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PostPosted: 19 May 2014 06:01 
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Clinical Guidelines | 4 March 2014

Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Synopsis of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline
Neil J. Stone, MD; Jennifer G. Robinson, MD, MPH; Alice H. Lichtenstein, ScD; David C. Goff Jr., MD, PhD; Donald M. Lloyd-Jones, MD, ScM; Sidney C. Smith Jr., MD; Conrad Blum, MD; J. Sanford Schwartz, MD, for the 2013 ACC/AHA Cholesterol Guideline Panel*

Ann Intern Med. 2014;160(5):339-343. doi:10.7326/M14-0126 This article was published online first at http://www.annals.org on 28 January 2014.
Abstract | Guideline Development Process | Recommendations | Summary | Appendices | References
Description: In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical practice guideline on the treatment of blood cholesterol to reduce cardiovascular risk in adults. This synopsis summarizes the major recommendations.

Methods: In 2008, the National Heart, Lung, and Blood Institute convened the Adult Treatment Panel (ATP) IV to update the 2001 ATP-III cholesterol guidelines using a rigorous process to systematically review randomized, controlled trials (RCTs) and meta-analyses of RCTs that examined cardiovascular outcomes. The panel commissioned independent systematic evidence reviews on low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol goals in secondary and primary prevention and the effect of lipid drugs on atherosclerotic cardiovascular disease events and adverse effects. In September 2013, the panel's draft recommendations were transitioned to the ACC/AHA.

Recommendations: This synopsis summarizes key features of the guidelines in 8 areas: lifestyle, groups shown to benefit from statins, statin safety, decision making, estimation of cardiovascular disease risk, intensity of statin therapy, treatment targets, and monitoring of statin therapy.
Summary
Abstract | Guideline Development Process | Recommendations | Summary | Appendices | References
Millions of U.S. adults are at increased ASCVD risk—some because they have had an ASCVD event, others because of ASCVD risk factors. Adherence to healthy lifestyle behaviors, control of blood pressure and diabetes, and avoidance of smoking is recommended for all adults. Statin therapy should be used to reduce ASCVD risk in individuals likely to have a clear net benefit (those with clinical ASCVD) or in primary prevention for adults with LDL-C levels ≥190 mg/dL, those aged 40 to 75 years with diabetes, and those with a 10-year ASCVD risk ≥7.5% without diabetes. A clinician–patient discussion that considers potential ASCVD risk reduction, adverse effects, and patient preferences is needed to decide whether to initiate statin therapy, especially in lower-risk primary prevention.

Appropriate intensity of statin therapy based on ASCVD risk and potential for adverse effects is recommended rather than focusing on specific LDL-C or non–HDL-C goals. Five of the 7 statins marketed in the United States, including a high-intensity statin, are available as low-cost generics.

The Pooled Risk Equations, which were developed in a geographically diverse sample of African Americans and non-Hispanic whites, identify adults at increased risk for an ASCVD event (including stroke as well as heart disease). They represent important steps forward in the ability to match intensity of preventive treatment to level of ASCVD risk. These risk equations will be reevaluated and revised as additional information becomes available, including research assessing other potentially useful markers of ASCVD risk and data required to develop equations specific to other ethnic groups.

Until heart-healthy lifestyles are adopted throughout the lifespan, the need for preventive measures using evidence-based drug therapy will remain high. As with all clinical guidelines, the 2013 ACC/AHA cholesterol guidelines must be implemented in conjunction with sound clinical judgment. These evidence-based recommendations focus statin treatment on patients likely to obtain the greatest benefit, thereby reducing the ASCVD burden in adults

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PostPosted: 20 May 2014 01:08 
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Thank you Raghu,

Took me quite while to read the full document. The following are some of my views.

What’s New in the Guideline?

1 Focus on ASCVD Risk Reduction: 4 statin benefit groups .

• Based on a comprehensive set of data from RCTs that identified 4 statin benefit groups which focus
efforts to reduce ASCVD events in secondary and primary prevention.

• Identifies high-intensity and moderate-intensity statin therapy for use in secondary and primary
prevention.

2 A New Perspective on LDL–C and/or Non-HDL–C Treatment Goals

• The Expert Panel was unable to find RCT evidence to support continued use of specific LDL–C and/or
non-HDL–C treatment targets.
The appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most likely to
benefit.


Nonstatin therapies do not provide acceptable ASCVD risk reduction benefits compared to their potential
for adverse effects in the routine prevention of ASCVD
.

3 Global Risk Assessment for Primary Prevention
• This guideline recommends use of the new Pooled Cohort Equations to estimate 10-year ASCVD risk in
both white and black men and women.

