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Health See other Health Articles Title: Cardiovascular Risk and Cholesterol: Making Sense of the New Guidelines Medscape... Editors' Recommendations New Cholesterol Guidelines Abandon LDL Targets New CV Risk-Assessment Guidance Counts Stroke With CHD Risk New ACC/AHA/NHLBI Guidance on Lifestyle for CVD Prevention Hello. I'm Dr. Sandra Fryhofer. Welcome to Medicine Matters. The topic: highlights from the new Cardiovascular Disease Prevention Guidelines, put out by the American Heart Association (AHA) and the American College of Cardiology (ACC), copublished in the Journal of the American College of Cardiology [1] and Circulation [2]. Here's why it matters. Heart disease is the leading killer of men and women in this country. That is why the details of this new prevention package addressing risk assessment, lipids, obesity, and lifestyle are so important. One major change is a new and somewhat controversial cardiovascular risk calculator. Although some experts have criticized this new calculator, saying it could overpredict risk by as much as 75%-150%, the AHA and ACC still stand in support of this new tool. It uses pooled cohort equations and incorporates age, sex, race, total and high-density lipoprotein cholesterol (HDL-C), systolic blood pressure, use of blood pressure-lowering medications, and smoking status. It applies to African American and non-Hispanic white men and women aged 40-79 years. The new guidelines say that patients with an estimated 10-year risk for cardiovascular disease of 7.5% or higher should be placed on moderate- to high-dose statin therapy. The same-intensity statin recommendation also applies to patients with clinical cardiovascular disease, anyone with a low-density lipoprotein cholesterol (LDL-C) level of 190 mg/dL or higher, and all diabetics aged 40-75 years. Another change is the emphasis on statin dose intensity, rather than specific LDL-C treatment goals. The authors say that using treatment targets could result in undertreatment with evidence-based statin therapy, or overtreatment with the addition of nonstatin drugs that have not been shown in randomized controlled trials (RCTs) to reduce cardiovascular events. However, review of RCTs showed that most patients on high-intensity statin therapy do have LDL-C values under 100 mg/dL. High-intensity therapy reduces cardiac events more than moderate-intensity statin therapy. For greatest protection, those who need statin therapy should take doses at the maximum tolerated intensity that does not cause side effects. There are 7 statins currently available. They differ in milligram dose potency. Table 5 in the guidelines classifies the different statins according to dose and intensity. This table also reveals that the best evidence from RCTs supports the use of simvastatin, atorvastatin, and rosuvastatin. The guidelines apply to persons aged 40-79 years. No RCT primary prevention data were available for those under 40 years, and not enough data were available for those over 75 years. Consider treatment on an individual basis for patients with LDL-C levels of 160 mg/dL or higher. The guidelines also identify 4 additional markers to consider: A family history of premature heart disease in a first-degree male relative under 55 years or first-degree female relative under 65 years; High-sensitivity C-reactive protein level of 2 mg/L or more; An ankle/brachial index less than 0.90; and A coronary artery calcium score of 300 Agatston units or higher, or in at least the 75th percentile of age, sex, and ethnicity. Of these 4 markers, the evidence for coronary artery calcium scores is the strongest. Although obtaining calcium scores does involve radiation exposure, it can be a determining factor in helping to decide whether treatment is appropriate. Here are some more practice pearls from the guidelines: Lipid panel monitoring. After statin therapy is started, check lipid panels again in 4-12 weeks to determine patient adherence, but not a specific LDL-C goal. Then check every 3-12 months as clinically indicated. Both medication adherence and adherence to lifestyle regimens are important. Consider lowering the statin dose if 2 consecutive LDL-C values are less than 40 mg/dL. The guidelines also advise against high-dose (80 mg) simvastatin. Liver tests. Do check baseline liver tests, specifically alanine aminotransferase (ALT), before starting therapy. But there is no recommendation for continued routine liver test monitoring. Recheck liver tests during therapy in patients with symptoms of liver toxicity, including unusual fatigue, weakness, loss of appetite, abdominal pain, dark-colored urine, or yellowing of the skin or