1 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Athersclerotic Risk Lynne T Braun, PhD, CNP, FAHA, FAAN Professor of Nursing, Nurse Practitioner Rush University Medical Center
5 What s New in the Guideline? Focus on ASCVD risk reduction: 4 statin benefit groups Goal is to reduce ASCVD events in secondary and primary prevention High-intensity and moderate-intensity statin use A new perspective on LDL-C and/or non-hdl-c treatment goals No evidence to support LDL-C and/or non-hdl-c treatment targets Appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most likely to benefit Stone NJ et al., Circulation
6 What s New in the Guideline? Global risk assessment for primary prevention Use of the new Pooled Cohort Equations to estimate 10- year ASCVD risk in both black and white men and women Safety recommendations Used RCTs to identify important safety considerations of statins and provides expert guidance on management of adverse effects Role of biomarkers and noninvasive tests Treatment decisions in selected individuals who are not in the 4 statin benefit groups may be informed by other factors 6
7 Lifestyle as the Foundation for Risk Reduction Guideline on Lifestyle Management A critical component of health promotion and ASCVD risk reduction Heart-healthy diet Regular exercise Avoidance of tobacco products Maintenance of a healthy weight Eckel RH et al., Circulation
8 4 Statin Benefit Groups 1. Individuals with clinical ASCVD, defined as the inclusion criteria for secondary prevention statin RCTs Acute coronary syndromes History of MI Stable or unstable angina Coronary or other arterial revascularization Stroke or TIA PAD 8
9 4 Statin Benefit Groups 2. Individuals with primary elevations of LDL-C 190 mg/dl 3. Individuals with diabetes aged years with LDL-C mg/dl and without clinical ASCVD 4. Individuals without ASCVD or diabetes with LDL-C mg/dl and estimated 10-year ASCVD risk 7.5% (estimated using the Pooled Cohort Equations) 9
10 Use of Statins Statins have an acceptable margin of safety when used in properly selected individuals and appropriately monitored. Statin therapy recommended for secondary and primary prevention of ASCVD Based on RCTs, statins reduce morbidity and mortality associated with ASCVD Cost-effective: many statins are now generic
11 Stone NJ et al., Circulation
12 Treat to Target was Abandoned Current trial data does not indicate what the target should be. No data from clinical trials on the magnitude of additional ASCVD risk reduction achieved with one target lower than another Potential for adverse effects of multidrug therapy that might be needed to achieve a specific goal 12
13 More on LDL-C and Non-HDL-C Goals RCT evidence shows that ASCVD events are reduced by using the maximum tolerated statin intensity in those groups shown to benefit. In secondary prevention, evidence supports highintensity statin therapy to maximally lower LDL-C. No RCTs titrated drug therapy to specific LDL-C and non-hdl-c goals to improve ASCVD outcomes. In AIM-HIGH, the additional reduction in non-hdl-c with niacin DID NOT further reduce ASCVD risk in individuals treated to LDL-C levels of mg/dl. 13
14 Primary Prevention Use the new Pooled Cohort Equations to estimate 10-year ASCVD risk. Guideline is patient centered Potential for risk reduction benefit, adverse effects, and drug-drug interactions, along with patient preferences, must be considered before statins are prescribed for the primary prevention of ASCVD. 14
15 Shared Decision Making (SDM) When Appropriate Engage in a clinician patient discussion before initiating statin therapy, especially for primary prevention in patients with lower ASCVD risk. The cholesterol guidelines recommend not only the risk calculation, but also the clinician patient review of the risk and the decision to take a statin.
16 Shared Decision Making (SDM) When Appropriate Age is a major contributor to the ASCVD risk calculation. A 65-year-old man and a 71-year-old woman with optimal risk factors have a >7.5% 10-year risk. Clinical judgment, statin safety issues, and consideration of patient preferences inform the treatment plan. Prescription of a statin is not automatic. Treatment plan is a comprehensive approach to risk reduction that begins with the use of the ASCVD risk calculator and incorporates addressing of the modifiable risk factors.
17 10-year ASCVD risk of 7.5% or higher These individuals can be identified by using the new Pooled Cohort Equations for ASCVD risk prediction, developed by the Risk Assessment Work Group. Stroke now included in ASCVD risk assessment, in addition to myocardial infarction (MI) Separate equations for nonwhite populations
18 Role of Biomarkers and Noninvasive Tests In select individuals who are not in 1 of 4 statin benefit groups, and for whom the decision to initiate statin therapy is unclear, additional factors may be used to inform treatment decisions. Factors include: LDL-C 160 mg/dl Family history of premature ASCVD Hs-CRP 2 mg/l CAC score 300 Agatston units or 75 th percentile for age, sex, and ethnicity ABI < 0.9 Elevated lifetime risk of ASCVD 18
19 Intensity of Statin Therapy High-intensity statin therapy is defined as a daily dose that lowers LDL-C by 50% Moderate-intensity statin therapy lowers LDL-C by 30% to <50%.
