ACP Evidence Based Lipid Practice Case Rubric Case Study read the case study and answer the questions in the word document using the posted guidelines 2018

ACP Evidence Based Lipid Practice Case Rubric Case Study read the case study and answer the questions in the word document using the posted guidelines 2018
AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/
NLA/PCNA
Guideline on the Management of Blood Cholesterol:
Executive Summary
Citation
This slide set is adapted from the 2018
AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/AP
hA/ASPC/NLA/PCNA Guideline on the Management
of Blood Cholesterol: Executive Summary. Published
on [Date], available at: Journal of the American
College of Cardiology [(insert full link)] and Circulation
[(insert full link)]
The full-text guidelines are also available on the
following Web sites: ACC (www.acc.org) and
AHA (professional.heart.org)
2018 Cholesterol Guideline Writing Committee
Scott M. Grundy, MD, PhD, FAHA, Chair
Neil J. Stone, MD, FACC, FAHA, Vice Chair
Alison L. Bailey, MD, FACC, FAACVPR†
Daniel W. Jones, MD, FAHA§
Craig Beam, CRE*
Donald Lloyd‐Jones, MD, SCM, FACC, FAHA*
Kim K. Birtcher, MS, PharmD, AACC, FNLA‡
Nuria Lopez‐Pajares, MD, MPH§§
Roger S. Blumenthal, MD, FACC, FAHA, FNLA§
Chiadi E. Ndumele, MD, PhD, FAHA*
Lynne T. Braun, PhD, CNP, FAHA, FPCNA, FNLA║
Carl E. Orringer, MD, FACC, FNLA║║
Sarah de Ferranti, MD, MPH*
Carmen A. Peralta, MD, MAS*
Joseph Faiella‐Tommasino, PhD, PA‐C¶
Joseph J. Saseen, PharmD, FNLA, FAHA¶¶
Daniel E. Forman, MD, FAHA**
Sidney C. Smith, Jr, MD, MACC, FAHA*
Ronald Goldberg, MD††
Laurence Sperling, MD, FACC, FAHA, FASPC***
Paul A. Heidenreich, MD, MS, FACC, FAHA‡‡
Salim S. Virani, MD, PhD, FACC, FAHA*
Mark A. Hlatky, MD, FACC, FAHA*
Joseph Yeboah, MD, MS, FACC, FAHA†††
*ACC/AHA Representa ve. †AACVPR Representa ve. ‡ACC/AHA Task Force on Clinical Prac ce Guidelines Liaison. §Prevention
Subcommittee Liaison. ║PCNA Representa ve. ¶AAPA Representa ve. **AGS Representa ve. ††ADA Representa ve. ‡‡PM Representa ve.
§§ACPM Representative. ║║NLA Representa ve. ¶¶APhA Representa ve. ***ASPC Representa ve. †††ABC Representa ve
Table 1. Applying Class
of Recommendation and
evel of Evidence to
Clinical Strategies,
Interventions,
Treatments, or
Diagnostic Testing
in Patient Care*
(Updated August 2015)
Top 10 Take‐Home Messages
2018 Cholesterol Guidelines
Top 10 Take Home Messages
1. In all individuals, emphasize a heart‐
healthy lifestyle across the life course.
A healthy lifestyle reduces atherosclerotic cardiovascular
disease (ASCVD) risk at all ages. In younger individuals,
healthy lifestyle can reduce development of risk factors
and is the foundation of ASCVD risk reduction.
In young adults 20 to 39 years of age, an assessment of
lifetime risk facilitates the clinician–patient risk discussion
(see No. 6) and emphasizes intensive lifestyle efforts. In all
age groups, lifestyle therapy is the primary intervention
for metabolic syndrome.
Top 10 Take Home Messages
2. In patients with clinical ASCVD, reduce low‐
density lipoprotein cholesterol (LDL‐C) with
high‐intensity statin therapy or maximally
tolerated statin therapy.
The more LDL‐C is reduced on statin therapy, the greater
will be subsequent risk reduction.
