Hyperlipidemia and ATP IV – What’s New, What’s Out, and Why It Matters 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Hobart Lee, MD FAAFP Assistant Professor Department of Family Medicine Loma Linda University March 6th, 2015
Disclosures ¤ I have nothing to disclose
ARS #1 ¤ Which patient group is NOT recommended to start statin therapy? ¤ Patients with history of transient ischemic attacks (TIAs) ¤ Patients with an LDL ≥ 160 ¤ Patients with Type 1 or 2 Diabetes AND Age 40-‐75 ¤ Patients with 10-‐year ASCVD Risk ≥ 7.5% and Age 40-‐75
ARS #2 ¤ Which statin dose is not considered a moderate intensity statin? ¤ Atorvastatin 80 mg ¤ Lovastatin 40 mg ¤ Pravastatin 40 mg ¤ Rosuvastatin 10mg
ARS #3 ¤ What is the 10 year ASCVD risk for a 50 year non-‐smoker male with a total cholesterol of 200, and HDL of 40, SBP 140 currently taking HCTZ for blood pressure control. ¤ 2% ¤ 6% ¤ 7% ¤ 18%
ARS #4 ¤ Which is NOT a recommendation of the 2013 AHA/ACC Guideline on Lifestyle management to reduce cardiovascular risk? ¤ Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-‐fat dairy products, poultry, fish, legumes, non-‐tropical vegetable oils, and nuts; and limits intake of sweets, sugar-‐sweetened beverages, and red meats. ¤ Consume no more than 2,400 mg of sodium/day. ¤ Aim for a dietary pattern that achieves 10%-‐12% of calories from saturated fat. ¤ In general, advise adults to engage in aerobic physical activity 3–4 sessions per week, lasting on average 40 min per session, and involving moderate-‐ to vigorous-‐intensity physical activity.
OBJECTIVES ¤ Identify the 4 types of individuals that benefit from statin therapy ¤ Become familiar with calculating an individual’s 10 year ASCVD risk ¤ Promote the critical role of lifestyle modification and health promotion in hyperlipidemia patients ¤ Understand the differences between moderate-‐intensity and high-‐ intensity statins
4 Individuals -‐-‐ #1. Clinical ASCVD ¤ A 22 year old female had a stroke last year. According to the new guidelines – she deserves what kind of therapy? ¤ A. Lifestyle modification only ¤ B. Lifestyle + Moderate-‐intensity statin ¤ C. Lifestyle + High-‐intensity statin
Clinical ASCVD ¤ Clinical ASCVD includes: ¤ ¤ ¤ ¤ ¤
History of MI Stable or unstable Angina Coronary or other arterial revascularization Stroke or TIA Peripheral artery disease presumed to be of atherosclerotic origin
¤ 21 < Age ≤ 75 years old ¤ Lifestyle + High-‐intensity statin
¤ Age > 75 years old or not a candidate for high-‐intensity ¤ Lifestyle + Moderate-‐intensity statin
4 Individuals -‐-‐ #2. LDL-‐C ≥ 190 ¤ A 40 year female comes in for suspected hyperlipidemia on a NON-‐ FASTING workplace screening. Her results: TC 290, HDL 40, TG 180, LDL-‐C 214. What should you do? ¤ A. Obtain a FASTING sample to confirm cholesterol values ¤ B. Treat with lifestyle only ¤ C. Treat with Lifestyle + moderate-‐intensity statin ¤ D. Treat with Lifestyle + high-‐intensity statin
Fasting vs. Non-‐fasting lipid values ¤ Lifestyle + High-‐intensity statin ¤ Does fasting matter? ¤ TC and HDL varied < 2% ¤ LDL varied < 10% ¤ TG varied < 20%
¤ Fasting and non-‐fasting LDL yield similar prognostic value for all-‐ cause mortality and CV-‐related mortality
Liver enzymes monitoring ¤ Routine monitoring of liver enzymes? ¤ Not recommended per FDA 2012
¤ Check ALT before starting, but “serious liver injury with statins is rare and unpredictable in individual patients, and that routine periodic monitoring of liver enzymes does not appear to be effective in detecting or preventing serious liver injury”
4 Individuals -‐-‐ #3. Diabetics ¤ A 40 year female has a new diagnosis of type 2 DM. She does not have HTN, CKD, or peripheral neuropathy. What therapy does she require? ¤ A. Lifestyle modification only ¤ B. Lifestyle + moderate-‐intensity statin ¤ C. Lifestyle + high-‐intensity statin
Diabetes needs statins ¤ Diabetes (type 1 or 2) Age 40-‐75 years old ¤ Moderate-‐intensity statin ¤ 10-‐year ASCVD risk ≥ 7.5% à High-‐intensity statin (expert opinion)
8/03/15
4 Individuals – #4. 10 year ASCVD risk ≥ 7.5% ¤ Gender: Male or Female
¤ Smoker: Yes or No
¤ Age: 40-‐79
¤ Treatment for HTN : Yes or No
¤ Race: White, AA, or Other
