Deciphering the New Guidelines

byApurva D. Shah, FACCNorthside Heart and

Vascular Institute

2013 ACC/AHA Lipid Guidelines

2001• ATP-3

Statin Trials&

Non Statin Trials

2013 • ACC/AHA

GUIDELINES ON THE TREATMENT

OF BLOOD CHOLESTEROL

8:00am Appointment

1. “Doc, why would you want to change my cholesterol medications?”

2. I need a trick to remember the guidelines; I can’t Google it in front of the patient

3. That wasn’t so bad, lets try it again on the next patient

8:00am Appointment

“Doc, why would you want to change my cholesterol

medications?”

The ATP III guidelines: 1. Assess risk based on the Framingham Risk Score

1. FRS underestimates cardiovascular risk2. Lots of patients with low FRS have MI’s

2. Sets goal LDL-C levels for therapy1. Clinical trials didn’t set LDL-C goals2. No trial was powered for and LDL-C = 70

Doc, why do you wanna change my cholesterol medications?

By using the Framingham Risk Score, we are missing people who can benefit from statin therapy

10 Year Predicted and Observed Rates of CV Disease and Heart Disease Mortality Quintiles of Framingham Predicted

CV Disease Events

Brindle P M et al. Br J Gen Prac 2005;55:838-845

Most clinical trials used fixed statin doses and did not treat to a goal LDL-C

Because the FRS missed at risk patients and the trials didn’t support a goal LDL,

the 2013 Lipid Guidelines were created

Watch the flash We need to start from scratch

8:00am Appointment

I need a trick and method to remember the guidelines that’s not Google!

HOW TO APPROACH THE NEW GUIDELINES

RISK GROUPS

Atherosclerotic Disease

LDL-C >190 mg/dl

Diabetes

Everyone Else

REMEMBER“ALDE”

•Atherosclerotic DiseaseA•LDL > 190 mg/dlL•DiabetesD•Everyone ElseE

HOW TO APPROACH THE NEW GUIDELINES

Fixed Statin Doses

•Lipitor 40-80 mg•Crestor 20-40 mg

High-Intensity statin therapy

•Lipitor 10-20 mg•Crestor 5-10 mg•Zocor 20-40 mg•Pravachol 40-80 mg

Moderate-Intensity statin

therapy

•Healthy lifestyleNo Statin Therapy

Atherosclerotic Disease

LDL-C >190 mg/dl

Diabetes

Everyone Else

Let’s see how it works….a patient walks into your office

ATHEROSCLEROTIC DISEASE

• High risk for cardiovascular event

• High risk requires High Intensity •Lipitor 40-80mg•Crestor 20-40mg

Atherosclerotic Disease NO

LDL-C >190 mg/dl

Diabetes

Everyone Else

Let’s see how it works….a patient walks into your office

LDL > 190

• LDL > 190 confers a high event risk

• High risk requires High intensity•Lipitor 40-80mg•Crestor 20-40mg

Atherosclerotic Disease NO

LDL-C >190 mg/dl NO

Diabetes

Everyone Else

Let’s see how it works….a patient walks into your office

DIABETIC

• Not all Diabetic are created equalBut

• All Diabetics benefit from statin therapy

• Must calculate risk score

RISK CALCULATOR

• Found at Google Play Store:• ASCVD Risk Estimator

• Estimates 10 year risk for a cardiovascular event

• High risk > 7.5%

DIABETIC“Deciding on Statin Intensity”

Calculate Risk Score

Risk > 7.5%:

High Intensity Statin Therapy

Risk < 7.5%:

Moderate Intensity Statin

Atherosclerotic Disease NO

LDL-C >190 mg/dl NO

Diabetes NO

Everyone Else

Let’s see how it works….a patient walks into your office

EVERYONE ELSE(No ASCVD; LDL<190; NonDiabetic)

Calculate Risk Score

Risk > 7.5%:

High Intensity Statin

Therapy

Risk < 7.5%:

No Statin Indicated

SUMMARY

•High Dose StatinAtherosclerotic Disease

•High Dose StatinLDL-C >190

•High Dose Statin (Risk>7.5%)•Moderate Dose Statin (Risk<7.5%)Diabetes

•High Dose Statin (Risk>7.5%)•No Statin (Risk<7.5%)

Everyone Else

8:00am Appointment

That wasn’t so bad, let’s try it again on the next patient

Case Study #1

42 year old Male with a Coronary

Stent•Total cholesterol, 140 mg/dl•HDL cholesterol, 35 mg/dl•LDL cholesterol, 110 mg/dl•Normal BP•Not diabetic•Nonsmoker

What therapy would you

initiate•A) Niacin 1000mg daily•B) Lipitor 80mg daily•C) Zocor 10mg daily•D) No therapy

Case Study #2

52 year old Male with Gastric

Bypass•Total cholesterol, 300 mg/dl•HDL cholesterol, 15 mg/dl•LDL cholesterol, 210 mg/dl•Normal BP•Not diabetic•Nonsmoker

What therapy would you

initiate•A) Niacin 1000mg daily•B) Crestor 40mg daily•C) Lipitor 10mg daily•D) No therapy

Case Study #3

50 year old with Diabetes•Total cholesterol, 210 mg/dl•HDL cholesterol, 50 mg/dl•LDL cholesterol, 180 mg/dl•No ASCVD•Diabetic•Smoker•Calculated 10 year risk of CHD or stroke, 9.8%

What therapy would you

initiate•A) Vytorin 10/40mg daily•B) Lipitor 80mg daily•C) Pravachol 10mg daily•D) No therapy

Case Study #4

48 year old with Diabetes•Total cholesterol, 210 mg/dl•HDL cholesterol, 45 mg/dl•LDL cholesterol, 165 mg/dl•No ASCVD•Diabetic•Non-Smoker•Calculated 10 year risk of CHD or stroke, 2.5%

What Therapy should be Initiated

•A) Lipitor 80mg •B) Crestor 5mg•C) Vytorin 10/40mg•D) Niacin 1000mg