ACC/AHA Guidelines Not the Final or Only Word

Contemporary Guidelines 2011-14

National Cholesterol Education Program Adult Treatment Panels (ATP)

NCEP ATP III (2002) Expanded Risk Groups

ATP III (continued)

ATP III: Increased emphasis on Non-HDL Cholesterol when TG >= 200

Updates to ATP III: More intensive LDL-C Goals for Higher Risk Patients.

ATP III- Treat to Target Based on Risk

Recommendation 2: Use Statins in these 4 Groups Regardless of Lipid Levels

Recommendation 3: Use Only Evidence Based Statin Doses

Definition of High, Moderate and Low Intensity Statin Agents and Doses

Recommendation 4: Non-Statin Medication NOT Generally Recommended

Recommendation 5: No LDL or non-HDL Goals

Committee’s Rationale for Doing Away with Treatment Targets

Recommendation 6: Use New GLOBAL RISK- Assessment for Primary Prevention

Committee’s Rationale for Using 7.5% Global Risk Cut-off (as opposed to cholesterol Levels)

Controversy Concerning Global Risk (Pooled Cohort) Calculator

Recommendation 7: Consider Emerging Risk Factors in Some Patients

NLA Expert Panel: Clinical Utility of Inflammatory Markers and Advanced Lipid Testing

Recommendation 8: Put Statin Safety in Context

Population Health Aspects of 2013 ACC/AHA Guidelines

American Diabetes Association/American College of Cardiology Consensus Statement

American Diabetes Association (ADA) Lipid Goals and Treatment

American Association of Clinical Endocrinologists (AACE) Guidelines 2013

European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)

Risk Assessment

European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)

Treatment Targets

European Society of Cardiology/European Atherosclerosis Society (ESC/EAS)

Drug Therapy

IAS(International Atherosclerosis Society) Atherogenic Cholesterol

IAS(International Atherosclerosis Society) Focus on Long Term (Not 10 year) Risk of ASCVD (Up to age 80)

IAS(International Atherosclerosis Society) Drug Therapy: Primary Prevention

IAS(International Atherosclerosis Society) Drug Therapy: Secondary Prevention

Comparison of Recent Major Guidelines UP TO 2013

NLA Recommendation (2014) Targets of Therapy

NLA Recommendations (2014 Stepwise Approach to ASCVD Risk Assessment

NLA Recommendations (2014) Other Risk Indicators- Consider for Refinement of Risk

NLA Recommendations (2014) Initiate Therapy Based on Risk and Lipid Levels and Treat to Specific Goal

NLA Recommendations (2014) Drug Therapy Considerations

KDIGO (Kidney Disease Improving Global Outcomes) 2013

• CKD IS CONSIDERED A CHD RISK … the following are the categories and recommendations

• 1A -statin or statin/ezetimibe in aged>506o with eGFR<60ml/min not on HD or transplant

• 1B -statin in adult >50yo with eGFR > 60• 2A -recommend a statin if >1 of the following & aged is 18-49 (not HD or

transplant) - CAD, CVA, DM, 10 yr coronary death > 10%• 2A – statin or statin/ezetimibe (not recommended with HD)• 2C -lipid-lowering agent should be continued if already receiving at time of HD• 2A – Treatment w a statin is suggested in adult recipients of kidney transplants• 2D -Triglyceride lowering recommended in CKD & HD or kidney transplants

• Don’t initiate statins with HD patients, but continued maintenance ok if it does• Not interfere with antirejection medications.

IMPROVE-IT RANDOM CONTROLLED TRIAL

• Took 18,000 patients who had experienced an acute coronary syndrome within the past 10 days and put them on EITHER… simvastatin 40mg monotherapy or

• Simvastatin 40mg + ezetimibe 10 mg daily.

• There was a 24% further lowering of LDL with the combination• 13% relative risk reduction in MI• 21% reduction in ischemic stroke• 10% reduction in CV death, nonfatal MI, or nonfatal stroke.• LDL reduction… hazard ratio 0.8

• Weakness: In real life, an intensive therapy statin would have been used.

AIM-HIGH • To establish a role of niacin in the setting of intensive LDL control.. 3400

pts with ASCVD received simvastatin with or without ezetimibe were randomized to receive either 1500-2000mg niacin/day or placebo.

• Patient population had very low levels of etherogenic lipoproteins and did not represent the patient population.

• Results: Niacin did not help when combined with statins.

HPS2-THRIVE• Similar to AIM-HIGH… study compared simvastatin 40mg alone or with ezetimibe

10mg (but added laropiprant to reduce flushing response.)

• RESULTS:• Increased HDL and decreased LDL• NO DIFFERENCE in major vascular events• Group with niacin experienced increased adverse effects• Hazards- DM control, new DM, GI effects, myopathy, skin-related events, infection,

and bleeding.

Alirocumab (trade name Praluent)• is a biopharmaceutical drug approved by the FDA on July 24, 2015 as a second line

treatment for high cholesterol for adults whose cholesterol is not controlled by diet and statin treatment. It is a human monoclonal antibody that belongs to a novel class of anti-cholesterol drugs, known as PCSK9 inhibitors, and it was the first such agent to receive FDA approval

• Alirocumab is used as a second line treatment to lower LDL cholesterol for adults who have a severe form of hereditary high cholesterol and people with atherosclerosis who require additional lowering of LDL cholesterol when diet and statin treatment have not worked. It is administered by subcutaneous injection.[3] As of July 2015, it is not known whether alirocumab prevents early death from cardiovascular disease or prevents heart attacks.

• Alirocumab works by inhibiting the PCSK9 protein. PCSK9 binds to the low-density lipoprotein receptor (LDLR) (which takes cholesterol out of circulation), and that binding leads to the receptor being degraded, and less LDL cholesterol being removed from circulation. Inhibiting PCSK9 prevents the receptor from being degraded, and promotes removal of LDL cholesterol from circulation

Latest JNC8 guidelines

JNC 8 Therapy