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Overview of the 2013 ACC/AHA Guideline On the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

2014; Future Medicine; Volume: 10; Issue: 2 Linguagem: Inglês

10.2217/fca.14.8

1744-8298

Jennifer G. Robinson,

Pharmaceutical Economics and Policy

Future CardiologyVol. 10, No. 2 EditorialFree AccessOverview of the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in AdultsJennifer G RobinsonJennifer G Robinson*Department of Epidemiology, 145 N Riverside Dr S455 CPBH, University of Iowa, Iowa City, IA 52242, USA; E-mail Address: jennifer-g-robinson@uiowa.eduPublished Online:25 Apr 2014https://doi.org/10.2217/fca.14.8AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInReddit Keywords: cholesterolevidence-basedguidelinepreventionsystematic reviewThe recently published 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults published by the American Heart Association (AHA) and American College of Cardiology (ACC) changes the treatment paradigm for cholesterol treatment [1]. Based on a rigorous, systematic review of randomized, controlled clinical trials (RCTs), the new guideline no longer targets LDL-C levels. The new recommendations now focus on treating cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk. The 2013 guideline approach is consistent with the 2011 report of the Institute of Medicine (IOM) on trustworthy guidelines [2]. Only data from RCTs of cholesterol-lowering drug therapies with cardiovascular outcomes, or meta-analyses of these RCTs, were considered. RCTs are the most objective assessment of cardiovascular event reduction benefits and adverse effects that can be used to guide clinical practice. The cholesterol guideline effort was supported by the lifestyle and risk assessment working groups, which undertook a similarly rigorous process to developing their evidence-based recommendations [3,4].RecommendationsBecause the focus is on the evidence-based treatment of cholesterol to reduce ASCVD risk in adults, the recommendations emphasize statin therapy. A very large body of evidence from multiple populations is available for statins, with less evidence available for nonstatin drug therapy for ASCVD risk reduction.• A healthy lifestyle is the foundation for ASCVD risk reductionThe RCTs were performed in the setting of healthy lifestyle advice. Long-term adherence to healthy lifestyle habits and control of other ASCVD risk factors is an essential component of ASCVD risk-reduction efforts. The cholesterol panel endorsed the recommendations of the 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk [3].• Use statin therapy to reduce ASCVD risk in those most likely to benefitStrong RCT evidence supports a net benefit from statin therapy in individuals with clinical ASCVD (secondary prevention), and in three groups of individuals without clinical ASCVD (primary prevention), age ≥21 years with LDL-C ≥190 mg/dl, diabetes aged 40–75 years or ≥7.5% 10-year ASCVD risk aged 40–75 years with LDL-C 70–189 mg/dl. Moderate evidence supports the use of a statin for primary prevention in those with 5–<7.5% 10-year ASCVD risk aged 40–75 years with LDL–C 70–189 mg/dl. Statin therapy may also be considered in those who do not meet these criteria if other indications of increased ASCVD risk are present. For those in whom a risk-based decision is unclear, an LDL-C ≥160 mg/dl, family history of premature ASCVD (first-degree male relatives before age 55 years or female relatives before age 65 years), high lifetime ASCVD risk, elevated coronary artery calcium, high-sensitivity CRP ≥2 mg/l or an ankle-brachial index 75 years, a history of statin intolerance, or other characteristics or drug therapy that may influence statin safety).Muscle symptoms are common, but not necessarily related to statin use. The relationship of muscle or other symptoms to statin therapy should be established by discontinuing the statin, then rechallenging with the original or lower dose of the same or a different statin. Statin-related severe myopathy (with creatine kinase elevations), rhabdomyolysis and hemorrhagic stroke are rare.Statins modestly increase the risk of diabetes, but the ASCVD risk-reduction benefit exceeds the risk of diabetes in all but the lowest-risk individuals. Screening for diabetes should occur according to current diabetes guidelines. Healthy lifestyle habits should be encouraged in all patients.