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Incorporating the Newly Released ACC/AHA Guidelines into Practice - - PowerPoint PPT Presentation
Incorporating the Newly Released ACC/AHA Guidelines into Practice - - PowerPoint PPT Presentation
Incorporating the Newly Released ACC/AHA Guidelines into Practice Dawn Mutchko, MSN, RN, NP-C, APN The Heart Institute AtlantiCare Regional Medical Center Brief review of prior guidelines New individualized risk calculator and its role
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I have no disclosures for this presentation.
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Who made them?
ATP IV panel Expert reviewers Representatives of federal agencies
How?
Randomized controlled trials Systematic reviews Meta-analyses
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Goal: treatment of blood cholesterol to reduce
atherosclerotic cardiovascular risk in adults, currently the leading cause of death and disability in America
No Longer Appropriate To:
Treat to target Lower is better Treat for lifetime risk
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Statin eligibility could increase by 13 million 56 million Americans ages 40-75 are eligible
to consider a statin
43 million under ATP III
10.4 million of newly eligible would have NO
history of heart disease
Ages 60-75 will have the largest effect
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Individuals with clinical ASCVD Individuals with LDL-C =/> 190mg/dL Individuals 40-75 yo with DM and LDL-C 70-189
mg/dL without clinical ASCVD
Individuals without clinical ASCVD or DM, who
are 40-75 yo with LDL-C 70-189 mg/dL and have 10 year risk of 7.5%+
using the Pooled Cohort Equations for ASCVD risk prediction
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HOW DO WE KNOW?
Cardiac cath Q waves on EKGs TEE cCTA ACS Coronary or other
arterial revascularization
Non-invasive testing Carotid duplex UE/LE arterial duplex Peripheral angiography PVD presumed to be
atherosclerotic
CVA/TIA
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High intensity statin +/- another agent If intolerant, ezetimibe or others with a > 50%
reduction goal
FH often unable to reach previous goals even
with polypharmacy
Goal reduction of LDL >50%
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High intensity with 10 year risk > 7.5% Moderate intensity with 10 year risk < 7.5%
INDICATED IN ALL PATIENTS WITH DIABETES
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Moderate to high intensity statin indicated
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Family history of premature ASCVD LDL > 160 hsCRP > 2.0 Coronary calcium scores > 300 ABI < 0.9
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Lifestyle modification No more specific lipid targets Pooled Cohort Equations Those outside of 4 Statin Benefit Groups Define high & moderate intensity statin
therapy
Who should receive high vs. moderate therapy
A PARADIGM SHIFT
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Risk assessments identify the likelihood of
heart disease, MI or CVA
Calculated using age, gender, race,
cholesterol/BP levels, diabetes and smoking status as well as BP medications
Calculate 10 year risk and lifetime Family history and CRP Repeat 4-6 years Discuss
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Continue to measure/treat cholesterol Identify those who have OR are at risk of
having ASCVD
Select most effective treatments in those most
likely to benefit
Collect/Review history, lipid panel
Coronary Artery Calcium score, hs-CRP, ABI FH of hypercholesterolemia
Healthy living discussions +/- medical therapy
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Statins
Very high LDL DM Type II, age 40-75 >7.5%+ risk in 10 years, age 40-75 Others
Other cholesterol-lowering medications
Statin side-effects Cannot tolerate ideal dose Contradictions to statin use – labs, meds, etc Additional therapy
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Non-statin therapies alone and in combination
with statins, do not provide acceptable risk reduction given their side effect profiles
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Consider confirming myalgias Consider other conditions Readdress:
Lifestyle Decrease dose Change statin Check serum vitamin D levels and replete
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Healthy choices
Diet, exercise, weight, smoking, drug therapy
Side effects Medication compliance Laboratory compliance Communicate
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Diet rich in vegetables, fruits and whole grains Regular exercise Maintaining healthy weight NOT smoking or cessation efforts Compliance with health, risk factors and
medical orders
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Dietary recommendations
Lower cholesterol
Saturated and trans-fats
Lower blood pressure
Sodium
DASH Diet USDA’s Choose My Plate/Food Pattern AHA Diet
Physical activity
Recommendations
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Definition Benefits of weight loss (if needed) Weight Loss Strategies Bariatric surgery
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BMI
Overweight BMI >25.0-29.9 kg/m2 Obesity BMI > or = 30 kg/m2
Class I 30-34.99 Class II 35-39.99 Morbid Obesity 40+
Waist circumference
Men >40 inches/102 cm Women >35 inches/88 cm
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78 million Americans Five critical questions related to CV risk
reduction
Weight loss BMI/waist circumference Different diets Comprehensive lifestyle intervention Bariatric surgery
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Weight loss >5% Caloric intake Men 1500-1800 kcal/day Women 1200-1500 kcal/day Evidence based diet Comprehensive Lifestyle Program (6+ months) Medically monitored diets Long-term comprehensive weight loss maintenance Bariatric surgery
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Risk Assessment
Long-Term Risk Assessment Implementation Lifetime Risk
Lifestyle Management
Blood Pressure Lipids Diet – sodium, potassium
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NYHA Class 2-4 Dialysis patients HIV + patients Solid organ transplant recipients
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Will additional GLs come out for groups when
RCT are available to review?
