10/10/19 DISCLOSURES 20 2018 ACC/ CC/AHA Guideline on the Eugene - PDF document

10/10/19 DISCLOSURES 20 2018 ACC/ CC/AHA Guideline on the Eugene Yang Alka Kanaya Ma Manageme ment of Blood Cholesterol: • Consultant • None • RubiconMD Co Controve versies in Cl Clinical al Prac actice • Medical Advisory Board • Clocktree Eugene Yang, MD, MS, FACC Clinical Professor of Medicine Carl and Renée Behnke Endowed Professorship for Asian Health University of Washington School of Medicine • Research Funding Alka Kanaya, MD • Amgen Professor of Medicine • The Medicines Company University of California, San Francisco School of Medicine • NHLBI 1 2 1 2 OUTLINE 2018 ACC/AHA Cholesterol Guidelines • Review the 2018 ACC/AHA Guideline on the Management of • Strong emphasis on lifestyle changes and shared decision making Blood Cholesterol Changes to definition of intermediate and high risk groups • • Patient cases: • Low risk Added risk enhancers to guide treatment for borderline/intermediate risk groups • • Intermediate risk with risk enhancers • Intermediate risk and CAC score LDL-C targets restored for very high/high risk groups • • Very high risk • Take home points Grundy SM, et al. J Am Coll Cardiol 2018. 3 4 3 4 1

10/10/19 2018 2018 AH AHA/ A/ACC/AA AACVP VPR/ R/AAP AAPA/ A/AB ABC/ACPM/AD ADA/ A/AGS/AP APhA/A /ASPC To Top 10 Take-Ho Home Messages /N /NLA/P /PCNA 2018 Cholesterol Guidelines Guideline on the Management of Blood Cholesterol: Gu Ex Executive Summar ary 5 6 To Top 10 Take Home Messages Top 10 Take Home Messages To 1. In all individuals, emphasize a heart- 2. In patients with clinical ASCVD, reduce low- healthy lifestyle across the life course . density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally A healthy lifestyle reduces atherosclerotic cardiovascular tolerated statin therapy. disease (ASCVD) risk at all ages. In younger individuals, healthy lifestyle can reduce development of risk factors The more LDL-C is reduced on statin therapy, the greater and is the foundation of ASCVD risk reduction. will be subsequent risk reduction. In young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician–patient risk discussion Use a maximally tolerated statin to lower LDL-C levels by (see No. 6) and emphasizes intensive lifestyle efforts. In all ≥50%. age groups, lifestyle therapy is the primary intervention for metabolic syndrome. 7 8 2

10/10/19 To Top 10 Take Home Messages Top 10 Take Home Messages To 4. In patients with severe primary hypercholesterolemia 3. In very high-risk ASCVD, use a LDL-C threshold of 70 (LDL-C level ≥ 190 mg/dL [≥4.9 mmol/L]) without mg/dL (1.8 mmol/L) to consider addition of non- calculating 10-year ASCVD risk, begin high-intensity statins to statin therapy. statin therapy without calculating 10-year ASCVD risk. • Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions. • If the LDL-C level remains ≥100 mg/dL (≥2.6 mmol/L), • In very high-risk ASCVD patients, it is reasonable to add ezetimibe to adding ezetimibe is reasonable maximally tolerated statin therapy when the LDL-C level remains ≥70 • If the LDL-C level on statin plus ezetimibe remains ≥100 mg/dL (≥1.8 mmol/L). mg/dL (≥2.6 mmol/L) & the patient has multiple factors that • In patients at very high risk whose LDL-C level remains ≥70 mg/dL (≥1.8 increase subsequent risk of ASCVD events, a PCSK9 inhibitor mmol/L) on maximally tolerated statin and ezetimibe therapy, adding may be considered, although the long-term safety (>3 years) is uncertain and economic value is low at mid-2018 list prices. a PCSK9 inhibitor is reasonable, although the long-term safety (>3 years) is uncertain and cost- effectiveness is low at mid-2018 list prices. 9 10 To Top 10 Take Home Messages To Top 10 Take Home Messages 5. In patients 40 to 75 years of age with diabetes 6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician–patient risk mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), discussion before starting statin therapy. start moderate-intensity statin therapy without calculating 10-year ASCVD risk. Risk discussion should include a review of major risk factors (e.g., cigarette smoking, elevated blood pressure, LDL-C, hemoglobin A1C [if indicated], and calculated 10-year risk of ASCVD); • In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 • the presence of risk-enhancing factors (see No. 8); to 75 years of age, it is reasonable to use a high- • the potential benefits of lifestyle and statin therapies; intensity statin to reduce the LDL-C level by ≥50%. • the potential for adverse effects and drug–drug interactions; • the consideration of costs of statin therapy; and • the patient preferences & values in shared decision-making. 11 12 3

