by Apurva D. Shah, FACC Northside Heart and Vascular Institute

2001 ATP-3 Statin Trials & Non Statin Trials 2013 ACC/AHA GUIDELINES ON THE TREATMENT OF BLOOD CHOLESTEROL

1.“Doc, why would you want to change my cholesterol medications?” 2.I need a trick to remember the guidelines; I can’t Google it in front of the patient 3.That wasn’t so bad, lets try it again on the next patient

“Doc, why would you want to change my cholesterol medications?”

The ATP III guidelines: 1.Assess risk based on the Framingham Risk Score 1.FRS underestimates cardiovascular risk 2.Lots of patients with low FRS have MI’s 2.Sets goal LDL-C levels for therapy 1.Clinical trials didn’t set LDL-C goals 2.No trial was powered for and LDL-C = 70

By using the Framingham Risk Score, we are missing people who can benefit from statin therapy 10 Year Predicted and Observed Rates of CV Disease and Heart Disease Mortality Quintiles of Framingham Predicted CV Disease Events Brindle P M et al. Br J Gen Prac 2005;55:

I need a trick and method to remember the guidelines that’s not Google!

Prescribe statin dose based on risk group Place in risk group

Atherosclerotic DiseaseLDL-C >190 mg/dlDiabetesEveryone Else

Atherosclerotic Disease A LDL > 190 mg/dl L Diabetes D Everyone Else E

Prescribe statin dose based on risk group Place in risk group

Lipitor mg Crestor mg High-Intensity statin therapy Lipitor mg Crestor 5-10 mg Zocor mg Pravachol mg Moderate- Intensity statin therapy Healthy lifestyle No Statin Therapy

Atherosclerotic DiseaseLDL-C >190 mg/dlDiabetesEveryone Else

High risk for cardiovascular event High risk requires High Intensity Lipitor 40-80mg Crestor 20-40mg

Atherosclerotic Disease  NO LDL-C >190 mg/dlDiabetesEveryone Else

LDL > 190 confers a high event risk High risk requires High intensity Lipitor 40-80mg Crestor 20-40mg

Atherosclerotic Disease  NOLDL-C >190 mg/dl  NO DiabetesEveryone Else

Not all Diabetic are created equal But All Diabetics benefit from statin therapy Must calculate risk score

Found at Google Play Store: ASCVD Risk Estimator Estimates 10 year risk for a cardiovascular event High risk > 7.5%

Calculate Risk Score Risk > 7.5%: High Intensity Statin Therapy Risk < 7.5%: Moderate Intensity Statin

Atherosclerotic Disease  NOLDL-C >190 mg/dl  NODiabetes  NO Everyone Else

Calculate Risk Score Risk > 7.5%: High Intensity Statin Therapy Risk < 7.5%: No Statin Indicated

High Dose Statin Atherosclerotic Disease High Dose Statin LDL-C >190 High Dose Statin (Risk>7.5%) Moderate Dose Statin (Risk<7.5%) Diabetes High Dose Statin (Risk>7.5%) No Statin (Risk<7.5%) Everyone Else

That wasn’t so bad, let’s try it again on the next patient

42 year old Male with a Coronary Stent Total cholesterol, 140 mg/dl HDL cholesterol, 35 mg/dl LDL cholesterol, 110 mg/dl Normal BP Not diabetic Nonsmoker What therapy would you initiate A) Niacin 1000mg daily B) Lipitor 80mg daily C) Zocor 10mg daily D) No therapy

52 year old Male with Gastric Bypass Total cholesterol, 300 mg/dl HDL cholesterol, 15 mg/dl LDL cholesterol, 210 mg/dl Normal BP Not diabetic Nonsmoker What therapy would you initiate A) Niacin 1000mg daily B) Crestor 40mg daily C) Lipitor 10mg daily D) No therapy

50 year old with Diabetes Total cholesterol, 210 mg/dl HDL cholesterol, 50 mg/dl LDL cholesterol, 180 mg/dl No ASCVD Diabetic Smoker Calculated 10 year risk of CHD or stroke, 9.8% What therapy would you initiate A) Vytorin 10/40mg daily B) Lipitor 80mg daily C) Pravachol 10mg daily D) No therapy

48 year old with Diabetes Total cholesterol, 210 mg/dl HDL cholesterol, 45 mg/dl LDL cholesterol, 165 mg/dl No ASCVD Diabetic Non-Smoker Calculated 10 year risk of CHD or stroke, 2.5% What Therapy should be Initiated A) Lipitor 80mg B) Crestor 5mg C) Vytorin 10/40mg D) Niacin 1000mg