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2013 ACC/AHA Blood Cholesterol Treatment GuidelinesIntensity Of Statin Therapy

Aim to Reduce RISK not at Target levels

DR.PRAVEEN NAGULA

Scope of guidelineto reduce atherosclerotic cardiovascular disease(ASCVD)risk {RCTs,systematic analysis and metaanalysis of RCTs}.

ASCVD coronary heart disease(CHD),stroke,and peripheral arterial disease,all of presumed atherosclerotic origin.to provide strong evidence-based foundation.only evidence from statin RCTs were used to develop guidelines.****

Comprehensive approach to lipid management for purposes with relation to ASCVD reduction only,not for complex lipid disorders.

What do present guidelines say.....

Patient centered approach rather than one treatment fits allWhats new in the guideline?

Benefits of StatinsHigh intensity therapy lowering LDL cholesterol by >50%.Moderate intensity therapy - lowering LDL cholesterol by 30-50%.Reduces ASCVD events across the spectrum of baseline LDL-C levels > 70 mg/dl.Relative reduction in ASCVD risk is consistent for primary and secondary prevention.

Absolute reduction in ASCVD events is proportional to baseline absolute ASCVD risk.

Statin therapy only for individuals at increased ASCVD risk .

Who are to be benefited by Statins ?????

Primary prevention of ASCVDBased on the estimated absolute 10 yr risk of ASCVD (non fatal MI,CHD death,nonfatal and fatal stroke)

The omnibus CV risk calculator for

Pts without clinical ASCVD and LDL 70-189mg/dl Estimates 10 yr risk of ASCVDIn diabetics ,for primary prevention

Not in pts with clinical ASCVD

Statin treatment:Recommendations

Primary prevention in patients with LDL>190mg/dlPrimary prevention in patients with diabetesStatins in Heart Failure,Hemodialysis patients

High- Moderate and Low Intensity Statin Therapy Clinical application by Statin doseSTATINSHIGH INTENSITY THERAPYMODERATE INTENSITY THERAPYLOW INTENSITY THERAPYDaily dose lowers LDL-C on average,by approximately 50% Daily dose lowers LDL C on average,by approximately 30-50% Daily dose lowers LDL C 10yrs? Why Target level therapy ignored..how came the picture of statin benefit groups?Hypothesis or Evidence based..Myth or reality A.Secondary Prevention Evidence high intenisty therapy to maximally lower LDL C than using a target.

Ex LDL C 78mg/dl on a dose of atorvas 80 mg/dl receiving EBT.

No data to show that adding a nonstatin drug to high intenisty statin therapy will provide incremental ASCVD risk reduction benefit with acceptable margin of safety.(AIM HIGH,ACCORD).

This patient may be exposed to adverse effects if started of a drug with no evidence of benefit,just because his LDLis more than arbitrarily level.

This is treated as a case of failure..for a lag of 8 mg/dl..Is it justifiable ???

AIM HIGH trial NewEngl J Med 2011;365:2255-67 ACCORD, N Engl J Med 2010;362:156374.B.FH with LDL C >190 mg/dlmany does not achieve 50% ,more ASCVD risk reduction.Not treatment failures.C.Type2Diabetes :have lower LDL-C than with without diabetes.goal directed therapy encourages low statin doses,use of drugs for addressing HDL-C/high TG.maximally tolerated therapy to be given primary importance.D.Estimated ASCVD >7.5% Cholesterol Treatment Trialists Collaboration, Lancet 2012;380:58190. Taylor F, Ward K, Moore TH et al. 2011:CD004816

LimitationsClinical judgement required in pts,for whom RCT evidence is insufficientYounger adults< 40 yrs with 75 yrs ageAlternate treatment strategies.Effectiveness of submaximal doses of statins vs nonstatins in intolerant ptsEvaluation of the incidence of new onset diabetes associated with statin therapy.Outcomes of RCTs of new lipid modifying agents to determine the incremental ASCVD reduction when added to statin therapy.Future updates required for..

1.The treatment of Hypertriglyceridemia.2.Use of NonHDL-C in decision making.3.Whether on-treatment markers such as apoB,Lp(a),LDLparticles are useful in guiding decisions.4.Best approaches to use noninvasive imaging for refining risk estimates to guide treatment.5.Optimal age for starting treatment for reducing lifetime risk of ASCVD.6.What to do in pts with HF,hemodialysis.7.Long term effects of statin associated new onset diabetes and management.ConclusionsPatient centered approach is to be given importance rather than one treatment fits all concept.Statins to be given at high intenisty,moderate intensity doses but not with target levels of attainment.Nonstatins give no ASCVD benefit in pts with high intensity statin therapy.Use of lipoprotein a ,non HDLcholesterol levels assessment is not recommended.Pts without ASCVD should be started of the statins after assessing 10 yr risk by omnibus calculators.New onset diabetes due to statins needs further assessment in future.New drugs in pipeline,RCT s required for their incremental benefit in ASCVD risk reduction when added to statinsLifestyle modification remains the key concept of the management of blood cholesterol.

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