Hyperlipidemia and ATP IV What s New, What s Out, and Why It Matters

Hyperlipidemia  and  ATP  IV  –  What’s   New,  What’s  Out,  and  Why  It  Matters     2013  ACC/AHA  Guideline  on  the  Treatment  of  Blood  Chole...
Author: Willis Page
1 downloads 2 Views 2MB Size
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?