Lipid Guidelines Update Richard C. Padgett, MD Oregon Cardiology, 2 - - PowerPoint PPT Presentation

Lipid Guidelines Update

Richard C. Padgett, MD Oregon Cardiology,

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Applying Classification of Recommendation and Level of Evidence.

Neil J. Stone et al. Circulation. 2014;129:S1-S45

Change can be hard

• Class 0

Things that I Believe

• Class 0a Things that I Believe, despite available data
• Class I

RCCT trials that Agree with what I Believe

• Class 2

Prospective Clinical Data that agree with what I Believe

• Class 3

Expert opinion that agree with what I Believe

• Class 4

RCCT trial that Don’t Agree with what I Believe

• Class 5

Things that you Believe, that I don’t

New Cholesterol Guideline Myths

New Cholesterol Guideline Myths

New Cholesterol Guideline Myths

New Cholesterol Guideline Myths

New Cholesterol Guideline Myths

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• ACS, h/o MI, angina, revascularization, TIA,

stroke, peripheral arterial disease

• No RCTs identified that titrated drug therapy to

specific LDL goals to improve ASCVD outcomes

• Often genetic (family screening)
• Consider secondary causes

− Drugs (diuretics, cyclosporin, glucocorticoids,

amiodarone)

− Biliary obstruction, nephrotic syndrome − Hypothyroidism, pregnancy* * Statins contraindicated in pregnancy & lactation

• Extrapolation of data for primary prevention in high risk

(≥ 7.5% 10 yr risk) who did not have diabetes

− Expert opinion, some conflicting data (IIa, B)

• < 40 or > 75 yrs the decision to initiate statin therapy

should be individualized

− Expert opinion, divergent opinions (IIa, C)

• Most controversial area of guideline because of risk

equations & lower cut off

• Reasonable to offer statin therapy to those with risk of 5-

7.5% [conflicting evidence (IIa, B)]

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Increased in statin utilization (“statinization”)?

• 101 million people in US aged 40-79 yrs without cardiovascular

disease

• 33 million expected to have ≥ 7.5% predicted risk
• 13 million expected to have 5-7.4% predicted risk
• US population 1/20th global population in this age range

− (33+13) x 20 = 920 million worldwide would be new statin

candidates (JAMA 12/2/13)

• Risk calculator overestimates risk
• Lower thresholds to initiate statin therapy

Why a new risk predictor?

• Previously used Framingham risk score was not felt to be adequate

because of its “derivation in an exclusively White sample population and the limited scope of the outcome (in determining CHD alone).”

• Other risk scores also suffered from “nonrepresentative or historically

dated populations, limited ethnic diversity, narrowly defined endpoints, endpoints influenced by provider preferences (e.g., revascularizations), and endpoints with poor reliability (e.g., angina and heart failure [HF]).”

• Broader outcomes of interest
• ASCVD: first occurrence of nonfatal myocardial infarction or CHD

death, or fatal or nonfatal stroke

External Validation

• How many of the 33 million expected to have risk >7.5%

actually have risk that is much lower?

The Lancet, Volume 382, Issue 9907, Pages 1762 - 1765

What should you do about risk assessment?

• Use the pooled risk estimation equations
• Use other risk scores (eg Framingham, QRISK, etc)
• Ignore any risk assessment and consider that

almost everyone benefits from primary prevention

• Use eligibility criteria of the primary prevention trials

Other recommendations from the guidelines

• In lower risk patients (5-7.5%, < 40 or > 75 yrs) clinicians should

discuss with patients:

• ASCVD risk reduction benefits (30% RRR MIS, 45% HIS)
• Adverse effects (diabetes NNH 200)
• Drug-drug interactions
• Patient preferences
• In lower risk individuals also consider:
• FH of premature CAD (< 55yo M, < 65yo F)
• hsCRP > 2
• CAC score >300 Agatston units (or >75 percentile for age)

Other recommendations from the guidelines

• CK should not be routinely measured
• Measure baseline ALT and only remeasure if symptoms suggest

hepatotoxicity

• Screen for diabetes following current diabetes screening guidelines
• Muscle symptoms:
• Temporarily d/c statin and assess for rhabdo if severe & other

conditions that cause muscle symptoms

• Rechallenge with lower or same dose of statin

− If statin causative then give lower dose of different statin

Other recommendations from the guidelines

• No recommendations for add-on therapy to lower

LDL after optimal statin dosing

• Separate guideline on triglycerides (Circul 2012)
• No gemfibrozil
• Fenofibrate only if TG > 500 mg/dl and benefits judged

to outweigh risks

• Consider rechecking lipid panel 4-12 wks after

initiation to assess for adherence but not to adjust therapy