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  Discuss the 2013 ACC/AHA recommendations for risk reduction for MI & CVA through:  Cholesterol level managment  Weight management  Lifestyle modications including diet & exercise  Apply the 2013 guidelines for lipid management in clinical practice

 I have no disclosures for this presentation.

 Who made them?  ATP IV panel  Expert reviewers  Representatives of federal agencies  How?  Randomized controlled trials  Systematic reviews  Meta-analyses

 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

 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

 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

HOW DO WE KNOW?  Cardiac cath  Non-invasive testing  Carotid duplex  Q waves on EKGs  UE/LE arterial duplex  TEE  Peripheral angiography  cCTA  PVD presumed to be  ACS atherosclerotic  Coronary or other  CVA/TIA arterial revascularization

 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%

 High intensity with 10 year risk > 7.5%  Moderate intensity with 10 year risk < 7.5% INDICATED IN ALL PATIENTS WITH DIABETES

 Moderate to high intensity statin indicated

 Family history of premature ASCVD  LDL > 160  hsCRP > 2.0  Coronary calcium scores > 300  ABI < 0.9

 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

 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

 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

 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

 Non-statin therapies alone and in combination with statins, do not provide acceptable risk reduction given their side effect profiles

 Consider confirming myalgias  Consider other conditions  Readdress:  Lifestyle  Decrease dose  Change statin  Check serum vitamin D levels and replete

 Healthy choices  Diet, exercise, weight, smoking, drug therapy  Side effects  Medication compliance  Laboratory compliance  Communicate

 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

 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

 Definition  Benefits of weight loss (if needed)  Weight Loss Strategies  Bariatric surgery

 BMI  Overweight BMI >25.0-29.9 kg/m 2  Obesity BMI > or = 30 kg/m 2  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

 78 million Americans  Five critical questions related to CV risk reduction  Weight loss  BMI/waist circumference  Different diets  Comprehensive lifestyle intervention  Bariatric surgery

 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

 Risk Assessment  Long-Term Risk Assessment  Implementation  Lifetime Risk  Lifestyle Management  Blood Pressure  Lipids  Diet – sodium, potassium

 NYHA Class 2-4  Dialysis patients  HIV + patients  Solid organ transplant recipients

 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?

 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

 No targets  Identify patients  4 high risk groups  Use statins  Healthy lifestyle

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.

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.

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.