Guideline on the Treatment of Cardiovascular Risk in Adults

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2013 ACC/AHA& 2012 ESC Guideline on the Treatment of Cardiovascular Risk in Adults

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2013 ACC/AHA Guideline on the Treatment of Cardiovascular Risk in Adults Dr . RABIE Z. AL-ANSI

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2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

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Pooled Cohort ASCVD Risk Equations

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Pooled Cohort ASCVD Risk Equations

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Pooled Cohort ASCVD Risk Equations

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I IIa IIb III B I IIa IIb III c Use of the sex-specific Pooled Cohort Equations for nonHispanic Whites may be considered when estimating risk in patients from populations other than African Americans and nonHispanic Whites. Recommendations for Assessment of 10-Year Risk for a First Hard ASCVD Event The race- and sex-specific Pooled Cohort Equations* to predict 10-year risk for a first hard ASCVD event should be used in nonHispanic African Americans and nonHispanic Whites, 40 to 79 years of age.

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Critical Question 1 “What is the evidence regarding reclassification or contribution to risk assessment when hs - CRP, ApoB , GFR, microalbuminuria , family history, cardiorespiratory fitness, ABI, CAC, or CIMT are considered in addition to the variables that are in the traditional risk scores?” Summary of Systematic Reviews and Meta-Analyses for CQ1

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Expert Opinion Thresholds for use of Optional Screening Tests When Risk-Based Decisions Regarding Initiation of Pharmacological Therapy are Uncertain Following Quantitative Risk Assessment

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I IIa IIb III B I IIa IIb III NV CIMT is not recommended for routine measurement in clinical practice for risk assessment for a first ASCVD event. Use of Newer Risk Markers After Quantitative Risk Assessment The contribution to risk assessment for a first ASCVD event using ApoB , CKD, albuminuria , or cardiorespiratory fitness is uncertain at present. If, after quantitative risk assessment, a risk based treatment decision is uncertain, assessment of 1 or more of the following— family history, hs -CRP, CAC score, or ABI—may be considered to inform treatment decision making. I IIa IIb III B

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I IIa IIb III c I IIa IIb III B Recommendations for CQ2: Long-Term Risk Assessment Assessing 30-year or lifetime ASCVD risk based on traditional risk factors‡ may be considered in adults 20 to 59 years of age without ASCVD and who are not at high short-term risk. It is reasonable to assess traditional ASCVD risk factors‡ every 4 to 6 years in adults 20 to 79 years of age who are free from ASCVD and to estimate 10-year ASCVD risk every 4 to 6 years in adults 40 to 79 years of age without ASCVD.

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2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

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What’s New in the Guideline 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. 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.

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What’s New in the Guideline 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. 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 complex lipid disorders and incorporate refinements in risk stratification based on critical review of emerging data. · RCTs comparing alternate treatment strategies are needed in order to inform future evidence-based guidelines for the optimum ASCVD risk reduction approach.

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What’s New in the Guideline 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. 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.

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Four Major Statin Benefit Groups Individuals with clinical ASCVD. Primary elevations of LDL–C >190 mg/ dL . Diabetes aged 40 to 75 years with LDL– C 70 to189 mg/ dL and without clinical ASCVD. Without clinical ASCVD or diabetes with LDL–C 70 to189 mg/ dL and estimated 10-year ASCVD risk >7.5%. Clinical ASCVD is defined by the inclusion criteria for the secondary prevention statin RCTs ( acute coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin ) . The estimated absolute 10-year risk of ASCVD (defined as nonfatal MI, CHD death, nonfatal and fatal stroke)

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Intensity of Statin Therapy in Primary and Secondary Prevention Classifying specific statins and doses by the percent reduction in LDL–C level is based on evidence that the relative reduction in ASCVD risk from statin therapy is related to the degree by which LDL–C is lowered. Statins and doses that are approved by the U.S. FDA but were not tested in the RCTs reviewed are listed in italics. †Evidence from 1 RCT only: down-titration if unable to tolerate atorvastatin 80 mg in IDEAL . ‡Although simvastatin 80 mg was evaluated in RCTs, initiation of simvastatin 80 mg or titration to 80 mg is not recommended by the FDA due to the increased risk of myopathy , including rhabdomyolysis .

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III NV Treatment Targets 1. The panel makes no recommendations for or against specific LDL–C or non-HDL–C targets for the primary or secondary prevention of ASCVD.

