. Individuals with primary elevations of low-density lipoprotein chol (LDL-C) 190 mg/dl.

23 Four Statin Benefit Groups (2) 3. Individuals years of age with -- diabetes, and -- LDL-C mg/dl -- without clinical ASCVD. 4. Individuals years of age without clinical ASCVD or diabetes, with LDL-C mg/dl, estimated 10-year ASCVD risk of 7.5% or higher.

24 Guidelines: Flow Chart

25 New Guidelines: ACC/AHA 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.

26 Pooled Risk Spreadsheet

27 Factors in Pooled Cohort Risk assessment Risk Factor Sex Age Race Total Cholesterol HDL-Cholesterol Systolic Blood Pressure Treatment for High Blood Pressure Diabetes Smoker Units M (for males) or F (for females) years AA (for African Americans) or WH (for whites or others) mg/dl mg/dl mm Hg Y (for yes) or N (for no) Y (for yes) or N (for no) Y (for yes) or N (for no)

28 New Paradigms in Lipid Recommendations The following are no longer considered appropriate strategies: treat to target, lower is best. The new guideline 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.

29 Treatment Guidelines: High vs Moderate Intensity High-intensity statin therapy is defined as a daily dose that lowers LDL-C by 50% and moderateintensity by 30% to <50%. All patients with ASCVD should receive highintensity statin therapy; or if not a candidate for high-intensity, should receive moderate-intensity statin therapy All patients age > 75 should receive high intensity statin therapy

30 Guidelines: Specific Recommendations for Rx

31 Goals for Therapy LDL-C 190 mg/dl should receive high-intensity statin Addition of other cholesterol-lowering agents can be considered to further lower LDL-C. Diabetics: 10-year ASCVD 7.5% should receive high-intensity statins <7.5% moderate-intensity statin therapy Persons years with a 7.5% 10-year ASCVD risk moderate- to high-intensity statin therapy.

32 Treatment Guidelines: Outside the 4 groups 1. No recommendations are made for individuals who are not included in the four statin benefit groups. 2. Other Factors may be used to enhance the treatment decision making: family history of premature ASCVD, LDL-C >160 mg/dl, high-sensitivity C-reactive protein 2 mg/dl, coronary calcium score 300 Agatston ankle-brachial index <0.9 elevated lifetime risk of ASCVD

33 Greatly expanded treatable population New guidelines would increase the number of U.S. adults receiving or eligible for statin therapy from 43.2 million (37.5%) to 56.0 million (48.6%). Most of this increase in numbers (10.4 million of 12.8 million) would occur among adults without cardiovascular disease. Increase for adults between the ages of 60 and 75 years without cardiovascular disease who are not receiving statin therapy % to 87.4% among men 21.2% to 53.6% among women

34 Impact of New Guidelines: N Engl J Med 2014; 370: Greatly expanded population

35 Changes in practice with new guidelines 1. avoidance of cholesterol-lowering therapy in certain groups; 2. elimination of routine assessments of LDL cholesterol levels 3. avoidance of non-statin LDL cholesterol lowering agents in statin-tolerant patients; 4. more conservative use of statins in patients older than 75 years of age who have no ASCVD 5. diminished use of surrogate markers such as C-reactive protein or calcium scores 6. the use of a new risk calculator that is certain to target larger N Engl J Med 2014; 370:

36 Conclusions Treatment is risk oriented, not goal specific Patients meeting guideline criteria will increase Whom should we treat? 1. clinical ASCVD 2. LDL> Diabetics without clinical ASCVD 4. those with pooled risk >7.5% at 10 years

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