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ACC/AHA Guidelines Not the Final or Only Word

ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

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National Cholesterol Education Program Adult Treatment Panels (ATP)

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Page 1: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

ACC/AHA Guidelines Not the Final or Only Word

Page 2: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Contemporary Guidelines 2011-14

Page 3: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

National Cholesterol Education Program Adult Treatment Panels (ATP)

Page 4: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

NCEP ATP III (2002) Expanded Risk Groups

Page 5: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

ATP III (continued)

Page 6: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

ATP III: Increased emphasis on Non-HDL Cholesterol when TG >= 200

Page 7: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Updates to ATP III: More intensive LDL-C Goals for Higher Risk Patients.

Page 8: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

ATP III- Treat to Target Based on Risk

Page 9: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Recommendation 2: Use Statins in these 4 Groups Regardless of Lipid Levels

Page 10: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Recommendation 3: Use Only Evidence Based Statin Doses

Page 11: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Definition of High, Moderate and Low Intensity Statin Agents and Doses

Page 12: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Recommendation 4: Non-Statin Medication NOT Generally Recommended

Page 13: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Recommendation 5: No LDL or non-HDL Goals

Page 14: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Committee’s Rationale for Doing Away with Treatment Targets

Page 15: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Recommendation 6: Use New GLOBAL RISK- Assessment for Primary Prevention

Page 16: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Committee’s Rationale for Using 7.5% Global Risk Cut-off (as opposed to cholesterol Levels)

Page 17: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Controversy Concerning Global Risk (Pooled Cohort) Calculator

Page 18: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Recommendation 7: Consider Emerging Risk Factors in Some Patients

Page 19: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

NLA Expert Panel: Clinical Utility of Inflammatory Markers and Advanced Lipid Testing

Page 20: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Recommendation 8: Put Statin Safety in Context

Page 21: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Population Health Aspects of 2013 ACC/AHA Guidelines

Page 22: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

American Diabetes Association/American College of Cardiology Consensus Statement

Page 23: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

American Diabetes Association (ADA) Lipid Goals and Treatment

Page 24: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

American Association of Clinical Endocrinologists (AACE) Guidelines 2013

Page 25: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)

Risk Assessment

Page 26: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)

Treatment Targets

Page 27: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)

Drug Therapy

Page 28: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

IAS(International Atherosclerosis Society) Atherogenic Cholesterol

Page 29: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

IAS(International Atherosclerosis Society) Focus on Long Term (Not 10 year) Risk of ASCVD (Up to age 80)

Page 30: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

IAS(International Atherosclerosis Society) Drug Therapy: Primary Prevention

Page 31: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

IAS(International Atherosclerosis Society) Drug Therapy: Secondary Prevention

Page 32: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Comparison of Recent Major Guidelines UP TO 2013

Page 33: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

NLA Recommendation (2014) Targets of Therapy

Page 34: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

NLA Recommendations (2014 Stepwise Approach to ASCVD Risk Assessment

Page 35: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

NLA Recommendations (2014) Other Risk Indicators- Consider for Refinement of Risk

Page 36: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

NLA Recommendations (2014) Initiate Therapy Based on Risk and Lipid Levels and Treat to Specific Goal

Page 37: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

NLA Recommendations (2014) Drug Therapy Considerations

Page 38: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

KDIGO (Kidney Disease Improving Global Outcomes) 2013

• CKD IS CONSIDERED A CHD RISK … the following are the categories and recommendations

• 1A -statin or statin/ezetimibe in aged>506o with eGFR<60ml/min not on HD or transplant

• 1B -statin in adult >50yo with eGFR > 60• 2A -recommend a statin if >1 of the following & aged is 18-49 (not HD or

transplant) - CAD, CVA, DM, 10 yr coronary death > 10%• 2A – statin or statin/ezetimibe (not recommended with HD)• 2C -lipid-lowering agent should be continued if already receiving at time of HD• 2A – Treatment w a statin is suggested in adult recipients of kidney transplants• 2D -Triglyceride lowering recommended in CKD & HD or kidney transplants

• Don’t initiate statins with HD patients, but continued maintenance ok if it does• Not interfere with antirejection medications.

Page 39: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

IMPROVE-IT RANDOM CONTROLLED TRIAL

• Took 18,000 patients who had experienced an acute coronary syndrome within the past 10 days and put them on EITHER… simvastatin 40mg monotherapy or

• Simvastatin 40mg + ezetimibe 10 mg daily.

• There was a 24% further lowering of LDL with the combination• 13% relative risk reduction in MI• 21% reduction in ischemic stroke• 10% reduction in CV death, nonfatal MI, or nonfatal stroke.• LDL reduction… hazard ratio 0.8

• Weakness: In real life, an intensive therapy statin would have been used.

Page 40: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

AIM-HIGH • To establish a role of niacin in the setting of intensive LDL control.. 3400

pts with ASCVD received simvastatin with or without ezetimibe were randomized to receive either 1500-2000mg niacin/day or placebo.

• Patient population had very low levels of etherogenic lipoproteins and did not represent the patient population.

• Results: Niacin did not help when combined with statins.

Page 41: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

HPS2-THRIVE• Similar to AIM-HIGH… study compared simvastatin 40mg alone or with ezetimibe

10mg (but added laropiprant to reduce flushing response.)

• RESULTS:• Increased HDL and decreased LDL• NO DIFFERENCE in major vascular events• Group with niacin experienced increased adverse effects• Hazards- DM control, new DM, GI effects, myopathy, skin-related events, infection,

and bleeding.

Page 42: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Alirocumab (trade name Praluent)• is a biopharmaceutical drug approved by the FDA on July 24, 2015 as a second line

treatment for high cholesterol for adults whose cholesterol is not controlled by diet and statin treatment. It is a human monoclonal antibody that belongs to a novel class of anti-cholesterol drugs, known as PCSK9 inhibitors, and it was the first such agent to receive FDA approval

• Alirocumab is used as a second line treatment to lower LDL cholesterol for adults who have a severe form of hereditary high cholesterol and people with atherosclerosis who require additional lowering of LDL cholesterol when diet and statin treatment have not worked. It is administered by subcutaneous injection.[3] As of July 2015, it is not known whether alirocumab prevents early death from cardiovascular disease or prevents heart attacks.

• Alirocumab works by inhibiting the PCSK9 protein. PCSK9 binds to the low-density lipoprotein receptor (LDLR) (which takes cholesterol out of circulation), and that binding leads to the receptor being degraded, and less LDL cholesterol being removed from circulation. Inhibiting PCSK9 prevents the receptor from being degraded, and promotes removal of LDL cholesterol from circulation

Page 43: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14
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Page 45: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

Latest JNC8 guidelines

Page 46: ACC/AHA Guidelines Not the Final or Only Word. Contemporary Guidelines 2011-14

JNC 8 Therapy