Treatment of Cholesterol in 2018: Time to Level Up 1. Most Important Slide Three Things Learned that Will be Applied 2. 3.
2013 Top Ten Points 1. Expert committee. Evidence used. 2. Four groups identified 3. Fourth group gets risk calculated 4. Lifestyle modification 5. No targets 6. No good evidence for non-statins 7. Group outside the four groups 8. Definition of moderate and high intensity 9. Who gets how much 10. Treat the risk, not number, provider patient review Comfort Case 25-year-old white man with no medical history Total cholesterol level of 310 mg/dl, HDL-C 50 mg/dl, triglycerides 400 mg/dl, and calculated LDL-C 184 mg/ dl. Non-smoker, No HTN, No DM Father (36) and Uncle (40) died of MI BMI is 25 kg/m 2 Objectives Review the 2013 ACC/AHA Guidelines Present Emerging Evidence for Lipid Management in 2018 What to do with statin intolerance. Answer the question Are statins for everyone? Non-Statins: Yay or Nay?
Patient Centeredness = Medical Evidence http://www.acc.org/latest-in-cardiology/articles/ 2017/08/11/08/35/aace-and-eas-lipid-guidelines
(2nd) Most Important Slide LIFESTYLE MODIFICATION Stand during television/commercials Cut out massive amounts of animal proteins (A) High Fructose Corn Syrup is the devil (A) Calculate cola calories Calculate dollars spent on cigarettes and set a goal Cup of nuts per day keeps the doctor away (A) 180 minutes of aerobic exercise per week (A) DASH diet for lipid control (A) Kid s meals Water Unchanged!!!
2013 ACC/AHA: The Good News LDL targets gone!!! No longer giving anything but statins!!! Evidence based!!!
2018 ACC/AHA: The Good News LDL targets are coming back (MAYBE)!!! No longer giving anything but statins!!! Except maybe ezetimibe Evidence based!!! Well, they thought it was Step 1: When do you check LIPIDS? USPSTF (DROPPED!!!-replaced for primary prevention with STATIN recommendation.) All Men >35, Women >45 (A) Men 20-35 and Women 20-45 AT INCREASED risk of CVD (B) WHO in Murica falls into this category? No recommendation for or against Men 20-35 and Women 20-45 NOT AT INCREASED risk of CVD (C) Answer? Step 1b: There s an app for that! DISCLAIMER: It does not definitively recommend statin therapy for individuals with 10-year risk > 7.5%
Primary vs. Secondary Prevention Primary vs. Secondary Prevention remember*
2013 ACC/AHA Cholesterol Treatment Guidelines 4 Statin Benefit Groups: 1. With clinical ASCVD 2. With primary elevations in LDL-C > 190 3. 40-75 yrs with DM and LDL-C 70-189 4. 40-75 yrs without DM or clinical ASCVD, LDL-C 70-189, and an estimated 10-year ASCVD risk of 7.5% or higher 2013 ACC/AHA Cholesterol Treatment Guidelines In select individuals who are not in 1 of the 4 statin benefit groups, additional factors may be considered, including: LDL > 160 or other evidence of genetic hyperlipidemia FH premature ASCVD (male < 55, female < 65) hs CRP > 2 mg/dl CAC score > 300 Agatston units or > 75th percentile Ankle brachial index (ABI) < 0.9 Elevated lifetime risk of ASCVD Circulation. 2014;129(suppl 2):S1-S45 DOI: 10.116/01.cir.0000437738.63853.7a
Statin Intensity vs. Statin Benefit Group 1. Individuals with clinical ASCVD Age < 75: High intensity Age > 75: Moderate intensity 2. With primary elevations of LDL C > 190 mg/dl High intensity 3. 40 75 yrs with diabetes and LDL C 70 189 Estimated 10 y ASCVD risk > 7.5%: High intensity Estimated 10 y ASCVD risk < 7.5%: Moderate intensity 4. Without clinical ASCVD or diabetes, age 40 75, LDL C 70 189 and estimated 10 year ASCVD risk of > 7.5% Moderate to high-intensity Circulation. 2014;129(suppl 2):S1-S45 DOI: 10.116/01.cir.0000437738.63853.7a Step 2: Case Study 54y black Male New diagnosis of PAD Total CHOL 114; HDL 54 No HTN, No DM, No smoker SBP is 112 Exercises 5x/week and BMI is 25
Step 2b (or not 2b): Case Study 59y white male HTN on amlodipine, No DM, 42 PYH Smoker SBP is 150 Total chol 240, HDL 35; TG 187 BMI 34; Sedentary Father died of MI at 62