• A clinician–patient discussion prior to statin initiation is important, especially in lower-risk primary preventionEstimation of 10-year ASCVD risk is the first step in evaluating the potential for an ASCVD risk-reduction benefit from statin therapy used for primary prevention (2013 Prevention Guidelines Tools CV Risk Calculator using the Pooled Cohort Equations can be found at [5-7]). The Pooled Cohort Equations should be used to estimate risk in white and African–American women and men who are not receiving statin therapy and have an LDL-C <190 mg/dl. In those with diabetes, 10-year ASCVD risk can now be estimated using the new equations, and may inform the choice of statin intensity. Do not estimate 10-year risk in those with clinical ASCVD or with LDL-C ≥190 mg/dl because all such adults ≥21 years of age should receive statin therapy.Once 10-year ASCVD risk has been estimated, the clinician and patient should then engage in a discussion of the potential for an ASCVD risk-reduction benefit based on estimated 10-year ASCVD risk and other factors noted in the section 'Use statin therapy to reduce ASCVD risk in those most likely to benefit', adverse effects, drug–drug interactions and patient preferences when deciding whether to initiate statin therapy. The discussion also provides the opportunity to address healthy lifestyle habits and control of other risk factors. After age 75 years, there is less evidence for primary prevention and decisions should be individualized in this age group.• Choose the appropriate intensity of statin therapy to reduce ASCVD riskHigh-intensity statins lower LDL-C by ≥50% (atorvastatin 40–80 or rosuvastatin 20–40 mg). Moderate-intensity statins lower LDL-C by 30– 75 years, or if safety concerns are present for high-intensity statin therapy.In primary prevention, strong evidence supports the use of moderate-intensity statins in individuals with diabetes aged 40–75 years and in those with ≥7.5% 10-year ASCVD risk. Moderate evidence supports the use of high-intensity statins only in those with ≥7.5% 10-year ASCVD risk (with or without diabetes) and moderate intensity statins in those with 5 to <7.5% 10-year ASCVD risk and LDL-C 70–189 mg/dl. High-intensity statins should be used in those with LDL-C ≥190 mg/dl; addition of nonstatin therapy can be considered when LDL-C levels remain unacceptably elevated (see section 'Regularly monitor adherence & safety, including LDL-C measurement').• Do not titrate cholesterol-lowering drug therapy to LDL-C or non-HDL-C goalsBecause the RCTs to date have used fixed doses of statin and/or nonstatin drugs, there is insufficient evidence to recommend titration to specific LDL-C or non-HDL-C goals. Use of such goals has the potential to result in inappropriate therapy. For example, a patient with clinical ASCVD may have an LDL-C <100 mg/dl on pravastin 10 mg daily, yet this intensity of statin therapy provides less than optimal therapy for ASCVD prevention. Or, a patient may have an LDL-C of 105 mg/dl on a high-intensity statin. There is no evidence that addition of a nonstatin to high (or even moderate)-intensity statin therapy will further reduce ASCVD risk, nor is there evidence that such an approach has an acceptable margin of safety.• Regularly monitor adherence & safety, including LDL-C measurementAll RCTs regularly evaluated drug adherence and safety. A follow-up visit should be performed within 4–12 weeks of statin initiation or changes in therapy, and should include a fasting lipid panel and assessment of adherence and safety. Percentage reduction in LDL-C consistent with statin intensity may provide a guide to the anticipated response to therapy: approximately ≥50% for a high-intensity statin, or approximately 30–50% for a moderate-intensity statin. When baseline LDL-C is unknown, it is noted that an LDL-C <100 mg/dl was achieved by most participants receiving a high-intensity statin. Percentage reduction or LDL-C level should never be used as performance measures.If a less-than-anticipated response occurs, improved adherence to lifestyle and drug therapy should be encouraged, and/or statin therapy can be increased. Rule out secondary causes of hypercholesterolemia if indicated (most common causes are weight gain or obesity, high saturated or trans-fat intake, hypothyroidism, biliary obstruction or pregnancy).In those receiving maximally tolerated statin therapy but still having an unacceptable response to therapy, addition of a nonstatin therapy can be considered in high-risk individuals if the ASCVD risk-reduction benefits are considered to outweigh the increased risk of adverse effects. High-risk individuals include those with clinical ASCVD, LDL-C ≥190 mg/dl or diabetes aged 40–75 years and LDL-C 70–189 mg/dl.Once a stable lifestyle and drug therapy regimen has been established, follow-up should occur at 3–12-month intervals.SummaryThe 2013 ACC/AHA cholesterol guideline provides a comprehensive, evidence-based approach to reducing ASCVD risk. As with all guidelines, these recommendations require consideration of the potential net benefit for each patient, based on their unique characteristics and preferences.Financial & competing interests disclosureJG Robinson was the Vice Chair for the 2013 ACC/AHA cholesterol guideline. In the past year the author has received research grants from Amarin, Amgen, AstraZeneca, Daiichi Sankyo, Esperion, Genentech/Hoffmann-La Roche, GlaxoSmithKline, Merck, Regeneron/Sanofi and Zinfandel/Takeda, and has served as consultant for Amgen, Hoffmann-La Roche, Pfizer and Sanofi. