lipid guideline controversies

7/25/2019 Lipid Guideline Controversies

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Lipid Guideline Controversiesin 2014: The Decision is Yours

Carl E. Orringer !D "#CC"$L#


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O%&ectives

To provide an overvie' o( the #)ericanCollege o( Cardiolog*+#)erican ,eart#ssociation and the $ational Lipid#ssociation lipid )anage)entapproaches (or #-CD prevention

To identi(* the si)ilarities and di/erences

%et'een the t'o approaches To provide the in(or)ation needed to

decide 'hich approach to use and 'hen


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T'o #-CD revention #pproaches

T'o Di/erent erspectives

Eternal revie'er #uthor


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US age-standardized death rates

attributable to CVD, 2000 to 2010

Go A S et al. Circulation. 201412!"e2#-e2!2

Copyright American Heart Association, Inc. All rights reserved.

elease o( $CE#T 333 elease o( $CE

#T 333 pdate


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Mean age-adjusted LDL-C trends 20012011in theUnited States: Analysis of 105 illion!atient re"ords

fro a single national diagnosti" la#oratory

10.1561+&ournal.pone.0075417


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3s There a $eed (or a Dra)atic Changein #pproach to #-CD revention8

CC-3#-

E#-+E-C9#-$3CE$L#

Changes in:

Evidence %aseCentral (ocusLipid goalsse o( nonstatinsis; calculator

#CC+#,#


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The ules

The topic 'ill %e identi


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Evidence =ase

ACC$A%A

ando)i>ed

controlled trials?CT@ o( statintherap*

!etaanal*ses o(CT

&LA

CT o( statins andnonstatin drug

therap*

!etaanal*ses o( CT

O%servationalepide)iologic studies

Genetic studies

!eta%olic studies

!echanistic studies


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ando)i>ed Controlled Trials ?CT@

-*ste)aticall* test e/ect?s@ o( an interventionon prespeci


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O%servational Epide)iologic -tudies

orld'ide in scope and )a* assess#-CD ris; across populations

Cohort studies evaluate )ortalit* and

)or%idit* 'ithin populations Con(ounding )a* occur even a(ter

)atching strati


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O%servational Epide)iologic Cohort -tud* o(2147 atients 'ith ", and no C,D at =aseline

ers)issen 9 et al =!9 200B 556: a2425


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Genetic -tudies

Genetic epide)iolog* reduces theli;elihood o( con(ounding %* (ocusing on

single varia%les: genetic )utations 3denti


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Data De)onstrating Genetic

ariants #/ecting #-CD is;

-euence variants in the gene

encoding (or C-F resulting in loss o((unction )utations are associated'ith 2H reduction in LDLC an Hreduction in C,D ris; and provide

support (or the value o( long ter) lo'LDLC in pro)oting C,D ris; reduction

9 Cohen et al. $ Engl 9 !ed 2007B5I4:127462


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'(iden"e )ase: Suary

#CC+#,# =* li)iting the scope to CT o( statins and

)etaanal*ses o( CT onl* the highest level o(evidence on statins in de


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Central "ocus o( Guideline

ACC$A%A

3denti


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#CC+#,# -tatin =ene


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,igh and !oderate3ntensit*Dail* -tatin Therap*

,igh 3ntensit*?Lo'ers LDLC I0H@ Ator(astatin 0-30

g

4osu(astatin 20-40 )g

!oderate 3ntensit*?Lo'ers LDLC 50

I0H@ Ator(astatin 10 ?20@

g

4osu(astatin ?I@10

g Si(astatin 200

g

Si(astatin 30 g 6ra(astatin 0 ?0@

g

Lo(astatin 0 g "luvastatin NL 0 )g 7lu(astatin 0 g

28$day

Bold = ested in !C and

revie"ed #y $%pert &anel'ello"=(ot tested in !Crevie"ed #y $%pert &anel


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EPcac* o( 3ntensive Lo'ering o( LDLC in -u%&ects 'ith Lo' =aseline LDLC

!etaanal*sis o( CTAs o( Q1000 participantsand M2 *ears treat)ent duration o( )oreversus less intense statin trials involving

1715 su%&ects The )a&or vascular event reduction a)ong in

those 'ith %aseline LDLC R66)g+dL per(urther 5 )g+dL reduction 'as 2H ?H C3

24 pS0.006@B in those 'ith %aseline LDLCR60 )g+dl si)ilar reduction in LDLCcontinued to de)onstrate !E reduction ?0.75 H C3 0.410.I pS0.004@.

