NEW GUIDELINES FOR CHOLESTEROL

NEW GUIDELINES FOR CHOLESTEROL

NEW CHOLESTEROL GUIDELINES 2013 Recently updated guidelines for the treatment of high blood cholesterol levels is a major update since 2002. The news media have trumpeted that it will lead doctors to prescribe statins to millions more people; calling it a tectonic shift in the way doctors will treat high cholesterol. The new guidelines could double the number of people on statin. In contrast to older ones, the new guideline has been a subject of controversy. Nevertheless, these recommendations are likely to have a major effect on the clinical practice of lipid management.

WHAT IS NEW? An approach that disregards target levels and is based only on risk level and intensity of statin therapy. In essence, it is switch from treating lab tests to treating patients. No evidence to support adjusting treatment to achieve specific target levels of LDL-C. A new risk calculator to identify those with a risk of 7.5% or higher for having a cardiovascular event in the next 10 years. The guidelines are the same for women as for men.

WHAT IS ASCVD ATHEROSCLEROTIC CVD? The following are the examples of ASCVD - Acute coronary syndromes - Stable and unstable angina - History of MI - Coronary revascularization - Stroke or TIA presumed to be from atherosclerotic origin - Peripheral arterial disease & revascularization

RISK CALCULATOR This downloadable spreadsheet is a companion tool to the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. The spreadsheet helps us estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD. The information required to estimate ASCVD risk includes - age, sex, race, - total cholesterol, HDL cholesterol, - systolic blood pressure, blood pressure lowering medication use, - diabetes status, and smoking status.

HOW TO CALCULATE RISK Step 1. Click on this link (or copy paste if link does not work) http://my.americanheart.org/professional/statementsguidelines/preventionguidelines/prevention- Guidelines_UCM_457698_SubHomePage.jsp Step 2. Click on the tab that says download CV risk calculator on right side (we need MS office/excel software on our computer ) Step 3. Once we start filling in the blank in column C (age, sex, race etc..), we will automatically start seeing colorful bars and calculations; very innovative!

AN EXAMPLE OF ASCVD RISK CALCULATION

NEW GUIDELINE FOR STATIN THERAPY

INTENSITY OF STATIN THERAPY ( HIST & MIST )

KEY FEATURES OF THE NEW GUIDELINES It identifies 4 subgroups of patients for whom the benefit of statins clearly outweighs the risk and require high-intensity statin therapy (HIST) 1. Clinically evident atherosclerotic cardiovascular disease, 2. Primary LDL cholesterol levels of at least 190 mg per deciliter, 3. Type 1 or 2 diabetes and LDL level of 70 or higher, 4. 10-year risk of atherosclerotic cardiovascular disease of at least 7.5% and an LDL level of at least 70. In these patient groups, high-intensity statin therapy (designed to reduce LDL cholesterol levels by 50%) is generally recommended.

MODERATE INTENSITY STATIN THERAPY : MIST MIST : (aiming for a reduction of 30 to <50% in LDL cholesterol levels) is recommended for patients who cannot tolerate high-intensity treatment or patients with diabetes and a 10-year risk of atherosclerotic cardiovascular disease of < 7.5%. Persons receiving statin therapy should be monitored for muscle and hepatic injury and for new-onset diabetes.

WHO NOT TO TREAT WITH STATIN The new guidelines also identifies patients for whom available data do not support statin therapy and for whom no recommendation is made. These groups are 1. Age of > 75 years, unless clinical atherosclerotic cardiovascular disease is present; 2. Need for hemodialysis; or 3. New York Heart Association class II, III, or IV heart failure. The panel found no evidence to support the use of non-statin cholesterol-lowering drugs, either combined with statin therapy or in statin-intolerant patients.

OTHER FACTORS TO BE CONSIDERED 1. Primary LDL C 160 mg/dl or other evidence of genetic hyperlipidemias, 2. Family history of premature ASCVD with onset <55 years of age in a first degree male relative or <65 years of age in a first degree female relative, 3. High-sensitivity C-reactive protein >2 mg/l, 4. CAC score 300 Agatston units or 75 percentile for age, sex, and ethnicity, 5. Ankle-brachial index <0.9, or 6. Elevated lifetime risk of ASCVD. CAC Score : The presence of calcification on a coronary artery calcium (CAC) scan These patients are likely to need individualized or specialized care

IMPORTANT ROLE OF PROVIDERS The guidelines are not intended to be a cookbook, one-size-fits-all approach. Providers are expected to - Look for secondary causes of hyperlipidemia, to take other individual patient factors into consideration - Encourage Lifestyle modification: ( heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight)

OVERALL HEART HEALTH In addition to the guidelines on evaluating cholesterol risk, two other sets of guidelines relating to overall heart health has also been released. 1. Eating a heart-healthy diet, including reducing saturated and trans fats as well as limiting sodium to 2,400 mg per day -- 2. Treatment guidelines on managing weight loss in patients. A. Help create individualized weight loss plans and recommend counseling with a dietitian or other certified weight loss professional for at least six months. B. Offer bariatric surgery as a potentially viable option for patients with a BMI over 40, or those with a BMI over 35 and other complicating factors.

INITIATING STATIN THERAPY

MONITORING PATIENTS ON STATINS 1. Regular assessment of adherence to medication and lifestyle 2. Re-testing lipid levels at intervals as long as 12 months 3. Other safety measures as clinically indicated 4. No routine monitoring of liver function tests unless there are symptoms suggesting liver toxicity.

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SECONDARY CAUSES OF HYPERLIPIDEMIA

FINALLY, THE GOOD NEWS - The new methods of assessing cardiovascular risk includes for the first time not only the risk for heart attack, but also for stroke - Almost all statins are now available as generics including Lipitor.