2013 ACC/AHA Guidelines:Blood Cholesterol And

Assessment of Cardiovascular Risk

Elena Kuklina, MD, Ph.D.Senior Service Fellow

State Grantee Webinar, Hypertension, Cholesterol and Sodium Guidelines: Implications for

Cardiovascular Health February 12, 2014

National Center for Chronic Disease Prevention and Health Promotion

Division for Heart Disease and Stroke Prevention

Background

ACC/AHA published new cholesterol and cardiovascular risk assessment guidelines in 2013. 1

This is an overview of the 2013 ACC/AHA guidelines and a comparison to preceding guidelines.

1. Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print November 12 2013]. Circulation. 2013. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98.citation. Accessed February 3, 2014.

ATP III Lipid and Lipoprotein Classification

(The “Old Familiar Classification”)

LDL Cholesterol (mg/dL)

<100 Optimal100–129 Near optimal/above optimal130–159 Borderline high160–189 High190 Very high

Old vs. New: Lifestyle Modification

Old guidelines: Diet: low fat and

low cholesterol

New guidelines:Diet: healthy patternDASH, USDA , AHA DietCalorie requirements, personal and cultural preferences, and nutrition therapy for other medical conditions

regular exercise habits avoidance of tobacco products maintenance of a healthy weight

Old vs. New: Statin Eligibility

Old NewAge Statin eligible

groups

1 ≥21 years Clinical CVD

2 ≥21 years LDL-C ≥190 mg/dl

3 40-75 years +LDL-C 70-189 mg/dl

Diabetes

4 40-75 years + LDL-C 70-189 mg/dL

High CVD risk

≥7.5%, 10 years, CHD or stroke

Determining Risk for the 4th Group

New Pooled Cohort Equations to estimate 10-year risk Adults 20-79 years of age who are free from ASCVD 4 racially and geographically diverse cohorts ASCVD risk: heart disease and stroke Calculated from sex, age, race, total cholesterol, HDL

cholesterol, systolic blood pressure, and whether on treatment for high blood pressure, has diabetes, or is a smoker

See Flowchart (addendum)

New: Classification of Statin Intensity

Intensity of statin therapy: is defined as a daily dose that lowers LDL-C by

High-intensity: by 50%

Moderate-intensity: by 30% to <50%

New: Intensity Instead of Levels

What about the Rest?

There are people who may benefit from statin therapy who do not fall into one of the four groups.

As with other guidelines, clinicians may use their judgment in considering other factors such as:• family history of ASCVD. biomarkers such as C - reactive protein. ankle-brachial index, etc.

Summary

Statin is the first line therapy. Statin eligible groups based on benefit, not only on the LDL-C

measurement. Treatment is based on statin intensity instead of specific

treatment goals for blood cholesterol. New global risk assessment tool.

Healthy Dietary Patterns (servings per day unless specified) (2000 kcal)

Implications

High cholesterol is a major and controllable risk factor for heart attacks and strokes.

One goal of the ACC/AHA guidelines is to better identify and focus statin therapy on those who are most at risk for (or have) ASCVD.

Implications

We have much room for improvement for increasing the level of healthy lifestyles and statin therapy even among those most at risk.

We can use the guidelines to identify those who do not yet know they are at risk, and increase healthy lifestyle choices and statin therapy for those who are.

Program Considerations

New performance measures for cholesterol are in the development phase.

Right now, we can: Increase adaptation of healthy lifestyle and levels statin

therapy for those who do know they are at risk. Help them adhere to that therapy for the rest of their longer

lives.

Sources

Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print November 12 2013]. Circulation. 2013. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437741.48606.98.citation. Accessed February 3, 2014.

Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online ahead of print November 12 2013]. Circulation. 2013. http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.citation. Accessed February 3, 2014.

Journal of American College of Cardiology. 2013. http://www.sciencedirect.com/science/article/pii/S0735109713060282. Accessed February 3, 2014

Education materials for patients

“Getting Healthy” by AHA: https://www.heart.org/HEARTORG/GettingHealthy/GettingHealthy_UCM_001078_SubHomePage.jsp

“Chose my plate” by USDA: http://www.choosemyplate.gov/

“Lowering your blood pressure with DASH” by NIH” https://www.nhlbi.nih.gov/health/health-topics/topics/dash/

Thank you!

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for Chronic Disease Prevention and Health PromotionDivision for Heart Disease and Stroke Prevention