• By more accurately identifying higher risk individuals for statin therapy, the guideline focuses statin
therapy on those most likely to benefit.

• It also indicates, based on RCT data, those high-risk groups that may not benefit.

Before initiating statin therapy, this guideline recommends a discussion by clinician and patients.

4 Safety Recommendations

• This guideline used RCTs to identify important safety considerations in individuals receiving treatment
of blood cholesterol to reduce ASCVD risk.

• Using RCTs to determine statin adverse effects facilitates understanding of the net benefit from statin
therapy.

Provides expert guidance on management of statin-associated adverse effects, including muscle
symptoms.


5 Role of Biomarkers and Noninvasive Tests
• Treatment decisions in selected individuals who are not included in the 4 statin benefit groups may be
informed by other factors as recommended by the Risk Assessment Work Group guideline.

6 Future Updates to the Blood Cholesterol Guideline
• This is a comprehensive guideline for the evidence-based treatment of blood cholesterol to reduce
ASCVD risk.
• Future updates will build on this foundation to provide expert guidance on the management of this multifactorial aspect of the issue on hand.

Dr G Mohan.

See also below.


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PostPosted: 20 May 2014 01:16 
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Majority of panelists on controversial new cholesterol guideline have current or recent ties to drug manufacturers

BMJ 2013;347:f6989
The chairman and one of two additional co-chairs of the working panel that wrote the controversial cholesterol guidelines on reducing cardiovascular risk, released last week,1 2 had ties to the drug industry at the time they were asked to lead the panel. And, in all, eight of the 15 panelists had industry ties.

The chairman, Neil J Stone, professor of medicine at the Feinberg School of Medicine, Northwestern University, Chicago, told the BMJ, “When I was asked by NHLBI [the National Heart, Lung and Blood Institute] to chair the [cholesterol] panel, I immediately severed ties with all industry connections prior to assuming my role as chair.”

He severed those ties in May 2008. Later he had to complete a disclosure statement regarding financial ties to industry, and in response to the question regarding his ties from 2008 to 2012 he wrote “None.”

David Newman, a physician researcher at the Icahn School of Medicine at Mt Sinai in New York City, told the BMJ that dropping industry ties on taking up such roles without declaring these previous ties was against the spirit of competing interests declarations.

This was published in the British Medical Journal, one week after the guideline.

Stone acknowledged to the BMJ that before being empanelled he had financial ties to Abbott, AstraZeneca, Merck, Pfizer, Sanofi-Aventis, and Schering-Plough, and he had served as a consultant to Abbott, AstraZeneca, Merck, Pfizer, Reliant, Schering-Plough, and Sonaste. All six corporations to which Stone had financial ties make drugs to treat hyperlipidemia.

Dr G Mohan.

I do not think this should detract from the strength of the Guideline. Because of the reasons , as i see it as below.

See Below for more !!?


Last edited by gmohan on 20 May 2014 01:25, edited 1 time in total.

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PostPosted: 20 May 2014 01:24 
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A well written and thoroughly researched , evidence supported document.

The salient points to address and apply are as follows:

1. The clear advise to move away from treating just Cholesterol numbers, towards a wholesome approach to practice.

2. Defining the distinction between Primary Prevention , and the decisive methodologies to manage Secondary Prevention in cardiovascular diseases.

3. A somewhat controversial recommendation in Primary prevention for the population , on risk assessment to aim at management of ages starting at 45 years

4. And also to aim at 7.5% risk in over 10yrs in Non Diabetics, in the population at large.

5. In my view correctly , focussing on the best evidenced drugs : Statins.

6. Particularly welcome is the distinctions of the Potency of the Statins.

7. The need to manage each individual , based on sound clinical judgment , and with well informed joint decision making between doctor and patient.

8. The European guidelines of 2013, and the Internationally well respected UK guidelines of 2014 do not differ too widely . We can compare all these if needed by our fora.

9. We need to utilize all these documents and also our own extensive experience that we have collectively , in applying guidance from USA and Europe , to manage and treat people in Asia- particularly India.

Thank you again.

Dr G Mohan.


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PostPosted: 20 May 2014 02:37 
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Hi Mohan,
Thank you for a well researched discussion on the subject. My take is pretty similar to yours and the last paragraph summarizes the message, that heart healthy lifestyle starting at a very young age is of paramount importance. Fast foods, food additives and substitutions with complex carbs,sedentary life style are just some of the culprits. A selective drug that can triple or quadruple the HDL without any side effects would be an answer.

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