Cardiovascular Controversies: Exploring the ACC and AHA Guidelines on the Treatment of Blood Cholesterol

Transcription

1 Transcript Details This is a transcript of a continuing medical education (CME) activity accessible on the ReachMD network. Additional media formats for the activity and full activity details (including sponsor and supporter, disclosures, and instructions for claiming credit) are available by visiting: Released: 05/01/2015 Valid until: 05/01/2016 Time needed to complete: 15 minutes ReachMD info@reachmd.com (866) Cardiovascular Controversies: Exploring the ACC and AHA Guidelines on the Treatment of Blood Cholesterol Announcer: Welcome to CME on ReachMD. This segment, Cardiovascular Controversies: Exploring the ACC and AHA Guidelines on the Treatment of Blood Cholesterol, is sponsored by the New Jersey Academy of Family Physicians and supported by an educational grant from Pfizer, Amgen, Sanofi- Aventis US, and Regeneron Pharmaceuticals. This segment will focus on the use of the ACC and AHA Guidelines in primary care practice. The target audience for this educational activity includes primary care providers and other clinicians who treat lipid-related disorders. This activity is approved for.25 Prescribed credits by the American Academy of Family. This activity is approved for.25 AMA PRA Category 1 Credits by the Texas Academy of Family Physicians. Your moderator is Dr. Brian McDonough. Dr. McDonough will be 2018 ReachMD Page 1 of 7

2 speaking with Dr. Seth Martin, Clinical Research Fellow at Johns Hopkins Ciccarone Center for the Prevention of Heart Disease in Baltimore, MD. Both Dr. McDonough and Dr. Martin have indicated that they have nothing to disclose. After participating in this educational activity, participants should be better able to employ the new ACC/AHA guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk Dr. McDonough: The American College of Cardiology and American Heart Association ACC/AHA recently published new guidelines for risk assessment for cardiovascular disease and cholesterol treatment which focused on the assessment of an individual s aggregate cardiovascular risk and providing treatment for those at the greatest risk overall with more aggressive therapy. Many of the recommendations represent a paradigm shift which will have implications on the way primary care physicians treat their patients. We are lucky to have Dr. Seth Martin with us. Dr. Martin, welcome to our program. I want to ask you a first question: This is definitely a paradigm shift as they say, what was the impetus behind the development of these new ACC/AHA Guidelines? Dr. Martin: Thanks for having me Dr. McDonough, it is a pleasure. The new guidelines, the impetus wato update the recommendations based on current best evidence. So, we had our old ATP guidelines from 2001 which were updated in 2004, and then the NHLBI set out to update the guidelines in Ultimately, they asked for the help of the ACC/AHA who helped complete and publish the guidelines in Dr. McDonough: Well, these new guidelines, they were developed differently from previous guidelines. Can you tell us about how they were developed, because they were quite different? Dr. Martin: Yes, they were very different. This guideline panel used a more restricted process. So the focused on three critical questions that they conducted systematic reviews on. The first two questions looked at the evidence for lipid goals in primary and secondary prevention and then the third question focused on the impact on lipid levels, effectiveness and safety of specific cholesterol-modifying drugs. So, to answer these questions, the guideline panel chose to restrict their evidence review to clinical trials and they found that most of the trial evidence was for statin therapy, so that s why the guidelines end up being what they are, which is very much focused on statin trials. Dr. McDonough: So, when you did that and you looked at those things and you looked at the statins, there are obviously new recommendations. What were some of the recommendations in these guidelines? Dr. Martin: So, the guideline panel tried to make things as easy as they could for providers. So they 2018 ReachMD Page 2 of 7