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.References1 Stone N, Robinson J, Lichtenstein A et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation doi:10.1161/01.cir.0000437738.63853.7a (2013) (Epub ahead of print).Google Scholar2 Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical Practice Guidelines We Can Trust. Institute of Medicine, DC, USA (2011)Google Scholar3 Eckel RH, Jakicic JM, Ard JD et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation doi:10.1161/01.cir.0000437740.48606.d1 (2013) (Epub ahead of print).Google Scholar4 Goff DC, Lloyd-Jones DM, Bennett G et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation doi:10.1161/01.cir.0000437741.48606.98 (2013) (Epub ahead of print).Google Scholar5 American Heart Association. 2013 Prevention Guidelines Tools. CV Risk Calculator (iTunes version). https://itunes.apple.com/us/app/ascvd-risk-estimator/id808875968?mt=8&ign-mpt=uo%3D2Google Scholar6 ASCVD Risk Estimator (Android version). https://play.google.com/store/apps/details?id=org.acc.cvrisk&hl=enGoogle Scholar7 ASCVD Risk Estimator* (desktop version). http://tools.cardiosource.org/ASCVD-Risk-EstimatorGoogle ScholarFiguresReferencesRelatedDetailsCited ByAn international perspective on low-dose aspirin for the primary prevention of myocardial infarctionInternational Journal of Cardiology, Vol. 373A Comparative Study of Effectiveness of Two Intensive Statin Regimen in the Treatment of Coronary Artery Disease in A Tertiary Care Hospital15 September 2022 | International Journal of Pharmaceutical Sciences Review and Research, Vol. 92Dyslipidemia and its relationship with shift work in petrochemical workersObesity Medicine, Vol. 33Developments of CRBN-based PROTACs as potential therapeutic agentsEuropean Journal of Medicinal Chemistry, Vol. 225The effects of dyslipidemia on noise-induced hearing loss in petrochemical workers in the Southwest of IranWork, Vol. 70, No. 3The Projected Impact of Population-Wide Achievement of LDL Cholesterol <70 mg/dL on the Number of Recurrent Events Among US Adults with ASCVD2 October 2021 | Cardiovascular Drugs and Therapy, Vol. 25The Haiti cardiovascular disease cohort: study protocol for a population-based longitudinal cohort1 November 2020 | BMC Public Health, Vol. 20, No. 1The impact of statin discontinuation and restarting rates on the optimal time to initiate statins and on the number of cardiovascular events prevented11 May 2020 | Pharmacoepidemiology and Drug Safety, Vol. 29, No. 6Assessment methods and possibilities of instrumental diagnosis of subclinical atherosclerosis of coronary arteries22 December 2019 | Cardiovascular Therapy and Prevention, Vol. 18, No. 6Observational Study Investigating the Prescription of Lipid-Lowering Drugs for Primary and/or Secondary Prevention in Residents Aged 80 Years and Over Institutionalized in Nursing Homes in Brest26 October 2019 | The journal of nutrition, health & aging, Vol. 23, No. 10Disparities in Statin Use in New York City: Implications for Health Reform19 November 2018 | Journal of Racial and Ethnic Health Disparities, Vol. 6, No. 3Net benefit of statins for primary prevention of cardiovascular disease in people 75 years or older: a benefit–harm balance modeling study25 September 2019 | Therapeutic Advances in Chronic Disease, Vol. 10Do Pregnancy Experiences Predict Cardiovascular Disease in Women?The Journal for Nurse Practitioners, Vol. 12, No. 7Fixed-dose Strategy Is Lacking23 September 2016 | Deutsches Ärzteblatt internationalPrescripción inadecuada en pacientes polimedicados mayores de 64 años en atención primariaAtención Primaria, Vol. 47, No. 1The Metabolic Investigation of Erectile Dysfunction: Cardiometabolic Risk Stratification10 October 2014Genomic Determinants of Triglyceride and Cholesterol Distribution into Lipoprotein Fractions in the Rat8 October 2014 | PLoS ONE, Vol. 9, No. 10NOVEL OPPORTUNITIES TO REACH THE TARGET LEVELS OF LOW DENSITY CHOLESTEROL20 August 2014 | Cardiovascular Therapy and Prevention, Vol. 13, No. 4Assessment of the Common Risk Factors Associated with Type 2 Diabetes Mellitus in JeddahInternational Journal of Endocrinology, Vol. 2014 Vol. 10, No. 2 Follow us on social media for the latest updates Metrics History Published online 25 April 2014 Published in print March 2014 Information© Future Medicine LtdKeywordscholesterolevidence-basedguidelinepreventionsystematic reviewFinancial & competing interests disclosureJG Robinson was the Vice Chair for the 2013 ACC/AHA cholesterol guideline. In the past year the author has received research grants from Amarin, Amgen, AstraZeneca, Daiichi Sankyo, Esperion, Genentech/Hoffmann-La Roche, GlaxoSmithKline, Merck, Regeneron/Sanofi and Zinfandel/Takeda, and has served as consultant for Amgen, Hoffmann-La Roche, Pfizer and Sanofi. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.PDF download