Lipids, An Issue of Endocrinology and Metabolism Clinics of North America (eBook)

Donald A. Smith (Autor)

eBook Download: EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-32647-6 (ISBN)

Infos

This issue of Endocrinology and Metabolism Clinics, devoted to Lipids, is edited by Dr. Donald A. Smith. Articles in this issue include: Advanced Lipoprotein Testing; Improving Cardiovascular Risk Assessment: Coronary calcium scor and CT coronary imaging; Understanding HDL; Statin Strategies for Maximizing Public Health: benefits and harms; Cellular Cholesterol Regulation: SREBP and miRNA; Mediterranean Diet - the best diet for CV protection?; Pediatric Lipidology: An Earlier Approach; Newer LDL-lowering Therapies; and Statin Combination Therapies.

Textauszug

The 2013 American College of Cardiology/American Heart Association Guidelines on Treating Blood Cholesterol and Assessing Cardiovascular Risk

A Busy Practitioner’s Guide

Arpeta Gupta, MDa and Donald A. Smith, MD, MPHb∗[e-mail],     aDivision of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, Box 1055, New York, NY 10029, USA; bMount Sinai Heart, Icahn School of Medicine, Box 1014, 1 Gustave Levy Place, New York, NY 10029-6574, USA

∗Corresponding author.

The 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults and Guideline on the Assessment of Cardiovascular Risk were released in mid-November 2013. This article explains the guidelines, the risk equations, and their derivations, and addresses criticisms so that practicing physicians may be more comfortable in using the guidelines and the risk equations to inform patients of their atherosclerotic cardiovascular risk and choices to reduce that risk. The article also addresses patient concerns about statin safety if lifestyle changes have been insufficient to reduce their risk.

Keywords

2013 ACC/AHA cholesterol guidelines

Pooled cohort equations

Ten-year ASCVD risk

Statin therapy

Primary prevention of ASCVD

Blood cholesterol guideline

Cardiovascular risk guideline

Key points

• The 2013 American College of Cardiology/American Heart Association practice guidelines on the treatment of blood cholesterol and assessment of risk now include stroke in addition to coronary heart disease.

• New risk assessment equations for both 10-year and lifetime risk for atherosclerotic cardiovascular disease (ASCVD) events that include African Americans have been developed.

• Moderate-dose to high-dose statins are recommended for specific groups of persons; those greater than or equal to 21 years of age and low-density lipoprotein cholesterol greater than or equal to 190 mg/dL, and those 40 to 75 years of age with clinical ASCVD, diabetes, or 10-year ASCVD risk greater than or equal to 7.5%.

• New lifetime ASCVD risk equations may be useful in individuals 20 to 59 years of age and with less than 7.5% 10-year risk.

• Intensity of statin therapy can be modified based on probability of adverse statin side effects.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality, accounting for every 1 in 3 deaths in the United States.1 Over the last decade, death rates attributable to CVD declined 31.0% and the number of CVD deaths per year declined by 16.7%. Death rates in 2010 attributable to stroke and coronary heart disease (CHD) were 39.1 and 113.6 down from 60.9 (−33%) and 186.8 (−36%) per 100,000 in 2000, respectively. In diabetic patients from 1990 to 2010 acute myocardial changes decreased 67.8%, stroke 52.7%, and amputations 51.4%.2 However, in 2010, CVD still accounted for 31.9% of all deaths in the United States. A recent report from a national American clinical laboratory (Quest) reported on low-density lipoprotein (LDL) cholesterol (LDL-C) levels in 150 million Americans from 2000 to 2011. Although there was a steady decline from 2000 to 2008, LDL-C levels remained the same from 2008 to 2011, with no change in the percentage achieving any LDL-C goal levels, including levels less than 100 mg/dL.3

On 13 November, 2013, the Joint Task Force of the American College of Cardiology (ACC) and the American Heart Association (AHA) published new atherosclerotic CVD (ASCVD) prevention guidelines as an update to the 2008 guidelines developed by the National Heart, Lung, and Blood Institute.4 This article restates the guidelines in a simpler format than the original synopsis5 and discusses further the new risk equations that can help physicians and patients make decisions on lifestyle and medications to significantly reduce patients’ lifetime risks of ASCVD.