sclera. Creatine kinase. There is no need to routinely check creatine kinase (CK). Check CK levels only in those with or at increased risk for adverse muscle symptoms. Statins and diabetes. Patients placed on statins should be monitored for new-onset diabetes, but even if they do develop diabetes, they should still continue taking statins. Statins are pregnancy category X, and women of childbearing age who take them should be using contraception and should not be nursing. Check out the full guidelines. There are many helpful tables and algorithms. The level of supporting evidence is also made clear for each recommendation. Dr. Emmanuel D. Zachariadis| Cardiology, General: This insane "statinmania" is being pushed by the pharmaceutical companies and their "oppinion leading" advocates.If it were up to them we would give statins to infants as well as people over 100 years old. All available evidence clearly reveal that any benefits from statin therapy is in infact UNRELATED to their cholesterol-LDL lowering properties but rather part of their inflammatory and other "pleiotropic" actions.Statins certainly have a role in secondary prevention but in primary prevention their benefit are scarce at best.(NNT= 100 in ASCOT -LLA).If the LDL -C lowering action would be of any value per se ,why is it that drugs like Ezetimibe have shown no clinical benefit whatsoever even though they do indeed lower LDL substantially ? Primary prevention clinical results provoke the possibility of not only the lack of primary cardiovascular protection by statin therapy but highlight the very real possibility of augmented cardiovascular risk in women, patients with Diabetes Mellitus and the young . Statins are associated with triple the risk of coronary artery and aortic calcification. These finding on statin major adverse effects had been under-reported and the way in which they withheld from the public, and even concealed, is a scientific farce. Dr. Cynthia Dalton| Physician: Why such a push on statins which are expensive, dangerous drugs. Plus including age in a calculation for prescribing a medicine means that everyone over a certain age will have a risk score higher than the baseline for statin use. Why in the world would someone suddenly need a statin just because they had a birthday???!!! I would like to see some strong evidence that statins for people with normal blood lipid panels is actually helpful when all complications from the drugs is taken into account. Rhabdomyolisis is not a laughing matter and is hard for the patient to recognize. It can cause permanent kidney damage if not treated promptly. Maybe it is because of my surgical training but I would be very hesitant to put any patient on any drug for life without a much longer follow-up period than we have had for statins. For people who do not have a familial hyper lipidosis, I would be much more comfortable with lifestyle changes such as smoking cessation, diet modification as necessary and exercise for a significant trial period, before adding statins. i am concerned that many patients see these drugs as an excuse to eat whatever they want to instead of adding them to a good diet regimin only when that does not adequately control lipid levels. Poster Comment: J...It is time we looked at reality. Then of course there is the only long term follow up study (>10 years) on what happens when you give people statins: PROSPER sept 2013, which showed that while statins caused fewer heart attacks more people died in the active group than the placebo. Add to that the prospective population based study (Honolulu heart study 2001) which showed that those with the highest cholesterol lived longest and those with the lowest cholesterol died soonest, reflected in other population based studies also. Then there is the ICU study 23 Oct 13 which had 15.2% deaths in placebo group and 21.2% deaths in statin group! In my clinic 9:10 patients have a myopathy shown not with blood tests but by a simple neurology exam. Using the standard 5:5 power test, patients range from 3:5 to 4:5 in triceps and biceps muscles. 6 weeks off the statin and on coQ 10 (150mg/day) and most (but not all) will be back to 5:5 power. Here is to true evidence-based medicine. Charles Wilson| Pharmacist Once again I'll say 750 mg of otc niacin made my Iranian LDL 34 and my trigs 34. I'm pretty sure that was too low Post Comment Private Reply Ignore Thread Top • Page Up • Full Thread • Page Down • Bottom/Latest
#1. To: Tatarewicz (#0)
There are some people that die of heart attacks who have perfectly clean arteries. Doctors don't have a clue what caused these people to have fatal heart attacks.
God is always good!
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