Use a maximally tolerated statin to lower LDL‐C levels by
≥50%.
Top 10 Take Home Messages
3. In very high‐risk ASCVD, use a LDL‐C threshold of 70
mg/dL (1.8 mmol/L) to consider addition of nonstatins
to statin therapy.
•
•
•
Very high‐risk includes a history of multiple major ASCVD events or 1
major ASCVD event and multiple high‐risk conditions.
In very high‐risk ASCVD patients, it is reasonable to add ezetimibe to
maximally tolerated statin therapy when the LDL‐C level remains ≥70
mg/dL (≥1.8 mmol/L).
In patients at very high risk whose LDL‐C level remains ≥70 mg/dL (≥1.8
mmol/L) on maximally tolerated statin and ezetimibe therapy, adding
a PCSK9 inhibitor is reasonable,
although the long‐term safety (>3 years) is uncertain and cost‐
effectiveness is low at mid‐2018 list prices.
Top 10 Take Home Messages
4. In patients with severe primary hypercholesterolemia
(LDL‐C level ≥ 190 mg/dL[≥4.9 mmol/L]) without
calculating 10‐year ASCVD risk, begin high‐intensity
statin therapy without calculating 10‐year ASCVD
risk.
•If the LDL‐C level remains ≥100 mg/dL (≥2.6 mmol/L),
adding ezetimibe is reasonable
• If the LDL‐C level on statin plus ezetimibe remains ≥100 mg/dL
(≥2.6 mmol/L) & the patient has multiple factors that increase
subsequent risk of ASCVD events, a PCSK9 inhibitor may be
considered,
although the long‐term safety (>3 years) is uncertain and economic value
is low at mid‐2018 list prices.
Top 10 Take Home Messages
5. In patients 40 to 75 years of age with diabetes
mellitus and LDL‐C ≥70 mg/dL (≥1.8 mmol/L),
start moderate‐intensity statin therapy
without calculating 10‐year ASCVD risk.
In patients with diabetes mellitus at higher risk,
especially those with multiple risk factors or
those 50 to 75 years of age, it is reasonable to
use a high‐intensity statin to reduce the LDL‐C
level by ≥50%.
Top 10 Take Home Messages
6. In adults 40 to 75 years of age evaluated for primary
ASCVD prevention, have a clinician–patient risk
discussion before starting statin therapy.
Risk discussion should include a review of major risk
factors (e.g., cigarette smoking, elevated blood pressure, (LDL‐C),
hemoglobin A1C [if indicated], and calculated 10‐year risk of ASCVD);
•
•
•
•
•
the presence of risk‐enhancing factors (see No. 8);
the potential benefits of lifestyle and statin therapies;
the potential for adverse effects and drug–drug interactions;
the consideration of costs of statin therapy; and
the patient preferences & values in shared decision‐making.
Top 10 Take Home Messages
7. In adults 40 to 75 years of age without diabetes
mellitus and with LDL‐C levels ≥70 mg/dL (≥1.8
mmol/L), at a 10‐year ASCVD risk of ≥7.5%, start a
moderate‐intensity statin if a discussion of
treatment options favors statin therapy.
Risk‐enhancing factors favor statin therapy (see No. 8).
If risk status is uncertain, consider using coronary
artery calcium (CAC) to improve specificity (see No.
9). If statins are indicated, reduce LDL‐C levels by
≥30%, and if 10‐year risk is ≥20%, reduce LDL‐C levels
by ≥50%.
Top 10 Take Home Messages
8. In adults 40 to 75 years of age without diabetes mellitus and
10‐year risk of 7.5% to 19.9% (intermediate risk), risk‐
enhancing factors favor initiation of statin therapy (see No. 7).
Risk‐enhancing factors include
• family history of premature ASCVD;
• persistently elevated LDL‐C levels ≥160 mg/dL (≥4.1 mmol/L);
• metabolic syndrome;
• chronic kidney disease;
• history of preeclampsia or premature menopause (age
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