1. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Scott W. Rypkema, M.D.

2. New Guidelines are based on RCT Departure from old guidelines – not treating to a target number Think in terms of Risk Assessment Treat the Patient, not a number Treatment with a statin reduces CV risk by 20% regardless of baseline lipid panel

3. 2013 American College of Cardiology–American Heart Association Guidelines for Use of Statin Therapy in Patients at Increased Cardiovascular Risk.

4. High-Intensity and Moderate-Intensity Statin Therapy, According to 2013 American College of Cardiology–American Heart Association (ACC-AHA) Cholesterol Guidelines.

5. Secondary Causes of Hyperlipidemia: - Diet: weight gain, high intake of carbohydrates, excessive alcohol intake, anorexia, very low fat diets - Drugs: estrogens, glucocorticoids, protease inhibitors, diurectics, cyclosporine, amiodarone, retinoic acid, anabolic steroids, tamoxifen, bile acid sequestrants - Diseases: biliary obstruction, nephrotic syndrome, pregnancy, hypothyroidism, diabetes (poor control)

6. Safety Recommendations: - baseline ALT, but no routine monitoring - no baseline CK - Pregnancy category X - caution in impaired hepatic and renal function - consider reduction in dose if LDL < 40 - avoid using simvastatin 80 mg - caution in age > 75 - do not use gemfibrozil + statin - caution using fenfibrate + statin

7. Monitoring statin therapy: - Adherence to lifestyle changes and medications - Fasting Lipid Panel 4-12 weeks after initiation - FLP every 12 months thereafter - Ask about muscle symptoms at baseline and every visit thereafter - Only check LFTs and CK as clinically indicated

8. Key Implications of New Guidelines: 1.Avoidance of statins in certain patient groups 2.Reduction of “routine” assessments of lipids and LFTs in patients receiving therapy because target levels are now longer used. 3.Emphasis on statins, avoidance of non-statin drugs 4.More conservative approach to those > 75 years old 5.Diminished use of surrogate markers like CRP or Ca scores 6.Use of new risk calculator

9. New Risk calculator: Developed by the RAWG (Risk Assessment Work Group) Pooled data from: 1. NHLBI Framingham Heart Study 2. Atherosclerotic Risk In Communities (ARIC) 3. Cardiovascular Health Study (CHS) 4. Coronary Artery Risk Development in Young Adults (CARDIA) Has not been prospectively tested for accuracy

10. ASCVD Risk Estimator – ACC/AHA Gender, Age, Race, Total Chol, HDL, Systolic BP, Treatment for HTN, DM, smoking status Get the App on your smart phone!

11. Case Study: 50 yo white male teacher with BMI of 32 wants to assess his risk after his father has a MI at age 74. No HTN or DM. -Smokes 1 ppd -TC 170 TG 170 HDL 35 LDL 101 -BP 120/78 What Would You Do? 1.Do not start a statin 2.Start a statin

12. 1.Do NOT start a statin: Quitting smoking will cut his CV risk in half HDL can be expected to raise with smoking cessation and TLC Diabetes risk in statins????? 1-3/1000/year with high-dose therapy Major Primary prevention trial with low HDL was AFCAPS/TexCAPS Lovastatin 20-40mg cut risk of cv events by 25% - mean HDL 36 BUT, he would not have been eligible for this study due to LDL 101

13. 2. Start a statin Guidelines – CV risk is 7.9% Metabolic syndrome – LDL of 101 underestimates his risk Increases risk of diabetes by factor of 5 It is unlikely that he will engage in TLC

14. 2013 American College of Cardiology–American Heart Association Guidelines for Use of Statin Therapy in Patients at Increased Cardiovascular Risk.