¤ Diabetes: Yes or No
¤ Total Cholesterol: 130-‐320
¤ http://tools.cardiosource.org/ ASCVD-‐Risk-‐Estimator/
¤ HDL: 20-‐100 ¤ SBP : 90-‐200
8/03/15
Overestimation of Risk ¤ Overestimation of risk by 75-‐150% ¤ Increase use of statins over time ¤ Increase in revascularization procedures ¤ Self-‐report and poor follow-‐ up ¤ Changes in contemporary populations (e.g. decreasing ASC VD incidence, change in smoking prevalence)
Lifestyle Modification & Health Promotion ¤ Adhering to heart health diet (DASH, AHA, USDA food pattern) ¤ Emphasis on vegetables, fruits, whole grains ¤ Reduce saturated fat (5-‐6% of calories) ¤ Lower sodium intake (1500-‐2400 mg daily)
¤ Regular exercise habits ¤ 3-‐4 sessions/week, 40 mins/session, moderate-‐vigorous physical activity
¤ Avoidance of tobacco products ¤ Maintenance of a healthy weight
2015 Dietary Guidelines for Americans ¤ Dietary Guidelines Advisory Committee (DHHS, USDA) ¤ 2010 guideline limited cholesterol to 300 mg/day (~ one egg)
¤ New draft guideline -‐-‐ Cholesterol is no longer a “nutrient of concern.” ¤ ACC/AHA dietary guidelines 2013 – no specific evidence regarding reduction of cholesterol consumption
Moderate vs. High Intensity Statins Moderate-‐Intensity (Lowers LDL-‐C by 30-‐50%) ¤
Atorvastatin 10 (20)
¤
Rosuvastatin (5) 10
¤
Simvastatin 20-‐40
¤
Pravastatin 40 (80)
¤
Lovastatin 40
¤
Fluvastatin XL 80
¤
Fluvastatin 40 BID
¤
Pitavastatin 2-‐4
High-‐Intensity (Lower LDL-‐C by ≥ 50%) ¤ Atorvastatin 40-‐80 ¤ Rosuvastatin 20 (40)
Tolerability & Alternative Dosing Strategies ¤ Hydrophilic (pravastatin, rosuvastatin) vs. Lipophilic (simvastatin, lovastatin, atorvastatin) ¤ Every other day dosing or once a week dosing ¤ May improve side effect profile (myalgias) ¤ No outcome data available
¤ Initial follow-‐up 4-‐12 weeks ¤ Reinforce continued adherence 3-‐12 months
Simvastatin & CYP3A4 enzyme metabolism pathway ¤ Simvastatin 80 – use only in patients who have tolerated this dose for > 12 months ¤ Switch to equivalent dose if drug-‐drug interaction concern ¤ Simvastatin 80 = Atorvastatin 40 = Rosuvastatin 10-‐20
¤ If Simvastatin 40 not working, switch to Atorvastatin or Rosuvastatin
8/03/15
Simvastatin interactions ¤ Contraindicated ¤ Itraconazole ¤ Ketoconazole ¤ Posaconazole ¤ Erythromycin ¤ Clarithromycin ¤ Telithromycin ¤ HIV Protease Inhibitors ¤ Nefazodone ¤ Gemfibrozil ¤ Cyclosporine ¤ Danazol
¤ Max: Simvastatin 20 ¤ Amiodarone ¤ Verapamil ¤ Diltiazem ¤ Max: Simvastatin 10 ¤ Amlodipine ¤ Ranolazine ¤ Avoid large quantities of grapefruit juice (> 1 qt daily)
OBJECTIVES ¤ Identify the 4 types of individuals that benefit from statin therapy ¤ Become familiar with calculating an individual’s 10 year ASCVD risk ¤ Promote the critical role of lifestyle modification and health promotion in hyperlipidemia patients ¤ Understand the differences between moderate-‐intensity and high-‐ intensity statins
ARS #1 ¤ Which patient group is NOT recommended to start statin therapy? ¤ Patients with history of transient ischemic attacks (TIAs) ¤ Patients with an LDL ≥ 160 ¤ Patients with Type 1 or 2 Diabetes AND Age 40-‐75 ¤ Patients with 10-‐year ASCVD Risk ≥ 7.5% and Age 40-‐75
ARS #2 ¤ Which statin dose is not considered a moderate intensity statin? ¤ Atorvastatin 80 mg ¤ Lovastatin 40 mg ¤ Pravastatin 40 mg ¤ Rosuvastatin 10mg
ARS #3 ¤ What is the 10 year ASCVD risk for a 50 year non-‐smoker male with a total cholesterol of 200, and HDL of 40, SBP 140 currently taking HCTZ for blood pressure control. ¤ 2% ¤ 6% ¤ 7% ¤ 18%
ARS #4 ¤ Which is NOT a recommendation of the 2013 AHA/ACC Guideline on Lifestyle management to reduce cardiovascular risk? ¤ Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-‐fat dairy products, poultry, fish, legumes, non-‐tropical vegetable oils, and nuts; and limits intake of sweets, sugar-‐sweetened beverages, and red meats. ¤ Consume no more than 2,400 mg of sodium/day. ¤ Aim for a dietary pattern that achieves 10%-‐12% of calories from saturated fat. ¤ In general, advise adults to engage in aerobic physical activity 3–4 sessions per week, lasting on average 40 min per session, and involving moderate-‐ to vigorous-‐intensity physical activity.
Questions?