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2014 ATPIV Guidelines

posted Mar 5, 2015, 5:16 PM by Kevin Hauck   [ updated Mar 5, 2015, 5:18 PM ]

Here's a fantastic Monte Minute brought to you by one of our rising chief residents, Mayce Mansour! 

2014 ATP-IV Evidence-Based Guidelines for the Management of Hyperlipidemia

Introduction:

Whether in the CCU or in primary care clinic, lipid management is a recurrent, bread-and-butter theme in medical management.  In recognition of myocardial infarction and stroke being leading causes of mortality, the National Cholesterol Education Program was created in 1985 to address hyperlipidemia as a public health concern.  The goal of this program was to raise awareness of hyperlipidemia as a risk factor for coronary heart disease.  Most recent guidelines have broadened this focus to include risk assessment of atherosclerotic cardiovascular disease (ASCVD)—i.e., non-fatal and fatal MI, non-fatal and fatal CVA.  A panel of experts, the Adult Treatment Panel (ATP), was subsequently created to provide data-driven practice guidelines.   The ATP-IV guidelines released in November 2013 have fundamentally changed the way we approach lipid management—moving from LDL goals to atherosclerotic cardiovascular disease risk stratification. 

Objectives:

-Who do we screen?

-Why have current guidelines moved away from LDL goals?

-What are suggested lifestyle modification guidelines?

-How are “statin benefit” groups defined?

-How are “statin intensity” categories defined?  Which statins fall into these categories?

-What are the new guidelines?

-Controversy!

Who do we screen?

Per the ATP-IV guidelines, we should be screening everyone >21yrs every 4-6 years.

Per the USPTF, we should be routinely screening men>35yrs (grade A), women>45yrs (grade A), OR men 20-35yrs and women 20-45yrs “at increased risk for coronary heart disease” (grade B).  We should be screening every 5 years.

Why have current guidelines moved away from LDL goals?

Prior to the newest ATP-IV guidelines, you may all remember our previously LDL goal targets (LDL<130 “desirable,” <100 “optimal,” <70 for highest-risk groups).  The most recent report moved away from these guidelines because most clinical trials did not treat to a goal, but instead used different intensities of statins in their treatment arms.  Therefore, insufficient evidence was found for LDL/HDL treatment goals in the prevention of primary and secondary ASCVD, and we have moved away from this management strategy.  Interestingly, since most trials with non-statin cholesterol medications focused solely on LDL-lowering (and NOT on clinical outcome reduction), you will notice non-statins are conspicuously missing from the newest ATP-IV guidelines.  Current guidelines suggest using non-statins only if statins are not tolerated or if goal LDL percent-reduction is not reached despite maximal statin therapy.

 

What are suggested lifestyle modification guidelines?

Remember, this is always the FIRST approach to lipid management—both on tests and in real life.

ACC/AHA lifestyle management guidelines:

·         Diet—

o   Increase intake of vegetables, fruits, whole grains

o   Include nuts, low-fat dairy products, poultry, fish and vegetable oils

o   Limit red meat

o   Fats:

§  <5-6% total calories from saturate fat

§  reduce % calories from transfats

o   Limit sodium intake to help with blood pressure reduction

·         Physical activity: aerobic exercise moderate to vigorous intensity, 3-4x/week, 40 mins/session

How are different “statin benefit” groups defined?

 

Group 1

Clinical ASCVD: acute coronary syndrome, primary MI, stable/unstable angina, prior coronary artery revascularization, stroke, TIA and peripheral artery disease

Group 2

LDL>190 mg/dl (ages 21 and older)

Group 3

Diabetes- Type 1 or 2 (ages 40-75)

Group 4

10-year ASCVD risk >7.5%

 

Conspicuously missing is guidance on folks in groups 3 and 4 who are <40yrs or >75yrs.  Additionally, our old friend Framingham is no longer in the picture, though in completing the ASCVD risk calculator, you’ll see a resemblance.  In order to broaden included patient populations, the ASCVD risk calculator is based on a combination Framingham, CARDIA, ARIC, and Cardiovascular Health studies.

 

How are “statin intensity” categories defined?  Which statins fall into these categories? 

Category

Goal: LDL reduction by…

RXs

Low-intensity

<30%

Simvastatin 10mg

Pravastatin 10-20mg

Lovastatin 20mg

Fluvastatin 20-40mg

Moderate-intensity

30-50%

Atorvastatin 10-20mg

Rosuvastatin 5-10mg

Simvastatin 20-40mg

Pravastatin 40-80mg

Lovastatin 40mg

Fluvastatin 40mg BID

High-intensity

>50%

Atorvastatin 40-80mg

Rosuvastatin 20-40mg

 

Finally…what are the new guidelines? 

****see Mayce's wonderful ATP4 diagram below****

*Don’t forget, this is simply a risk-estimator— at the end of the day, clinical judgment and patient-centered goals are crucial to starting any new intervention.

**Consider treating with statin (or increasing to high-intensity statin) in this category if:

·         Family history of premature CVD (1st degree M<55yrs, F<65yrs)

·         CRP>2mg/L

·         Coronary artery calcium score >300 Agatston units or >75th percentile for age, gender, ethnicity

·         Ankle-brachial index <0.9

Controversy!

For those of us strongly rooted in the race-as-social-construct camp, the heavy reliance on race in determination of risk calculation is tricky—particularly the markedly increased risk for patients classified as African American; per ATP-IV guidelines, in order to determine risk of patients with Asian or Hispanic descent (not specific categories in risk calculator), you should estimate risk for same-gender white individuals and assume lower-risk.  Additionally, the cut-off of ASCVD 10-year risk >7.5% is viewed as overly-aggressive by some groups.  In one subsequent analysis, the 10-year risk of having MI/stroke was overestimated by 75-150% by the risk calculator; subsequently, other expert panels have suggested that cut-offs of 10-15% may be more appropriate. 

Sources

ACC/AHA Expert Panel. 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. J Am Coll Cardiol, 2013.

ACC/AHA Expert Panel. 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, 2013.

ACC/AHA Risk Calculator: Calculator: http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp

Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet 201310.1016/S0140-6736(13)62388-0. 


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Kevin Hauck,
Mar 5, 2015, 5:16 PM
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Kevin Hauck,
Mar 5, 2015, 5:16 PM
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Kevin Hauck,
Mar 5, 2015, 5:16 PM
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