2014 Update in Medicine Update in Cholesterol Management. Donald L. Lappé MD, FACC, FAHA October 31, 2014

Transcription

1 2014 Update in Medicine Update in Cholesterol Management Donald L. Lappé MD, FACC, FAHA October 31, 2014

2 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Preventive Cardiology, Association of Black Cardiologists, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women with Heart Disease American College of Cardiology Foundation and American Heart Association, Inc.

3 Key Points Encourage adherence to a heart-healthy lifestyle. Statin therapy is recommended for adults in groups demonstrated to benefit. Statins have an acceptable margin of safety when used in properly selected individuals and appropriately monitored. Engage in a clinician-patient discussion before initiating statin therapy, especially for primary prevention.

4 Key Points (cont.) Use the newly developed Pooled Cohort Equations for estimating 10-year ASCVD risk (40-75 yo). hsp://clincalc.com/cardiology/ascvd/ PooledCohort.aspx Initiate the appropriate intensity of statin therapy to reduce ASCVD risk. Evidence is inadequate to support treatment to specific LDL-C or non-hdl-c treatment goals. Regularly monitor patients for adherence to lifestyle and appropriate intensity of statin therapy.

5 New Perspective on LDL-C & Non HDL-C Lack of RCT evidence to support titration of drug therapy to specific LDL-C and/or non HDL-C goals Strong evidence that appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most likely to benefit Quantitative comparison of statin benefits with statin risk Nonstatin therapies did not provide ASCVD risk reduction benefits or safety profiles comparable to statin therapy

6 Clinical ASCVD* 4 Statin Benefit Groups LDL-C 190 mg/dl, Age 21 years Primary prevention Diabetes: Age years, LDL-C mg/dl Primary prevention - No Diabetes : 7.5% 10-year ASCVD risk, Age years, LDL-C mg/dl *Atherosclerotic cardiovascular disease Requires risk discussion between clinician and patient before statin initiation Statin therapy may be considered if risk decision is uncertain after use of ASCVD risk calculator

7

8 Intensity of Statin Therapy *Individual responses to statin therapy varied in the RCTs and should be expected to vary in clinical practice. There might be a biologic basis for a less-than-average response. Evidence from 1 RCT only: down-titration if unable to tolerate atorvastatin 80 mg in IDEAL (Pedersen et al). Although simvastatin 80 mg was evaluated in RCTs, initiation of simvastatin 80 mg or titration to 80 mg is not recommended by the FDA due to the increased risk of myopathy, including rhabdomyolysis.

9 Beware of Drug Interactions with these Higher Doses of Statins!!!! Atorvastatin and simvastatin (>90% metabolism hepatic cytochrome P450 (CYP) 3A4) : 44 Major, 166 moderate, and 73 minor drug interactions Resuvastatin (10% hepatic cytochrome P450 2C9): 27 major, 166 moderate, and 28 minor drug interactions Pravastatin (minimal metabolism by CYP3A4, CYP2C8, or CYP2C9) 11 major, 132 moderate and 4 minor drug interactions

10 Statin Management Check FLP 6 weeks axer iniyayng stayn or axer any change and repeat annually: If LDL- C above 100, re- emphasize lifestyle changes, assure medicayon compliance. If LDL- C remains above 100, consider increasing stayn dose/strength (rosuvastayn may be more effecyve than atorvastayn) or adding ezetamide for payents at higher risk Consider cardiology referral if ongoing stayn intolerance or persistently elevated LDL- C

11

12 ACC Pooled Cohort Risk Calculator

13 Risk Calculator Filling in the numbers

14 Risk Calculator- - Recommendations

15 Risk Calculator Patient References

16

17

18

19

20 Yes: Patient is at High- Risk of ASCVD Implement treatment recommendations: A Aspirin / Antiplatelet therapy B Blood pressure control C Cholesterol control /Cigarette smoking cessation D Diet and weight management / Diabetes and blood sugar control E Exercise

21 Primary Prevention (LDL- C mg/dL, no known ASCVD, No DM) EsYmate 10- y ASCVD risk every 5 years beginning at 20 y. Using ACC/AHA Pooled Cohort Risk EquaYon For ages years, use lifeyme risk esymate of >40% to encourage use of stayns For people with < 7.5% 10- y ASCVD risk or borderline indicayons for stayns, consider other risk factors such as coronary calcificayon (payents > 50 yo, score > 300, high intensity stayn; moderate intensity; low intensity stayn), hscrp, FH, ABI <0.9

22 DIABETES AND AGE OR OVER 75: INTERMOUNTAIN RECOMMENDATIONS For non- pregnant payents age If lifeyme ASCVD risk is 30-40%, a low- intensity stayn is recommended If lifeyme ASCVD risk is >40%, a moderate- intensity stayn is recommended For payents age 75 and older, a moderate- intensity stayn is recommended.

23 Patient Education ACC CardioSmart Explorer

24 Thank You