Statin Intensity vs. Statin Benefit Group 1. Individuals with clinical ASCVD Age < 75: High intensity Age > 75: Moderate intensity 2. With primary elevations of LDL C > 190 mg/dl High intensity 3. 40 75 yrs with diabetes and LDL C 70 189 Estimated 10 y ASCVD risk > 7.5%: High intensity Estimated 10 y ASCVD risk < 7.5%: Moderate intensity 4. Without clinical ASCVD or diabetes, age 40 75, LDL C 70 189 and estimated 10 year ASCVD risk of > 7.5% Moderate to high-intensity I can t take this medicine!!! Within one month after starting Atorvastatin 40mg daily, he develops generalized fatigue, muscle soreness, and bilateral muscle aching. I can t take this medicine! The American College of Cardiology recommends the following strategy to assess, treat, and manage those with possible statin intolerance: 1. Evaluate 2. Follow-up 3. Drug compare
Statin Intolerance: Evaluate Check total CK If > 5x ULN, suggests rhabdomyolysis Symptoms suggesting statin intolerance: Muscle ache, Weakness, Soreness, Stiffness, Cramping, Tenderness, General Fatigue, Bilateral Symptoms unlikely to be statin intolerance: Tingling, Twitching, Shooting Pain, Nocturnal Cramps, Joint Pain, Unilateral Statin Intolerance: Evaluate Muscle Enzyme CK level Rhabdomyolysis Creatinine UA (particularly myoglobin) Risk Factors/Secondary Causes TSH Vit D 25-OH Hepatic panel (ALT) Electrolyte panel Renal panel ESR (erythrocyte sedimentation rate) Statin Intolerance: Evaluate Patient characteristics that increase risk of statin intolerance: Low BMI Frailty******* Excessive grapefuit juice consumption (>1.2L/d) Alcoholism Drug Abuse (amphetamine, cocaine, heroin) Heavy physical exertion/exercise (wait 48 hrs before getting CK) Recent Trauma Dehydration or decrease in daily fluid intake Personal or FH of statin intolerance Drug Interactions (Niacin, Fibrates, Strong CYP3A4 inhibitors)
Statin Intolerance: Follow up Take patient off original potentially offending statin until symptoms resolve Consider a re-challenge with lower dose or same dose of original statin Consider an alternate statin Consider statin characteristics (i.e., metabolism, lipophilicity, etc) Evaluate potential drug interactions Statin Intolerance: Drug Compare Statin characteristics considered when evaluating for statin intolerance: Dose intensity Half-life (Shorter better tolerated) Lipophilic? (Consider switching to Pravastatin or Rosuvastatin, not lipophilic better tolerated) P-glycoprotein substrate? (Atorvastatin, Lovastatin, Simvastatin--less tolerated) App available for ios and Android Web version also available at: http://tools.acc.org/statinintolerance/ #!/
Other Statin Hodge Podge CK Before and During Treatment Should NOT routinely be checked. (A) May check if myotoxicity symptoms (C) May instead opt to discontinue/alternate medicine (B) Hepatic Transaminases (ALT) Baseline and if signs of hepatotoxicity (C) Not tested routinely Screen Yearly For Diabetes (B) The Bad News Cohort data calculator PROBABLY DEFINITELY overestimates risk. Significant risk of Diabetes development in those at risk.
*Caveat The Good News If Guidelines Followed Compared to ATP-III guidelines and based on NHANES data 500,000 strokes, MI, and CV deaths over 10 years prevented Statin use amongst adults will increase from 37.5% to approximately 50% 87% of men over 60. 12,800,000 million more Americans on statins $5,000,000,000 dollars per year. Majority, 10.4mil, are w/o CAD where best evidence for statin use exists. 500,000 CVAs/MIs cost more than 12,800,000 more on STATINs? *Pencina MJ, Navar-Boggan AM, D'Agostino RB, etal. Application of New Cholesterol Guidelines to a Population-Based Sample. N Engl J Med 2014; 370:1422-1431. April 10, 2014.
Most Important Slide 1. Download the APP. Three Things Learned that Will be Applied 2. Anybody can put a patient on a statin. Help them change their behavior and you ll be exceptional. 3. Guidelines will change.