3 identified four groups what they called statin-benefit groups that would generally derive net benefit from treatment with statins. So the first group was patients with clinical ASCVD atherosclerotic cardiovascular disease. The second group was patients with primary elevations of LDL cholesterol of 190 or more. The third group was those patients age 40 to 75 with diabetes without clinical ASCVD who has an LDL cholesterol at baseline of 70 to 189. And then the fourth group was patients who didn t have ASCVD or diabetes and they did have an LDL of 70 to 189 and their estimated 10-year risk of MI or stroke was 7.5% or more by the new pooled cohort equations that the guidelines put out. Dr. McDonough: Where did that leave treatment strategies for these patients? What do you end up doing now with that kind of a setup? Dr. Martin: This makes it easy for patients to be identified who may benefit from statin therapy and it s crucial to talk to patients about whether they may be eligible; what their preferences are; what they think; whether they have any concerns about starting therapy and finding the right intensity of therapy for patients. We used to focus a lot on lipid targets and it is still very important to follow-up cholesterol profiles, but the panel didn t find evidence for or against LDL or non-hdl targets; those first two critical questions that they had. So, at this point, the focus is on the intensity of statin therapy and ensuring adherence to statin therapy. Dr. McDonough: That is definitely a different approach. So when you look at patients and you looked at a patient in a group that does not have ASCVD or diabetes, but have an LDL-C of 70 to 189, how do you calculate the risk of ASCVD? Dr. Martin: So when the patients don t fall into those criteria that the guideline identified for calculating risk, then the reason is that those types of patients weren t in the cohorts that were used to develop those risk equations. But you can use other factors; so you can consider if someone has a family history of premature coronary artery disease for instance. So, someone who is younger than 40 but has that family history would be someone you would still view as a higher risk patient and you could consider doing an artery calcium score which is something that is recommended by the guidelines to assess risk. So there are other ways and the guidelines give those options, but it becomes sometimes less straightforward. Dr. McDonough: So they really have figured a way of doing this. It is just, again, it is a little bit different than what we are thinking about. But when you are looking at all this and you are making these changes, what do the guidelines say about statin safety? Dr. Martin: The guidelines give a lot of recommendations about statin safety. They factored in diabetes 2018 ReachMD Page 3 of 7

4 risk in terms of net benefit as they identified those statin-benefit groups. They mentioned that the trials don t show any evidence for cognitive effects of statins adverse cognitive effects they also give a lot of recommendations about myopathy and they note a lot of additional testing and considerations that can be done for someone with myopathy and other treatment recommendations. So you can consider going to other types of statins and considering maybe not even a daily dose of a statin but something like rosuvastatin every other day or every third day in someone you are having a lot of trouble with. So they give a lot of recommendations about statin safety. Dr. McDonough: Yes, I noticed that when talking about it they looked at people when they are over 75 and pregnancy and a lot of things, so it s obviously been given a lot of thought as they evaluated this. By the way, if you are just tuning in, you are listening to CME on ReachMD. I am your host, Dr. Brian McDonough, and today I am speaking with Dr. Seth Martin. A fascinating conversation as we are talking about these new recommendations and really, in a sense, it is a C-Change* in how we are approaching things, but it makes a lot of sense what the group has come up with, and so, with all that in mind, how will primary care physician practices change based on these new guidelines recommendations, as you see it? Dr. Martin: I think primary care physicians will find that it is easier to identify patients who may benefit from statin therapy and I think there may be a shift towards greater focus on using statins as opposed to non-statin medications. Primary care physicians should know that the ACC/AHA have put out an app that can be accessed on the web or by Smartphone to calculate ASCVD risk and those calculations are then linked to recommendations. So, it makes it very easy. So I think that primary care physicians may find that they are using the web or a Smartphone even more than they did in the past to help guide their decisions. Dr. McDonough: I like the fact that you mentioned it is important to follow up on the LDL and the cholesterol because there is a sense maybe that we as primary care docs shouldn t be rigidly focusing on these numbers and that we are free of them. But, that really isn t the truth; it is just that we have got to keep them in mind, but it sounds like not focus on it so directly and so intensely. Dr. Martin: Yes, that is absolutely right. There has been some misconception about the guideline recommendation to drop fixed LDL and non-hl targets, folks thinking that you don t even need to measure lipid profiles during followup anymore. The fact is that the guidelines strongly recommend checking lipids 4 to 12 weeks after initiation of therapy and dose adjustment and then every 3 to 12 months thereafter. So it should be measured. The point of the guidelines is that it should be used to assess adequacy of therapy and the main metric there is adherence, so making sure that you see the expected response to therapy which, for example, would be 50% or more for a high intensity statin 2018 ReachMD Page 4 of 7