20 Heading Stone NJ et al., Circulation
21 Stone NJ et al., Circulation
22 Stone NJ et al., Circulation
23 Statin Safety Recommendations Use moderate-intensity statin therapy in patients who are predisposed to statin-associated adverse effects. Multiple or serious comorbidities, including impaired renal or hepatic function History of previous statin intolerance or muscle disorders Unexplained ALT elevations > 3 times ULN Concomitant use of drugs affecting statin metabolism > 75 years of age History of hemorrhagic stroke Asian ancestry CK should not be routinely measured, although it is reasonable to measure baseline CK in persons at increased risk for adverse muscle events
24 Statin Safety Recommendations During statin therapy, it is reasonable to measure CK for muscle symptoms (pain, stiffness, cramping, weakness) Baseline ALT should be performed before initiating statin therapy During statin therapy, it is reasonable to measure ALT if symptoms suggest hepatotoxicity (unusual fatigue, weakness, loss of appetite, abdominal pain, dark urine, jaundice) Decreasing the statin dose may be considered with 2 consecutive LDL-C levels < 40 mg/dl It may be harmful to initiate simvastatin at 80 mg daily or increase the dose to 80 mg daily
25 Statin Safety Recommendations Individuals on statin therapy should be evaluated for new onset DM. Those who develop DM should be counseled on a heart-healthy diet, physical activity, healthy body weight, stopping tobacco use. Statin therapy should be continued to reduce their risk of ASCVD events. Use caution in individuals > 75 years of age, persons taking concomitant meds that alter drug metabolism, taking multiple drugs, taking drugs for conditions that required complex medication regimens (transplant patients or patients with HIV). Review prescribing information before initiating any cholesterol-lowering drug.
26 Monitoring Statin Therapy A baseline lipid panel should be obtained followed by a second lipid panel 4 to 12 weeks after initiation of statin therapy to determine patient s adherence. Thereafter, assessments should be every 3 to 12 months as clinically indicated. LDL-C levels and per cent reduction are to be used only to assess response to therapy and adherence.
27 Insufficient Response to Statin Therapy In persons with a less-than-anticipated response to statin therapy or are intolerant to the recommended intensity of statin therapy: Reinforce adherence to medication and lifestyle changes Exclude secondary causes of hyperlipidemia Investigate statin intolerance In persons at high ASCVD risk receiving the maximum tolerated statin who have a less-than-anticipated therapeutic response, addition of a nonstatin LDL lowering agent may be considered if the benefits outweigh the potential for adverse effects Individuals with clinical ASCVD < 75 years of age Individuals with baseline LDL-C 190 mg/dl Individuals 40 to 75 years of age with diabetes
28 Synopsis of the Guideline 1. Adherence to a healthy lifestyle 2. Statins therapy for four groups 3. Safe use of statins 4. Shared Decision Making (SDM) when appropriate 5. Estimation of 10-year ASCVD risk 6. Intensity of statin therapy 7. No specific target LDL-C or non HDL-C goals 8. Regularly monitor patients for adherence Adapted from Stone NJ Ann Intern Med. Published online 28 Jan
29 Blood Pressure Guidelines By JNC 8 Panel
30 Background JNC I 1976 JNC JNC 8 Organized in 2008 Review submitted 06/2013
31 Background Submitted for review to 16 federal agencies and 20 individual reviewers NHLBI subsequently decided AHA/ACC should make future guidelines Panel members submitted guidelines to JAMA for review No official organization sponsorship
32 Methodology JNC 7 Followed methods of prior JNC committees Literature review by expert committee Evidence from all study designs evaluated RCT and observational Comprehensive overview of HTN management (measurement techniques, resistant hypertension, etc)
33 JNC 8 Methodology Based on 2011 Institute of Medicine guidelines recommendations 1 Systematic review of RCTs only No meta-analyses of RCTs or observational data Focused on 3 highest ranked questions for BP management Nine recommendations 1 Graham R et al. National Academies 2011
34 Guideline Questions 1) Does initiating antihypertensive treatment at specific BP thresholds improve health outcomes? 2) Does treatment with antihypertensive therapy to a specific BP goal improved health outcomes? 3) Are there differences in benefit/harm between antihypertensive drugs or drug classes on specific health outcomes?