10/10/19 To Top 10 Take Home Messages Top 10 Take Home Messages To 8. In adults 40 to 75 years of age without diabetes mellitus and 7. In adults 40 to 75 years of age without diabetes 10-year risk of 7.5% to 19.9% (intermediate risk), risk- mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 enhancing factors favor initiation of statin therapy (see No. 7). mmol/L), at a 10-year ASCVD risk of ≥ 7.5%, start a moderate-intensity statin if a discussion of Risk-enhancing factors include: treatment options favors statin therapy. • family history of premature ASCVD; Risk-enhancing factors favor statin therapy (see No. 8). • persistently elevated LDL-C levels ≥160 mg/dL (≥4.1 mmol/L); • metabolic syndrome; If risk status is uncertain, consider using coronary • chronic kidney disease; • history of preeclampsia or premature menopause (age <40 yrs) artery calcium (CAC) to improve specificity (see No. • chronic inflammatory disorders ( e.g., rheumatoid arthritis, psoriasis, 9). If statins are indicated, reduce LDL-C levels by or chronic HIV); ≥30%, and if 10-year risk is ≥20%, reduce LDL-C levels • high-risk ethnic groups (e.g., South Asian ); by ≥50%. • persistent elevations of triglycerides ≥ 175 mg/dL (≥1.97 mmol/L) 13 14 To Top 10 Take Home Messages To Top 10 Take Home Messages 8. In adults 40 to 75 years of age without diabetes mellitus 9. In adults 40 to 75 years of age without diabetes and 10-year risk of 7.5% to 19.9% (intermediate risk), risk- mellitus and with LDL-C levels ≥70 mg/dL- 189 enhancing factors favor initiation of statin therapy (see No. 7). mg/dL (≥1.8-4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is Risk-enhancing factors include: uncertain, consider measuring CAC. and, if measured in selected individuals • apolipoprotein B ≥130 mg/dL • If CAC is zero, treatment with statin therapy may be withheld or • high-sensitivity C-reactive protein ≥2.0 mg/L delayed, except in cigarette smokers, those with diabetes mellitus, • ankle-brachial index <0.9 and those with a strong family history of premature ASCVD. • lipoprotein (a) ≥50 mg/dL or 125 nmol/L, especially at higher • A CAC score of 1 to 99 favors statin therapy, especially in those ≥55 values of lipoprotein (a). years of age. • For any patient, if the CAC score is ≥100 Agatston units or ≥75th Risk-enhancing factors may favor statin therapy in patients at 10-year percentile, statin therapy is indicated unless otherwise deferred by risk of 5-7.5% (borderline risk) the outcome of clinician–patient risk discussion. 15 16 4

10/10/19 To Top 10 Take Home Messages 10. Assess adherence and percentage response to LDL- C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed. • Define responses to lifestyle and statin therapy by percentage reductions in LDL-C levels compared with baseline. • In ASCVD patients at very high-risk, triggers for adding non-statin drug therapy are defined by threshold LDL-C levels ≥70 mg/dL (≥1.8 mmol/L) on maximal statin therapy (see No. 3). 17 18 Case #1: Low risk patient Case #1: Laboratory tests • 55 year old black woman with history of migraine headaches presents to clinic for • Total cholesterol: 228 routine care. No family history of premature CAD, former smoker (quit 3 years ago). Triglycerides: 180 • Asymptomatic. Does not exercise regularly. HDL: 47 • LDL: 145 • • Exam: BP 126/76, P 65, BMI 28.5 Fasting glucose: 103 • • Physical exam unremarkable • HbA1c: 5.8% • Meds: • Sumatriptan PRN 19 19 20 20 19 20 5

10/10/19 In additional to lifestyle changes, you recommend: ACC/AHA 10 year ASCVD Risk Score • Do nothing, eat all the processed food you want! • Repeat fasting lipids in 3-6 months, no treatment • Initiate moderate intensity statin therapy • Perform CAC score for additional risk stratification 21 21 22 22 21 22 2019 ACC/AHA PREVENTION GUIDELINE • In 2019, the ACC/AHA published comprehensive guidelines to optimize health and reduce risk of atherosclerotic cardiovascular disease (ASCVD): • Aspirin • Blood pressure • Cholesterol • Cigarettes • Diabetes • Diet/weight optimization • Exercise 23 23 24 24 23 24 6