Paradigm shift from treat-to-target to intensity of statin therapy

For more than a decade, physicians have targeted LDL-C and non–high-density lipoprotein (HDL) cholesterol (non–HDL-C) goals by frequent laboratory testing, adjusting intensity of statin therapy, and using therapeutically unproven combinations of lipid-altering medication added to statin therapy. Unlike Adult Treatment Panel III (ATP-III) guidelines and the recent European and Canadian guidelines, the updated guidelines abandon these targets and recommend treating cholesterol by prescribing the appropriate intensity of statin therapy for those patients who are most likely to benefit. The panel’s decision for this recommendation is based on a rigorous systematic review of randomized controlled trials (RCTs), a few of which are listed in Table 1; systematic reviews; and meta-analyses (Table 2) rather than fewer RCTs and expert opinion, which were used by the ATP-III guidelines. The recommendation is to measure LDL-C at baseline and rule out severe hypertriglyceridemia (≥500 mg/dL), reassess LDL-C 1 to 3 months after statin initiation and every 3 to 12 months thereafter to check for compliance (ie, the stability of the expected percentage decreases in LDL-C). Routine monitoring of alanine aminotransferase (ALT) or creatine phosphokinase (CPK) is no longer recommended in asymptomatic patients. This recommendation translates into less frequent laboratory testing, fewer dose adjustments, and less use of combination lipid therapy.

Table 1

Some important statin trials for LDL-C goal setting

Scandinavian Simvastatin Survival Study40

4444

82/18

58

Simvastatin 20/40 vs PBO

Secondary

5.0

4.9

196

3.2

127

All deaths

0.70 (0.58–0.85)

All coronary deaths

0.58 (0.46–0.73)

MI, CHD death

0.73 (0.66–0.80)

Coronary revascularization

0.63 (0.54–0.74)

Heart Protection Study41

20,536

72/25

40–80

Simvastatin 40 vs PBO

Primary (DM ± hypertension) and secondary

5.4

3.4

136

2.4

96

Vascular deaths

0.83 (0.75–0.91)

MI, CHD death

0.73 (0.67–0.79)

Any stroke

0.75 (0.66–0.85)

Treating to New Targets42

10,001

81/19

35–75

Atorvastatin 80 vs 10

Secondary

4.9

2.6

101

2.0

77

MI, CHD death

0.78 (0.68–0.91)

Any stroke

0.75 (0.59–0.96)

Anglo-Scandinavian Cholesterol Outcomes Trial, Lipid-lowering Arm43

10,305 hypertension + 3 additional RFs

81/19

40–79

Atorvastatin 10 vs PBO

Primary (15% previous stroke or PAD)

3.3

3.4

132

2.3

90

MI, CHD death

0.64 (0.50–0.83)

Any stroke

0.73 (0.56–0.96)

Collaborative Atorvastatin Diabetes Study44

2838 type 2 DM + 1 additional RF + LDL-C ≤160 + LDL-C ≤100

68/32

40–75

Atorvastatin 10 vs PBO

Primary

3.9

3.1

120

2.1

81

Acute CHD, coronary revascularization, stroke

0.63 (0.48–0.83)

—	0.74 (P<.05)

Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin45

17,902 LDL-C <130 hs-CRP ≥2.0

62/38

M>50 F>60

Rosuvastatin 20 vs PBO

Primary

1.9

2.8

110

1.4

55

MI, CVA, CV death, hospitalization for angina, revascularization

0.56 (0.46–0.69)

All-cause mortality

0.80 (0.67–0.97)

Abbreviations: CI, confidence interval; CVA, cerebrovascular accident; DM, diabetes mellitus; F, female; F/U, follow-up; hs-CRP, high-sensitivity C-reactive protein; M, male; MI, myocardial infarction; PAD, peripheral artery disease; PBO, placebo; RF, risk factor.

Data from Refs.40–45

Table 2

Meta-analysis: efficacy...

Produkt-Details

• Erscheint lt. Verlag: 26.12.2014
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Endokrinologie
• Themenwelt: Medizinische Fachgebiete ► Innere Medizin ► Gastroenterologie
• Themenwelt: Studium ► 1. Studienabschnitt (Vorklinik) ► Biochemie / Molekularbiologie
• ISBN-10: 0-323-32647-1 / 0323326471
• ISBN-13: 978-0-323-32647-6 / 9780323326476