35 Level of Evidence
36 Strength of Recommendation James, PA et al. JAMA 2014
37 Quality of Evidence James, PA et al. JAMA 2014
38 James, PA et al. JAMA 2014
39 James, PA et al. JAMA 2014
40 JNC 8 Algorithm James, PA et al. JAMA 2014
41 JNC 8 Algorithm James, PA et al. JAMA 2014
42 JNC 8 Algorithm James, PA et al. JAMA 2014
43 Recommendations at a Glance Jin, J. JAMA 2014
44 The Minority View 5/17 panel members strongly disagreed with the age specific recommendation 1) Increased target -> reduction in antihypertensive intensity on a population level 2) Higher SBP goal may reverse current decline in CVD mortality, especially stroke 3) Insufficient evidence to support change Wright et al. Annals of Internal Medicine 2014
45 The Minority View Age 60 vs. 80 for different SBP treatment goals Wright et al. Annals of Internal Medicine 2014
46 The Minority View Age 60 vs. 80 for different SBP treatment goals Wright et al. Annals of Internal Medicine 2014
47 The Minority View we concluded that the evidence for increasing a blood pressure target in high-risk populations should be at least as strong as the evidence required to decrease the recommended blood pressure target Wright et al. Annals of Internal Medicine 2014
48 A Caveat for the Old Old A SBP goal of < 150 mmhg for frail persons aged 80 years is reasonable since they are at higher risk for treatment-related adverse effects
49 Go AS et al., Hypertension 2013
50 Population Level Effect of Small Changes in Blood Pressure >50% of those with HTN are older than 60 in the US 51% treated to goal (JNC 7) Median SBP: treated 136mmHg, untreated 152mmHg Cook NR, et al. Arch. Int. Med. 1995
51 Blood Pressure and CVD Outcomes Prospective Studies Collaboration 61 observational studies 56,000 vascular deaths 12.7 million person year follow-up
53 High Risk in Persons with the Higher Goal Age substantially increases risk for CV events. No justification for different targets for patients older and younger than 60 years Risk range for white and AA men aged 60 years is 9% to 30%. Men aged 70 years with controlled SBP at 140 mmhg, even without CVD or DM, have a 10-year risk > 20%. Based on absolute risk, using an age threshold of 60 years to define eligibility for less aggressive treatment lacks consistency. Wright et al. Annals of Internal Medicine
54 Insufficient Evidence for Differential HTN Treatment Benefit for Persons Older and Younger Than 60 Years HYVET and SHEP trials show that reducing SBP to 140 mmhg has substantial benefit without harm in older persons. Lack of benefit was shown in 2 Japanese trials that were underpowered (125 strokes and 67 CHD events combined). Uncertain generalizability to other populations, e.g., African Americans Need stronger justification to recommend less aggressive target in high-risk populations Wright et al. Annals of Internal Medicine
55 ACCORD BP 4,733 participants with diabetes type 2 Mean age 62, mean follow-up 5 years Clinical or subclinical CVD or 2 RF Primary outcome: nonfatal myocardial infarction, nonfatal stroke, or death from CVD
56 ACCORD BP 134mmHg 119mmHg Cushman, WC et al. NEJM 2010
57 Cushman, WC et al. NEJM 2010 ACCORD BP 134mmHg 119mmHg
58 ACCORD BP Cushman, WC et al. NEJM 2010
59 Go AS et al., Hypertension 2013.
60 Decreasing your sodium intake: where is salt found in our diets?
61 Treatment Recommendations: JNC 8 In the general nonblack population, including those with DM, initial treatment should include a thiazide-type diuretic, CCB, ACEI, or ARB. In the general black population, including those with DM, initial treatment should include a thiazide-type diuretic or CCB. In pts 18 years with CKD and HTN, initial or add-on treatment should include ACEI or ARB to improve kidney outcomes.
62 Treatment Recommendations: JNC 8 If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug. The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with 2 drugs, add a third drug. Do not use an ACEI and ARB in the same patient. Consider referral to a hypertension specialist for patients with difficult to control blood pressure.
63 Case Example 52-year-old Caucasian male History of hypertension; nonsmoker No known history of CAD; no symptoms of CAD Father had MI at age 55; mother has HTN BMI 29.5 kg/m 2 BP 160/88 mmhg (treated with lisinopril 10 mg) TC 210, HDL 33, TG 180, LDL 141, glucose 80
64 Pooled Cohort Risk Calculator Determines estimated 10-year risk for ASCVD events Estimator/ 10-year ASCVD risk: 11.5% vs 2.6% for male patient, same age, with optimal risk factors Lifetime ASCVD risk: 69% vs 5% for male with optimal risk factors
65 How would you manage this patient?
66 Primary Prevention with a 10-year ASCVD risk 7.5% Goals Moderate-to-high intensity statin Weight reduction; heart-healthy diet Blood pressure control (< 140/90 mmhg) -drug choices? -monitor in the office and at home Regular physical activity program
67 What if this patient s 10-year ASCVD risk was 7%?
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