LIPID AND HYPERTENSION GUIDELINE REVIEWRobert Ferrante

Objectives• Review new guidelines and recommendations proposed

by the Joint National Commission (JNC) and the American College of Cardiology / American Heart Association (ACC/AHA) for lipid and blood pressure.

• Compare newest guidelines to prior versions.• Explain the relevancy of these new guideline to current

pharmacy practice• Discuss the controversies presented by new

recommendations

Cholesterol Background:Adult Treatment Panel III (ATP III)

• Low-Density Lipoprotein• Below 100 mg/dL is ideal.• Between 130-159 mg/dL is borderline-high• Above 190 mg/dL is very high

• High Density Lipoprotein• Above 60 mg/dL is ideal. • Below 40 mg/dL is low

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ATP III Risk Factors• Cigarettes

• Hypertension (>140/90) or DM

• Low HDL

• Family history of CHD (Male <55, Female <65)

• Age (M ≥ 45 : F ≥ 55)

• Framingham Risk Score

ATP III Goals• Different goals depending upon risk category

• 0-1 risk factors• Goal below 160 mg/dL• Treat if above 190 mg/dL

• 2+ risk factors• LDL below 130 mg/dL• Treat above 130 mg/dL or 160 mg/dL based on 10 yr risk

• Coronary heart disease (CHD) OR 10 year CHD risk >20%• LDL below 100 mg/dL• Drug therapy if 130 mg/dL or greater

Therapeutic Lifestyle Changes• Saturated fat <7% of calories

• <200 mg/day of cholesterol

• Fiber increase to 10-25 mg/day

• Weight management

• Increased physical activity

ATP III Treatments

ATP III Take-Home Points• Goals and categories based on risk factors

• Goals are number based

• No specific outline for treatment

• Wide spectrum of possible treatments

2013 ACC/AHA Blood Cholesterol Guidelines

• Based upon:• Past history of heart disease • LDL levels

• Greater than or equal to 190 mg/dL

• The presence of diabetes mellitus (DM)• Type 1 or 2 DM and aged 40-75

• 10 year atherosclerotic cardiovascular disease risk calculator.• Greater than 7.5% estimated 10 year risk of ASCVD

10 year ASCVD Calculator• Can calculate 40-79 year olds 10 year risk.• Factors include

• Sex• Race• Age• Treatment for blood pressure• Cholesterol levels• Smoking• Diabetes

Statin Intensity

Statin Monitoring• Baseline lipid panel

• Follow up 4-12 weeks after initiation• Ever 3-12 months afterwards

• Baseline liver functioning tests

Take Home Points• Cholesterol-lowering medications, especially statins,

reduce risk for CV events

• Statins are effective in majority of patient groups. • Non-statins show little to no CV benefit.

• Patients at higher baseline risk, will have great absolute benefit from therapy

• Diabetes diagnosis is proportional to therapy intensity.

JNC 8• Reduce cardiovascular events through pharmacologic

control of blood pressure

• Major considerations:• Age (60 years old)• Race• Diabetes• Chronic Kidney Disease (CKD)

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Algorithm

Lifestyle Modifications• Weight loss 22 lbs = 5-20 mmHg• DASH/healthy diet = 8-14 mmHg• Limit salt = 2-8 mmHg• Exercise = 8-14 mmHg• Limit alcohol = 2-4 mmHg• Stop Smoking• Sleep

Dosing

Major Changes• Not included: beta-blockers, alpha-blockers, loop

diuretics, alpha 1/beta-blockers, central alpha2/adrenergic agonists, direct vasodilators, or aldosterone antagonists.

• What about patients already on these therapies with controlled HTN?

Conclusion• Although new guidelines continue to encourage lowering

of LDL and BP, seemingly small changes may have a massive impact on public perception of their healthcare.

• Both guidelines include lifestyle modifications as primary treatment.

• It is important to exercise professional judgment before blindly adhering to guidelines.

References• James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the

Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.

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Kavousi M, Leening MG, Nanchen D, et al. Comparison of Application of the ACC/AHA Guidelines, Adult Treatment Panel III Guidelines, and European Society of Cardiology Guidelines for Cardiovascular Disease Prevention in a European Cohort.JAMA. 2014;311(14):1416-1423. doi:10.1001/jama.2014.2632.

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Stone NJ, Robinson J, Lichenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JAMA. 2013;01

• National Cholesterol Education Panel. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143–3421.