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AHA / 1 Cholesterol: American cardiology companies have submitted new guidelines

New edition of manualsAmerican Heart Association (AHA) andAmerican College of Cardiology Cholesterol (ACC) is increasingly becoming a & dquo; In addition, it places great importance on risk stratification to give the right treatment for the risk of developing atherosclerotic cardiovascular disease in an individual patient. He introduced the concept of ı factors that increase risk “. The new edition of the guidelines, presented at the American Heart Association congress in Chicago, was simultaneously published in JACC.

11 NOVEMBER – On the day of congress dedicated to war veterans in the United StatesAmerican Heart Association A major cardiovascular prevention classic in Chicago continues to return: guidelines for the treatment of cholesterol in the updated 2018 edition.
78-page document published on circulation and JACC, written by. task force AHA and ACC (American College of CardiologyIn cooperation with other American scientific societies; to sign this new edition of the first name Scott Grundy.

High cholesterol is never good at any age because it increases the risk of heart attack or stroke during life. Therefore, the first step of the ships according to the health of the heart and experts; pioneerThen use the drugs, according to a step approach, if the risk is too high and LDL cholesterol levels target.

This new edition of the guidelines is characterized by detailing and personalizing patient risk in a much shorter time than in the past to truly customize treatment options. One of the new risk classification strategies, Evaluation of coronary calcium (CAC) score). Statins continue to be the first treatment option to lower LDL levels, but in those who are at high risk or have had a previous stroke or a heart attack, the guidelines recommend the addition of other nonin statin therapy, such as ezetimibe. and PCSK9 inhibitors.

"This update of the rules – reviews Ivor BenjaminchairmanAmerican Heart Association – Emphasizes the importance of a healthy lifestyle, changing the wrong habits, identifying and treating risk factors during the life of atherosclerotic cardiovascular diseases. High cholesterol increases this risk at any age. It is therefore very important that you live a healthy life as a young person and understand the importance of keeping cholesterol under control. "

"Hypercholesterolemia treatment cannot be unilateral" says Michael ValentinechairmanAmerican College of Cardiology – In the last five years, we've learned a lot about new treatment options and what patients can take advantage of. These rules offer doctors one road map and tools to help their patients understand and manage the risk of a healthy life, not only longer. "

These are the main ones get home message new edition
one. I propose to everyone a healthy lifestyle throughout life; This reduces the risk of atherosclerotic cardiovascular disease at any age. in smallA healthy lifestyle may reduce the development of risk factors and therefore constitute the basis for reducing atherosclerotic risk. in 20-39 years old subjectsA risk assessment facilitates dialogue with your doctor about prevention and emphasizes the importance of efforts to improve your lifestyle. Lifestyle-based treatment at all ages is the main intervention for the metabolic syndrome.

2nd. In individuals with atherosclerotic cardiovascular disease (ASCVD), LDL-cholesterol should be reduced by high-intensity statin therapy or by the maximum tolerated statin dose. With statins, more LDL decreases, risk reduction is more. Therefore, in the guideline of guidelines, the maximum tolerated posi- tology of a statin is used to reduce LDL levels by 50%.

3. In people with a high risk of atherosclerotic cardiovascular disease(the history of multiple ASCVD events or the ASCVD event and subjects with multiple high-risk situations), the therapeutic goal that LDL should achieve; 70 mg / dladding a non-statin therapy to the statin,ezetimibe. In people at very high risk of LDL cholesterol ≥ 70 mg / dl, guidelines recommend a statin and ezetimibe. PCSK9 inhibitor"Although safety long-term (ie more than 3 years) is unclear and there is a low cost-effectiveness at the current prices of these drugs vadeli.

4. In cases with severe primary hypercholesterolemia(LDL values ​​≥190 mg / dl), guidelines recommend that you start treatment with high-intensity statin, even without calculating the risk of ASCVD in 10 years. If the LDL level is mg100 mg / dl, it is recommended to add ezetimibe; If LDL is still ≥100 mg / dl despite statin therapy and ezetimibe, the guidelines suggest the addition of a PCSK9 inhibitor " safety long-term (ie more than 3 years) is unclear and there is a low cost-effectiveness at the current prices of these drugs vadeli.

5. In people aged 40-75 years with diabetes mellitus and LDL ≥70 mg / dlThe guide recommends that you start with moderate-to-severe statin, even without calculating the 10-year risk of ASCVD. In highly risky diabetic subjects, it is reasonable to prescribe high-density statin to reduce LDL levels by ≥ 50%, for example at very risky factors or at 50-75 years of age.

6. Evaluated for primary prevention of atherosclerotic cardiovascular disease in adults 40-75 years of ageThe doctor should discuss the opportunity to start a statin therapy with the patient. The interview should touch on all major risk factors (cigarette smoking, hypertension, LDL level, glycosylated hemoglobin and ASCVD risk in 10 years), factors that may worsen the impact of risk factors. (see number 8), the potential benefits of a healthy lifestyle and statins; potential side effects and drug interactions; cost of statin therapy; Patient preferences should be kept in mind in a shared decision-making process.

7. In adults 40-75 years of age without diabetes, LDL values ​​are mg70 mg / dl and 10 years risk of ASCVD ≥ 7.5%, the guidelines recommend starting treatment with a moderate severity of statin if the patient decides to take a statin after a justification for treatment options. The presence of risk-supporting factors recommends statin therapy. If the risk situation remains unclear, an option is to evaluate coronary calcium (see No. 9). If statin therapy is indicated, the therapeutic goal is to reduce LDL values ​​by ≥ 30%;however, if the 10-year risk is ≥ 20% then the reduction of LDL values ​​should be ≥ 50%.

8. In adults between 40-75 years of age without diabetes, & # 39; 10-year risk of ASCVD (7.5% -19.9%), The presence of risk-supporting factors suggests the initiation of a statin therapy. & # 39; FRrisk-promoting factors We mean: premature family ASCVD history, permanently elevated LDL levels (≥ 160 mg / dl), metabolic syndrome, chronic kidney disease, preeclampsia or premature menopause history (before age 40), chronic inflammatory disorders (such as arthritis), rheumatoid, psoriasis or HIV infection); increased risk of triglycerides (≥175 mg / dl) to high-risk ethnic groups (such as Southeast Asia); Possible increase in apolipoprotein B (≥ 130 mg / dl), high sensitivity C reactive protein ≥ 2.0 mg / dl, ankle arm index Cardiovascular risk cases at the 10-year border (5% to 7.5%).

9. In adults 40-75 years without diabetes, LDL values ​​≥70 mg / dl to 189 mg / dl and moderate 10-year risk of ASCVD (7.5% ve19.9%) can be used to measure coronary calcium (CAC) when statin therapy is initiated or not.If CAC is zero, statin therapy can be prevented and postponed in smokers, diabetic patients, and early ASCVD family history. A CAC score It is recommended to initiate statin therapy between 1 and 99, especially above 55 years. Finally, statin therapy is indicated for all subjects with a CAC score ≥ 100.

10. Evaluate the rate of commitment and response to hypocholesterolemic drugs and lifestyle changes (based on baseline values) by repeated measurement of plasma lipids.After 4-12 weeks of starting statin therapy or after dose adjustment, this will be repeated every 3-12 months if necessary. In subjects at very high risk, the LDL value should lead to the addition of mg70 mg / dl statins free therapy. The guide recommends that you first do a cholesterol test between 9 and 11 years, then again about 17-21 years. There is insufficient evidence to give precise advice about at the moment. timing Cholesterol control in young adults.

Maria Rita Montebelli

November 11, 2018
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