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AHA / 1 Cholesterol: Introduced the new guidelines of American cardiology companies


New Edition of the GuidelinesAmerican Heart Association (AHA) et alAmerican College of Cardiology (ACC) on cholesterol are increasingly "warts" and attaches great importance to stratification of risk in each patient to provide all appropriate therapy in terms of personal risk of developing atherosclerotic cardiovascular disease. Introduced the new concept of "risk factors". Presented at Chicago at the American Heart Association Congress, the new edition of the guides is published simultaneously on Circulation on JACC.

11 NOV "On the day of the war veterans in the United States at the congressAmerican Heart Association (AHA) ongoing in Chicago, a great classic of cardiovascular prevention is back: cholesterol treatment guidelines in the updated 2018 edition.
The 78-page document, published at circulation and the JACC, was written by task force AHA and ACC (American College of Cardiology), in collaboration with various other American science societies; to sign this new edition of the guidelines, as is the first name Scott Grundy.

High cholesterol is never good at any age, as it increases the risk of suffering a heart attack or stroke during life. The first step towards heart and vessel health, according to experts, is therefore to take an adequate lifestyle, then use the drugs according to a passive approach if the risk is too high and the LDL cholesterol levels are not aim.

This new edition of the guidelines is characterized by detailing and individualizing the patient's risk in a much more appropriate way than in the past, in order to truly personalize treatment options. One of the new strategies for risk stratification is represented by coronary calcium assessment (CAC score). Statins remain the first choice of treatment to lower LDL levels, but in those at high risk or who have already had a stroke or heart attack, the guidelines suggest adding other non-statin therapies, such as ezetimibe. and PCSK9 inhibitors.

"This update of the guidelines – comments Ivor Benjamin, president of theAmerican Heart Association – emphasizes the importance of a healthy lifestyle, the change of wrong habits, the identification and treatment of risk factors for atherosclerotic cardiovascular disease throughout life. Having high cholesterol increases this risk at any age. That's why it's so important, as a young woman, to lead a healthy life and to understand the importance of maintaining cholesterol control. "

"The treatment of hypercholesterolemia can not be unilateral," he says Michael Valentine, president of theAmerican College of Cardiology – Over the past five years, we've learned a lot about the new treatment options and which patients can benefit from. These guidelines give doctors one Roadmap and tools to help patients understand and manage the risk of living a life that is not only longer but healthier. "

These are the main ones Take your home message of the new edition:
1. It always recommends everyone to have a healthy lifestyle throughout life; this reduces the risk of atherosclerotic cardiovascular disease at any age. into the younger, a healthy lifestyle can reduce the development of risk factors and therefore form the basis for reducing the risk of atherosclerosis. into the subjects 20-39 years, a risk assessment facilitates the prevention dialogue with your doctor and emphasizes the importance of lifestyle adjustment efforts. Treatment based on lifestyle correction at all ages is the main intervention to be followed for metabolic syndrome.

2. In people with atherosclerotic cardiovascular disease (ASCVD), LDL-cholesterol should be reduced by high-intensity statin therapy or the tolerable maximum tolerated dose. The more LDL is reduced with statins, the greater the risk reduction. Therefore, the orientation of the guidelines should use the maximum tolerated dose of a statin to reduce LDL levels ≥ 50%.

3. In subjects with a very high risk of atherosclerotic cardiovascular disease(these are subjects with a history of multiple ASCVD events or an ASCVD event and multiple high risk conditions), the therapeutic target of LDL to reach is 70 mg / dl, also adding to a statin a non-statin therapy such asezetimibe. In subjects with a very high risk of LDL cholesterol ≥ 70 mg / dl, the guidelines recommend that a statin and ezetimibe Inhibitor PCSK9, "Although safety long-term (ie over 3 years) is not safe and these medications at current prices have a low profitability. "

