NEW 2013 ACC/AHA GUIDELINES ON

TREATMENT OF BLOOD CHOLESTEROL TO

REDUCE ATHEROSCLEROTIC CARDIOVASCULAR
RISK IN ADULTS
MINI-LECTURE
PEJMAN SOLAIMANI, PGY-2
FEB 2014

OBJECTIVES
I.

INTRODUCTION TO NEW GUIDELINES ON LIPID MANAGEMENT

II.

COMPARISON WITH ATP III GUIDELINES

III. CURRENT STATIN TREATMENT RECOMMENDATIONS

IV. CURRENT STATIN SAFETY RECOMMENDATIONS

OVERVIEW
GOAL: TREATMENT OF BLOOD CHOLESTEROL TO REDUCE ATHEROSCLEROTIC
CARDIOVASCULAR RISK IN ADULTS, CURRENTLY THE LEADING CAUSE OF
DEATH AND DISABILITY IN AMERICA

WHAT HAS CHANGED COMPARED TO ATP3

GUIDELINE?
INITIATE EITHER MODERATE-INTENSITY OR HIGH-INTENSITY STATIN THERAPY
FOR PATIENTS WHO FALL INTO THE FOUR CATEGORIES

UNLIKE ATP-III, DO NOT TITRATE TO A SPECIFIC LDL CHOLESTEROL TARGET

MEASURE LIPIDS DURING FOLLOW-UPS TO ASSESS ADHERENCE TO TREATMENT, NOT

TO ACHIEVE A SPECIFIC LDL TARGET

FOUR MAJOR STATIN BENEFIT GROUPS

1) INDIVIDUALS WITH CLINICAL ASCVD
2) INDIVIDUALS WITH LDL >190
3) INDIVIDUALS WITH DM, 40-75 YO WITH LDL 70-189 AND WITHOUT CLINICAL
ASCVD
4) INDIVIDUALS WITHOUT CLINICAL ASCVD OR DM WITH LDL 70-189 AND
ESTIMATED 10-YEAR ASCVD RISK >7.5%

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

NO RECOMMENDATIONS ON STATIN THERAPY FOR PTS WITH NYHA

CLASS II-IV OR ESRD ON DIALYSIS (GRADE N RECOOMENDATIONS)

INTENSITY OF STATIN THERAPY IN PRIMARY

AND SECONDARY PREVENTION

STATIN SAFETY RECOMMENDATIONS

SELECT THE APPROPRIATE DOSE
KEEP POTENTIAL SIDE EFFECTS AND DRUG-DRUG INTERACTION IN MIND
(GRADE A)

IF HIGH OR MODERATE INTENSITY STATIN NOT TOLERATED, USE THE

MAXIMUM TOLERATED DOSE INSTEAD

STATIN SAFETY RECOMMENDATIONS

CONDITIONS THAT COULD PREDISPOSE PTs TO STATIN
SIDE EFFECT:
o
o
o
o
o
o

IMPAIRED RENAL OR HEPATIC FUNCTION

HISTORY OF PREVIOUS STATIN INTOLERANCE OR MUSCLE DISORDER
AGE >75
UNEXPLAINED ALT ELEVATION > 3X ULN
HISTORY OF HEMORRHAGIC STROKE
ASIAN ANCESTRY

STATIN SAFETY RECOMMENDATIONS

CHECK BASELINE ALT PRIOR INITIATING THE STATIN (GRADE B)

CHECK LFTS IF PATIENT DEVELOPS SYMPTOMS OF HEPATIC DYSFUNCTION (GRADE E)

IF 2 CONSECUTIVE LDL <40, CONSIDER DECREASING THE STATIN DOSE (GRADE C,

WEAK RECOMMENDATION)

IT MAY BE HARMFUL TO INITIATE SIMVASTATIN 80MG, OR INCREASE THE DOSE OF

SIMVASTATIN TO 80MG (GRADE B)

CASE 1
62 YEAR OLD AA MALE
TOTAL CHOLESTEROL: 140
LOW HDL: 35
SBP: 130 MMHG
NOT TAKING ANTI-HYPERTENSIVE MEDICATIONS
NON-DIABETIC
NON-SMOKER
CALCULATED 10 YR RISK OF ASCVD : 9.1%

 MODERATE TO HIGH INTENSITY STATIN

CASE 2
50 YEAR OLD WHITE FEMALE
TOTAL CHOLESTEROL 180
HDL: 50
SBP: 130
TAKING ANTI-HTN MEDS
+DIABETIC
+SMOKER
CALCULATED 10 YR ASCVD: 9.8%

 HIGH INTENSITY STATIN

CASE 3
48 YO WHITE FEMALE
TOTAL CHOLESTEROL 180
HDL: 55
SBP: 130
NOT TAKING ANTI-HTN MEDS
+DIABETIC
NON-SMOKER
CALCULATED 10 YR RISK ASCVD : 1.8%

 MODERATE INTENSITY STATIN

CASE 4
22 YO WHITE MALE
LDL: 195
SBP: 120
NOT TAKING ANTI-HTN MEDS
NON-DIABETIC
NON-SMOKER

 HIGH INTENSITY STATIN

CASE 5
66 YO WHITE FEMALE
HIGH TOTAL CHOLESTEROL: 230
HDL: 55
SBP: 150
TAKING ANTI-HTN MEDS
NON-DIABETIC
NON-SMOKER
CALCULATED 10 YR RISK OF ASCVD : 2.0 %

 STATIN THERAPY NOT RECOMMENDED

TAKE HOME MESSAGE

1. RATHER THAN LDLC OR NON-HDL C TARGETS, NEW GUIDELINE USES THE
INTENSITY OF STATIN THERAPY AS THE GOAL OF TREATMENT.
2. KNOW THE 4 STATIN BENEFIT GROUPS:
I.

INDIVIDUALS WITH CLINICAL ASCVD

II.

INDIVIDUALS WITH PRIMARY ELEVATIONS OF LDLC 190 MG/DL

III.

INDIVIDUALS 40 TO 75 YEARS OF AGE WITH DIABETES AND LDLC 70 TO189 MG/DL

WITHOUT CLINICAL ASCVD

IV.

INDIVIDUALS WITHOUT CLINICAL ASCVD OR DIABETES WHO ARE 40 TO 75 YEARS OF

AGE WITH LDLC 70 TO 189 MG/DL AND HAVE AN ESTIMATED 10-YEAR ASCVD RISK
OF 7.5% OR HIGHER. (USING THE POOLED COHORT EQUATIONS FOR ASCVD
RISK PREDICTION)

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

REFERENCES:
Stone Nj, Robinson J, Lichtenstein Ah, Bairey Merz Cn, Lioyd-jones Dm, Blum Cb, Mcbride P, eckel Rh,
Schwartz Js, Goldberg Ac, Shero St, Gordon D, Smith Sc Jr, Levy D, Watson K, Wilson Pw. 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.
J Am Coll Cardiol.2013 Nov 7. Pii: S0735-1097
John F. Keaney, Jr., M.D., Gregory D. Curfman, M.D., And John A. Jarcho, M.D. A Pragmatic View Of The New
Cholesterol Treatment Guidelines. N Engl J Med 2014; 370:275-278