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III A I IIa IIb III A I IIa IIb III B 1. High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD*, unless contraindicated. 2. In individuals with clinical ASCVD* in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated† or when characteristics predisposing to statin -associated adverse effects are present, moderate-intensity statin should be used as the second option if tolerated 3. In individuals with clinical ASCVD >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin . It is reasonable to continue statin therapy in those who are tolerating it. Secondary Prevention

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III B I IIa IIb III B 1. Individuals with LDL–C ≥190 mg/ dL or triglycerides ≥500 mg/ dL should be evaluated for secondary causes of hyperlipidemia (Table 6). 2. Adults ≥21 years of age with primary LDL–C ≥190 mg/ dL should be treated with statin therapy (10-year ASCVD risk estimation is not required): · Use high-intensity statin therapy unless contraindicated. · For individuals unable to tolerate high-intensity statin therapy, use the maximum tolerated statin intensity. Primary Prevention in Individuals ≥21 Years of Age With LDL–C ≥190 mg/ dL

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III B I IIa IIb III B 3. For individuals ≥21 years of age with an untreated primary LDL–C ≥190 mg/ dL , it is reasonable to intensify statin therapy to achieve at least a 50% LDL–C reduction. 4. For individuals ≥21 years of age with an untreated primary LDL–C ≥190 mg/ dL , after the maximum intensity of statin therapy has been achieved, addition of a nonstatin drug may be considered to further lower LDL–C. Evaluate the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and consider patient preferences. Primary Prevention in Individuals ≥21 Years of Age With LDL–C ≥190 mg/ dL

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III A I IIa IIb III B I IIa IIb III C Primary Prevention in Individuals With Diabetes Mellitus and LDL–C 70-189 mg/ dL 1. Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. 2. High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk║ unless contraindicated 3. In adults with diabetes mellitus, who are <40 or >75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy.

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III B I IIa IIb III A I IIa IIb III B Primary Prevention in Individuals Without Diabetes Mellitus and With LDL–C 70 to 189 mg/ dL 1. The Pooled Cohort Equations should be used to estimate 10-year ASCVD║ risk for individuals with LDL–C 70 to 189 mg/ dL without clinical ASCVD* to guide initiation of statin therapy for the primary prevention of ASCVD. 2. Adults 40 to 75 years of age with LDL–C 70 to 189 mg/ dL , without clinical ASCVD* or diabetes and an estimated 10-year ASCVD║ risk ≥7.5% should be treated with moderate- to high-intensity statin therapy. 3. It is reasonable to offer treatment with a moderateintensity statin to adults 40 to 75 years of age, with LDL–C 70 to 189 mg/ dL , without clinical ASCVD* or diabetes and an estimated 10-year ASCVD║ risk of 5% to <7.5%.

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III C I IIa IIb III C 4. Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL–C 70- 189 mg/ dL without clinical ASCVD* or diabetes it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug-drug interactions, and patient preferences for treatment. Primary Prevention in Individuals Without Diabetes Mellitus and With LDL–C 70 to 189 mg/ dL 5. In adults with LDL–C <190 mg/ dL who are not otherwise identified in a statin benefit group, or for whom after quantitative risk assessment a riskbased treatment decision is uncertain, additional factors¶ may be considered to inform treatment decision making. In these individuals, statin therapy for primary prevention may be considered after evaluating the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and discussion of patient preferences.

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Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults— Statin Treatment I IIa IIb III N R 1. The Expert Panel makes no recommendations regarding the initiation or discontinuation of statins in patients with NYHA class II–IV ischemic systolic heart failure or in patients on maintenance hemodialysis . Heart Failure and Hemodialysis

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Figure 3. Initiating statin therapy in individuals with clinical ASCVD

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Summary of Statin Safety Recommendations I IIa IIb III B 1.To maximize the safety of statins , selection of the appropriate statin and dose in men andnonpregnant / nonnursing women should be based on patient characteristics, level of ASCVD* risk, and potential for adverse effects. Moderate-intensity statin therapy should be used in individuals in whom high-intensity statin therapy would otherwise be recommended when characteristics predisposing them to statinassociated adverse effects are present. Characteristics predisposing individuals to statin adverse effects include, but are not limited to: · Multiple or serious comorbidities , including impaired renal or hepatic function. · History of previous statin intolerance or muscle disorders. · Unexplained ALT elevations >3 times ULN. · Patient characteristics or concomitant use of drugs affecting statin metabolism. · >75 years of age.