Cholesterol Treat)ent Trialists Colla%oration. Lancet 2010B567:17601


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#CC+#,# erspective on -tatinTherap*

-tatin intensit* trials sho'ed clear%ene


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#CC+#,# erspective on $on-tatinLipid Drug Therap*

$onstatin drugs 'ithout de)onstrated#-CD ris; reduction )a* (avora%l* alterlipids %ut have an un(avora%le ris;+%eneeti)i%e

CET inhi%itors torcetrapi% and dalcetrapi%

The use o( nonstatin drugs should generall*%e avoided


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Overvie' o( the $L#eco))endations

1. #ll preventive therap* %egins 'ith ris; assess)ent and aproviderpatient discussion o( the pros and cons o( therap*

2. Li(est*le therap* is at the %asis o( all #-CD preventivereco))endations regardless o( %aseline ris;

5.9udicious use o( evidence%ased drug therap* particularl*)oderate and highdose statins is associated 'ith opti)al#-CD ris; reduction

4. hen ecessive circulating atherogenic cholesterol ?non,DLcholesterol and LDL cholesterol@ persists a(ter

appropriate li(est*le and statin therap* the use o( nonstatin therap* )a* %e considered

I. Longter) (ollo'up (ostered %* providerpatientco))unication is essential (or opti)al #-CD prevention


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$L# #-CD is; Categor* Criteria

4is Category Criteria

er* ,igh #-CD Dia%etes )ellitus ?t*pe 1 or 2@ M2 other )a&or #-CD ris;(actorsB or Evidence o( endorganda)age

,igh M5 )a&or #-CD ris; (actors Dia%etes )ellitus ?t*pe 1 or 2@ 01 other )a&or #-CD ris;(actor and no evidence o( endorganda)age

Chronic ;idne* disease -tage 5=or 4

LDLC M10 or non,DLC M220)g+dL

!oderate 2 )a&or #-CD ris; (actors "or speci


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$L# #-CD is; Categories Levels (orConsideration o( Drug Therap* and Treat)ent Goals

4is Category Consider Drug9hera!y

9reatent oal

$on,DLC +LDLCGoal ?)g+dL@

$on,DLC+LDLCGoal ?)g+dL@

er*high M100

M60

R100

R60,igh M150

M100R150R100

!oderate M170M150

R150R100

Lo' M10M170

R150R100

ts with ASCVD or diabetes mellitus, consider use of moderate or highrrespective of baseline atherogenic cholesterol levels.


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$L# erspective on -tatin

Therap* -tatin therap* is the )ost potent and evidence%ased approach to lo'ering atherogeniclipoproteins ?non,DLC and LDLC@

-tatin intensit* trials sho'ed clear %ene


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$L# erspective on$on-tatin Lipid Drug Therap*

3( non,DLC and LDLC goals are not achieved 'ith)ai)al tolerated statin therap* the addition o(nonstatin therap* should %e considered to lo'eratherogenic cholesterol levels and to achieve goals Doctors can %e instructed not to use niacin in patients on

aggressive statin regi)ens

#s e>eti)i%e is sa(e and lo'ers atherogenic cholesterolits use )a* %e considered in selected patients 'ith

elevated non,DLC and+or LDLC esins )a* %e considered in selected patients

!etaanal*ses o(


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3s ,ighDose -tatin Therap*the End o( the Line8

i %ili ( hi d


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!eta anal*sis

o( statin CTinvolving 51I5 su%&ectso( 'ho) I56had 727)a&or C

events andhad %aselineand 1 *earlipids andlipoproteins

aria%ilit* o( #chieved LDLCith ,igh3ntensit* -tatin

Therap*=oe;holdt -! et al. 9 #) Coll Cardiol 2014B74: 4I4

"ro) T$T-#CL 3DE#L and

93TEde)onstratingvaria%ilit* o(LDLC lo'ering.Q40H did not achieveLDLC R60 )g+dl onatorvastatin 0 orrosuvastatin 20 )gdail*

ater(all plot o(3ndividual values

er* Lo' LDL C and $on ,DL C


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er* Lo' LDLC and $on,DLCin -tatin Trials and !a&or CD

Event is;

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0/,1

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lipid guideline controversies

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