4. In subjects with severe primary hypercholesterolaemia(LDL values> 190 mg / dl), the recommendations recommend initiating therapy with a high-dose statin, even without calculating the risk of ASCVD at 10 years. If LDL remains ≥100 mg / dl, it is advisable to add ezetimibe; if LDL was still ≥100 mg / dl despite statin therapy and ezetimibe, the recommendations recommend the addition of a PCSK9 inhibitor "although safety long-term (ie over 3 years) is not safe and these medications at current prices have a low profitability. "

5. In subjects aged 40-75 years with diabetes mellitus and LDL ≥70 mg / dl, the guidelines recommend starting with a moderate statin, even without calculating the 10-year ASCVD risk. In high-risk diabetic subjects, such as those with multiple risk factors or those aged 50 to 75 years, it is reasonable to prescribe a high-intensity statin to reduce LDL levels ≥50%.

6. In adults aged 40-75 years evaluated for the primary prevention of atherosclerotic cardiovascular disease, the physician should discuss with the patient the possibility of starting a statin therapy. The conversation will have to address all the main risk factors (smoking, hypertension, LDL, glycated hemoglobin and 10-year ASCVD risk calculation), the presence of factors that may worsen the impact of risk factors (see 8), the potential benefits of a healthy lifestyle and statins; potential side effects and drug interactions; the cost of statin therapy; Patient preferences should be taken into account in a joint decision-making process.

7. In adults aged 40-75 years without diabetes with LDL values ​​≥70 mg / dl and at 10-year ASCVD risk ≥7.5% the guidelines recommend starting treatment with a statin at moderate intensity if, after motivating the patient with the therapeutic options, the patient agreed to take a statin. The presence of risk-promoting factors suggests statin therapy. If the risk status remains uncertain, an option is to evaluate coronary calcium (see 9). If statin therapy is indicated, the therapeutic goal is to reduce LDL ≥ 30%;but if the risk of 10 years is ≥ 20% then the reduction in LDL should be ≥ 50%.

8. In adults aged 40 to 75 without diabetes and with a 10-year "intermediate" ASCVD risk (7.5% – 19.9%), the presence of risk-promoting factors suggests initiating a statin therapy. for "factors that promote risk We have in mind: a history of premature familial ASCVD, persistent LDL (≥ 160 mg / dl), metabolic syndrome, chronic kidney disease, preeclampsia or premature menopause (ie before the age of 40), chronic inflammatory disorders (such as rheumatoid arthritis, psoriasis or HIV infection); belonging to high-risk ethnic groups (such as Southeast Asia), persistent increase in triglycerides (≥ 175 mg / dl); possible increase in apolipoprotein B (≥ 130 mg / dl), high reactive C protein ≥ 2.0 mg / dl, arm index subjects with cardiovascular risk at 10 years "bordeline" (between 5% and 7.5%).

9. In adults aged 40-75 years without diabetes with LDL values ​​of ≥ 70 mg / dl to 189 mg / dl and a 10-year (10% – 7.5% – 19.9%) 10-year intermediate ASCVD risk if is not sure when statin therapy is initiated or not, coronary calcium (CAC) measurement can be used.If CAC is zero, statin treatment can be avoided and postponed, except for smokers, in diabetic subjects and in the presence of an important family history of premature ASCVD. A CAC score from 1 to 99 suggest initiation of statin therapy, especially over 55 years. Finally, statin therapy is indicated in all subjects with a CAC score of ≥ 100.

10. Assess the degree of adherence and response (in terms of baseline values) to hypocholesterolemic medications and lifestyle changes by repeatedly measuring plasma lipids4-12 weeks after starting statin therapy or after dose adjustment, which will then be repeated every 3-12 months if necessary. In very high risk subjects, an LDL value of ≥70 mg / dl should result in the addition of non-statin therapy. The guidelines recommend that you conduct your first cholesterol test between 9 and 11 years, then again around 17-21 years. At present, there is not enough evidence to give accurate advice on timing cholesterol control in young adults.

Maria Rita Montebelli

November 11, 2018
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