Hypertriglyceridemia? Relevance of treatment markers such as Lp(a), LDL
particles, ApoB?
What non-invasive studies should we run? How should lifetime risk be used? What is the optimal age to start a statin? Role of pharmocogenomics? Long term effects of statin- associated new onset
diabetes and management?
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Calculator overestimates/doesn’t make sense
Dr. Nissen sites examples
47 yo AA male - TC 160, HDL 44, SBP 130 on HCTZ
25mg, -DM, - tobacco; 10 year risk 7.6%
60yo AA male – TC 150, SBP 125 w/o meds, - DM, -
tobacco (no risk factors); 10 year risk 7.5%
44 yo Caucasian male – strong FH of MI, TC 250, HDL
28, LDL 182, SBP 120 w/o meds, - DM, - tobacco; 10 year risk 5.0%
Similar for healthy Caucasian male age 58
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No targets Identify patients
4 high risk groups
Use statins Healthy lifestyle
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63 yo male, 2 weeks post STEMI
Former smoker with HTN
He was discharged on atorvastatin 80mg daily, dual anti-platelet therapy, long-acting metoprolol, and an ACE inhibitor.
One year before the acute MI, he was prescribed simvastatin 40mg which was then increased to simvastatin 80 mg. He stopped the simvastatin 80mg 2 weeks later after developing muscle cramps in his legs. At that time he was also on a calcium channel blocker for his hypertension. Although he has no muscle symptoms since he started the atorvastatin 80 mg, he is concerned about having had muscle cramps in the past on a statin and would like to decrease the atorvastatin to 20 mg daily.
Systematic meta-analyses of randomized clinical trials support using an intensive statin dose such as atorvastatin 80 mg/day over a moderate intensity statin. He should stay on atorvastatin 80 mg.
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After 2 years of treatment with atorvastatin 80mg daily free of muscle symptoms, the patient developed progressive muscle pains in both lower legs. He stopped the statin 2 weeks prior to his clinic visit but the muscle pain and weakness did not noticeably
- improve. He now wants to know if he can be switched to red rice
yeast.
On examination, he has mild difficulty getting out of a chair and also has weakness after doing 3 squats. He remembers he felt fine doing squats at the gym about 6 months ago.
He should stay off the statin until he is evaluated for possible causes of his muscle problems. A useful approach is to look for exogenous causes, systemic causes, and primary muscle disorders.
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44 yo female has a 10-year history of type 2 diabetes.
She is a nonsmoker with well-controlled hypertension and microalbuminuria.
She is on dietary management, metformin, and takes one omega-3 fatty acid capsule.
She takes lisinopril/HCTZ for HTN.
She has a family history of diabetes, but not premature ASCVD.
She has a BP 134/78 and a BMI of 36.0.
Her fasting lipid panel reveals an LDL–C 95, triglycerides 350 and HDL–C 38. Her hemoglobin A1c is 7.5%.
Her 10-year ASCVD risk should be calculated to determine if she needs a high- or moderate-intensity statin.
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26 yo female has an LDL–C of 260, HDL–C of 51 and triglycerides of 102.
She reports having elevated LDL–C levels of over 200 since her teens and has tried various diets without success but has never taken a drug to lower her cholesterol.
She is worried because her father died suddenly at age 38 and her father's brother had a myocardial infarction at age 32. Both were smokers. She is currently on a 2nd generation oral contraceptive and wonders if she should get off the contraceptive pill since she is engaged to be married in 6 months.
She has an occasional cigarette and says that it is "social smoking."
On exam, BP is 110/60 and BMI is 24. Her cardiovascular examination is normal.