5 therapy. Dr. McDonough: When you are doing this you are looking at it; you are following it; you are kind of doing those percentages and looking at them clinically too in how they are doing, I suppose? Dr. Martin: Yes, exactly. Every case is individual and so, I think, the new guidelines really recognize that, that it is not only about the numbers but it is also about the person and factoring in all the individual circumstances to that. Dr. McDonough: And you referred to high intensity statins. They are looking at them now as high, medium and low intensity for treatment? Dr. Martin: Yes, and the two high intensity statins would be rosuvastatin and atorvastatin used at higher doses. Dr. McDonough: Very interesting material. Obviously there are changes and I know also they have looked at managing myalgia and myositis and they are looking at those things, but what about controversial issues? Are there controversies surrounding these guidelines from your perspective? Dr. Martin: Yes, the one controversial issue is that they did only look at randomized trials and there is a lot of evidence out there. Prior guidelines focused on all the evidence and considered detection and evaluation of lipids in addition to treatment. So that has been one controversial point that might be considered in the future sets of guidelines. The pooled cohort equations have come under scrutiny because there has been several studies, most recently the MESA Study, showing that they overestimate risk, and so that could have important treatment implications, although again, it is important to highlight that that risk estimate is used to fuel a clinician-patient risk discussion and shouldn t lead to automatic statin prescription. Dr. McDonough: Now we are talking about some dramatic changes and things that have happened and probably for the rest of this segment I would like to talk to you about the future guidelines. What this has led to? What will future guidelines address? How do you see the future of what these recommendations have led to and where we can go from there? Dr. Martin: Yes, I think these guidelines are a great foundation and future guidelines could nicely build upon these and they are already in the works. The ACC/AHA are going to lead them. The last guideline panel had other critical questions that weren t addressed, and so, those could be addressed as well, for instance, treatment of hypertriglyceridemia, or best approaches to non-invasive imaging. The big trial that has come out since the guidelines is improve it, where we saw benefit of ezetimibe on top of statins, so that will be closely considered by the next guideline panel ReachMD Page 5 of 7

6 Finally, sort of as I hinted before, I think the next guideline panel has the opportunity to consider all the non-trial evidence and that could lead to a more comprehensive clinical guideline. Dr. McDonough: Thinking as a primary care physician in my own practice, we have trained patients to think one way; we have trained doctors to think one way, how do we go about getting the word out, I mean obviously through talks like this, but how do you get the word out and get people to think a little differently as they approach this and not be maybe so numbers focused? Dr. Martin: In my practice I have found that focusing on that early patient discussion is really critical I think. As physicians we have always tried to individualize care and work with our patients, consider their preferences, talk about why they are going on medicine its risks and benefits but perhaps we, and there is evidence to support this, we have room for improvement as a community of clinicians, and so, I think, that focusing on the clinician-patient risk discussion as highlighted by the guidelines is a really nice opportunity because that group, that for statin- benefit group is really where a lot of the increase, potential increase, in statin use is going to be. That s one of the potentially biggest changes from these guidelines. So I think it s an opportunity for us as clinicians to talk to our patients about all this great trial evidence that we have, potential risks, but also consider their preferences and really focus on this being these next 10 years being the time where we focus on shared decision making more than we ever have in the past, and I think that is really what personalized care is about. What evidence-based medicine is really supposed to be, which is applying current best evidence to the individual patient. Dr. McDonough: And it comes at a good time. I mean, you are looking at some of these metrics: patient age, sex, race, total cholesterol level, HDL-C levels, systolic blood pressure, diabetes, smoking status, these are all things we are already measuring. In our EMRs we are able to get the data and look at it. You can actually talk with your patients and show them changes; changes against other people in the country, and you are right, I think you can really make this a conversation where your patients become a part of this rather than just kind of maybe going back and getting a lab test and seeing what it says. They can feel more actively involved in making a difference. Dr. Martin: Yes, I couldn t agree more. It is such a nice opportunity. A lot of us are in offices where we have a computer screen right there with us and the patient in the clinic and it is an opportunity to use that screen to sort of work together; go through the information together and make a decision that really fits them as best as possible. So, I think, really as much as it can lead to sort of more it s sort of more up in the air. It is not that we follow a strict rule. Ultimately, I think it does lead to better care and it is a really nice opportunity that these guidelines value the art of medicine as much as they do. Dr. McDonough: I want to thank our guest, Dr. Seth Martin, for helping us better understand the current 2018 ReachMD Page 6 of 7

7 ACC/AHA guidelines in the reduction of cardiovascular risk. I think Dr. Martin you not only talked about the guidelines and the changes and those things, but really the spirit of it came across of what the goal is and I think this was clearly something that was thought about and hopefully will get the patients more involved in their own care. I want to thank you for taking the time to join us on the program. Dr. Martin: It has been my pleasure. Thank you very much. Announcer: This segment of CME on ReachMD is sponsored by the New Jersey Academy of Family Physicians and is supported by an educational grant from Pfizer, Amgen, Sanofi-Aventis US, and Regeneron Pharmaceuticals. To receive your free CME credit or to download this segment, go to ReachMD.com/CME or go to the ReachMD medical radio app on your iphone or ipod touch device. Thank you for listening ReachMD Page 7 of 7