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Lipid Guideline Controversies
Lipid Guideline Controversies
Lipid Guideline Controversies
Objectives
To provide an overview of the American
College of Cardiology/American Heart
Association and the National Lipid
Association lipid management
approaches for ASCVD prevention
To identify the similarities and differences
between the two approaches
To provide the information needed to
decide which approach to use and when
External reviewer
Author
Release of NCEP
ATP III
Release of NCEP
ATP III Update
10.1371/journal.pone.0063416
CCS
IAS
EAS/ESC
JAS
NICE
NLA
ACC/AHA
Changes in:
Evidence base
Central focus
Lipid goals
Use of non-statins
Risk calculator
The Rules
The topic will be identified
Common ground and
differences will be noted
Appropriate supporting
evidence will be introduced
Summary will be provided
You make the decision
Evidence Base
ACC/AHA
Randomized
controlled trials
(RCT) of statin
therapy
Meta-analyses of
RCT
NLA
RCT of statins and
non-statin drug
therapy
Meta-analyses of RCT
Observational
epidemiologic studies
Genetic studies
Metabolic studies
Mechanistic studies
Genetic Studies
Genetic epidemiology reduces the
likelihood of confounding by focusing on
single variables: genetic mutations
Identification of specific mutations may
serve to generate hypotheses for other
types of trials
Often limited in patient selection and
costly
NLA
By including evidence from RCT and other
sources, a broader evidence base for clinical
decision making is employed . This approach is
consistent with the perspective of previous
NCEP ATPs and the international community
Identification
of an
Central Focus of
Guideline
Identification of statin
ACC/AHA
benefit
groups
Initiation and
maintenance of high
or moderate intensity
statin therapy
Abandonment of lipid
goals
Avoidance of nonstatin therapy
because of
unfavorable
risk/benefit ratio.
individual patients
ASCVD risk
based on
NLA
clinical parameters and
risk factors
Initiation of ASCVD riskbased lipid-lowering
therapy
Maintenance of lipid goals
to assess effective
reduction of atherogenic
lipoproteins and enhace
adherence
Use of high or moderate
dose statins, nonstatins, if necessary, to
achieve goals
50%)
Atorvastatin 10 (20)
mg
Rosuvastatin (5) 10
mg
Simvastatin 2040
mg
Simvastatin 80 mg*
Pravastatin 40 (80)
mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Fluvastatin 40 mg
2x/day
Criteria
Very High
ASCVD
Diabetes mellitus (type 1 or 2)
2 other major ASCVD risk
factors; or
Evidence of end-organ
damage
High
Moderate
Consider Drug
Therapy
Treatment Goal
Non-HDL-C /LDL-C
Goal (mg/dL)
Non-HDL-C/LDL-C
Goal (mg/dL)
Very-high
100
70
<100
<70
High
130
100
<130
<100
Moderate
160
130
<130
<100
Low
190
160
<130
<100
NLA Perspective on
Non-Statin Lipid Drug Therapy
If non-HDL-C and LDL-C goals are not achieved with
maximal tolerated statin therapy, the addition of
non-statin therapy should be considered to lower
atherogenic cholesterol levels and to achieve goals
Doctors can be instructed not to use niacin in patients on
aggressive statin regimens
As ezetimibe is safe and lowers atherogenic cholesterol,
its use may be considered in selected patients with
elevated
non-HDL-C and/or LDL-C
Resins may be considered in selected patients
Meta-analyses of fibrate therapy in subgroups with
atherogenic dyslipidemia suggest ASCVD risk reduction
From TNT,
SPARCL, IDEAL and
JUPITER
demonstrating
variability of
LDL-C lowering.
>40% did not achieve
LDL-C <70 mg/dl on
atorvastatin 80 or
rosuvastatin 20 mg
daily
Non-HDL-C
1.00 1.00
0.89
0.57
0.60
0.51
0.64
0.56
0.69
0.58
0.75
0.64
0.44
0.71
Risk Calculators
ACC/AHA
Use Pooled Cohort Risk
calculator in non-Hispanic
Whites and non-Hispanic
African Americans age 4079 without ASCVD and not
on statin therapy; may be
considered in other
populations
Assessment of lifetime risk
may be considered in those
aged 20-59 with no ASCVD
and not at high short-term
risk
NLA
Consider 10-year FRS,
ACC/AHA Pooled
Cohort Risk calculator,
or 30-year risk in
those with 2 major
ASCVD risk factors; reclassify to higher risk
those with 10% 10year FRS, 15%
ACC/AHA risk, or
45% long-term risk
ttp://www.tools.cardiosource.org/ascvd-risk-estimator
Total
cholest
erol
HDL
cholest
erol
Systolic
BP
Treatme
nt for
HBP
Diabete
s
Smoker
10-year
ASCVD
risk
60
AA
170
50
125
No
No
No
7.5%
65
AA
178
50
130
No
No
No
7.5%
60 C
170
47
125
No
No
No
7.5%
Risk Calculators
ACC/AHA
Use Pooled Cohort Risk
calculator in non-Hispanic
whites and non-Hispanic
African Americans age 4079 without ASCVD and not
on statin therapy; may be
considered in other
populations
Assessment of lifetime risk
may be considered in those
aged 20-59 with no ASCVD
and not at high short-term
risk
NLA
ACC/AHA
NLA