She likely has heterozygous familial hypercholesterolemia and should start a high-intensity statin.
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60 yo AA female has asked whether she should be taking a statin to reduce her risk of stroke, but is worried about the statin causing diabetes.
Her mother had diabetes and had a stroke at age 62.
She is a nonsmoker.
Blood pressure is 142/88 on dual antihypertensives and BMI is 31.
Her fasting lipid panel reveals a total cholesterol 200, HDL–C 55, triglyceride 100, and LDL–C 125.
Her fasting blood sugar is 109 mm/dL and hemoglobin A1c is 5.9%.
According to the Pooled Cohort Equation for African-American Women, her estimated 10-year ASCVD risk is 8.7%.
She should start a moderate or high intensity statin.
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35 yo male has a strong family history of premature coronary disease, with both father and brother having an MI before age 55.
He is a nonsmoker, nondiabetic and exercises for 150 minutes/week. He has gained 10 lbs since age 18.
His BP is 140/90, weight is 170 pounds, height is 70 inches, and BMI is 24.4.
On a fasting lipid panel, his LDL–C is 160, HDL–C 45 and triglyceride 100.
His fasting blood glucose is 92 mg/dL.
He is on a heart-healthy diet and exercises 150 minutes a week. He and his wife would like to discuss statin therapy given his strong family history.
Should consider:
Strong family history of premature ASCVD
Lifetime risk of ASCVD of 46%
LDL-C ≥160 mg/dL
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32 yo male has gained 35 pounds since he graduated from college and started working as computer programmer.
He never smoked.
He has treated hypertension.
He has tried several popular diets to lose weight and lost about 20 pounds each time, but he always regains the weight lost within one year.
He bowls once a week.
He weighs 220 lbs and his BMI is 32.5, and the highest it has ever been.
His BP is 138/92.
TC 218, triglycerides 188, HDL–C 40, LDL–C 138 and non HDL–C 178.
His fasting glucose is 101 mg/dL. His father died of an MI at age 73.
Refer to a program providing a series of group counseling comprehensive lifestyle change sessions.
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55 yo male developed exertional chest pain. He had a positive stress exercise test and a coronary angiogram that revealed 2-vessel nonobstructive coronary disease.
His risk profile indicates he is a nonsmoker with treated hypertension, and a low HDL– C.
His father had an MI at age 67. His mother had type 2 diabetes diagnosed at age 60.
He is on a low dose aspirin, long-acting beta blocker, a high-intensity statin, and an ACE inhibitor.
His BP 135/86, pulse 58, weight 183 lbs and BMI 26.3.
His LDL–C is 95, HDL–C 39 and triglycerides are 145.
His fasting glucose is 109 mg/dL.
He wants to know what dietary change recommendations you would make.
His cardiologist has given him physical activity recommendations.
He should consume a dietary pattern that emphasizes vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats.
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48 yo male man with FH and history of 3-vessel coronary artery bypass surgery 7 years ago sees you now for statin intolerance.
The maximum dose of statin that he can tolerate is rosuvastatin 10 mg twice a week.
On more frequent dosing, he developed shoulder, low back, and thigh aching without weakness and a normal CK level.
He had similar symptoms on low doses of simvastatin, atorvastatin and pravastatin.
On rosuvastatin 10 mg twice a week, his most recent LDL–C was 168, triglycerides were 138 and HDL–C was 46.
Bile acid sequestrants have been shown to reduce ASCVD events when used as monotherapy in men with primary
- hypercholesterolemia. He should continue the rosuvastatin and
cholestyramine 4g packet BID should be added.
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Two months ago, a 63yo Hispanic male had a MI followed by an angioplasty and DES.
He was discharged on 80 mg atorvastatin, low-dose aspirin, clopidogrel, a long-acting beta blocker, and lisinopril 5 mg.
One year ago his LDL–C was 140. He was prescribed a low dose of pravastatin 10 mg/day at that time but never returned for a follow-up lipid panel.
He reported stopping the pravastatin about 6 months before his MI. He returns now for a follow-up visit. He reports adhering to a heart healthy diet and taking atorvastatin 80 mg/day for the first month after discharge.
He had no musculoskeletal or other symptoms during this period but did not refill the prescription. He thought he was already taking too many pills and did not understand why he was taking a pill for cholesterol. His fasting lipid panel returns with an LDL-C of 125.
Nonadherence to statin therapy is associated with an increased risk of stroke, MI and death.
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