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I IIa IIb III A I IIa IIb III C I IIa IIb III C 2b.Baseline measurement of CK is reasonable for individuals believed to be at increased risk for adverse muscle events based on a personal or family history of statin intolerance or muscle disease, clinical presentation, or concomitant drug therapy that might increase the risk for myopathy . 2a.CK should not be routinely measured in individuals receiving statin therapy. 2c.During statin therapy, it is reasonable to measure CK in individuals with muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or generalized fatigue. 3a.Baseline measurement of hepatic transaminase levels (ALT) should be performed before initiating statin therapy. Summary of Statin Safety Recommendations I IIa IIb III B

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I IIa IIb III C I IIa IIb III A 3b.During statin therapy, it is reasonable to measure hepatic function if symptoms suggesting hepatotoxicity arise (e.g., unusual fatigue or weakness, loss of appetite, abdominal pain, dark-colored urine or yellowing of the skin or sclera). 4. Decreasing the statin dose may be considered when 2 consecutive values of LDL–C levels are <40 mg/ dL . 5. It may be harmful to initiate simvastatin at 80 mg daily or increase the dose of simvastatin to 80 mg daily. Summary of Statin Safety Recommendations I IIa IIb III C

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6. Individuals receiving statin therapy should be evaluated for new-onset diabetes mellitus according to the current diabetes screening guidelines (93). Those who develop diabetes mellitus during statin therapy should be encouraged to adhere to a heart healthy dietary pattern, engage in physical activity, achieve and maintain a healthy body weight, cease tobacco use, and continue statin therapy to reduce their risk of ASCVD events. 7. For individuals taking any dose of statins , it is reasonable to use caution in individuals >75 years of age, as well as in individuals that are taking concomitant medications that alter drug metabolism, taking multiple drugs, or taking drugs for conditions that require complex medication regimens (e.g., those who have undergone solid organ transplantation or are receiving treatment for HIV). A review of the manufacturer’s prescribing information may be useful before initiating any cholesterol-lowering drug. I IIa IIb III B I IIa IIb III C Summary of Statin Safety Recommendations

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It is reasonable to evaluate and treat muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or fatigue, in statin -treated patients according to the following management algorithm • To avoid unnecessary discontinuation of statins , obtain a history of prior or current muscle symptoms to establish a baseline before initiating statin therapy. • If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and address the possibility of rhabdomyolysis by evaluating CK, creatinine , and a urinalysis for myoglobinuria . I IIa IIb III B Summary of Statin Safety Recommendations

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• If mild to moderate muscle symptoms develop during statin therapy: – Discontinue the statin until the symptoms can be evaluated. – Evaluate the patient for other conditions that might increase the risk for muscle symptoms (e.g., hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica , steroid myopathy , vitamin D deficiency, or primary muscle diseases.) – If muscle symptoms resolve, and if no contraindication exists, give the patient the original or a lower dose of the same statin to establish a causal relationship between the muscle symptoms and statin therapy. – If a causal relationship exists, discontinue the original statin . Once muscle symptoms resolve, use a low dose of a different statin . – Once a low dose of a statin is tolerated, gradually increase the dose as tolerated. – If, after 2 months without statin treatment, muscle symptoms or elevated CK levels do not resolve completely, consider other causes of muscle symptoms listed above. – If persistent muscle symptoms are determined to arise from a condition unrelated to statin therapy, or if the predisposing condition has been treated, resume statin therapy at the original dose. Summary of Statin Safety Recommendations I IIa IIb III B

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9. For individuals presenting with a confusional state or memory impairment while on statin therapy, it may be reasonable to evaluate the patient for nonstatin causes, such as exposure to other drugs, as well as for systemic and neuropsychiatric causes, in addition to the possibility of adverse effects associated with statin drug therapy. I IIa IIb III C Summary of Statin Safety Recommendations

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Summary of Nonstatin Safety Recommendations Safety of Niacin 1. Baseline hepatic transaminases , fasting blood glucose or hemoglobin A1c, and uric acid should be obtained before initiating niacin, and again during up-titration to a maintenance dose and every 6 months thereafter. 2. Niacin should not be used if: • Hepatic transaminase elevations are higher than 2 to 3 times ULN. • Persistent severe cutaneous symptoms, persistent hyperglycemia, acute gout or unexplained abdominal pain or gastrointestinal symptoms occur. • New-onset atrial fibrillation or weight loss occurs. 3. In individuals with adverse effects from niacin, the potential for ASCVD benefits and the potential for adverse effects should be reconsidered before reinitiating niacin therapy. I IIa IIb III B I IIa IIb III B I IIa IIb III B

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4. To reduce the frequency and severity of adverse cutaneous symptoms, it is reasonable to: • Start niacin at a low dose and titrate to a higher dose over a period of weeks as tolerated. • Take niacin with food or premedicating with aspirin 325 mg 30 minutes before niacin dosing to alleviate flushing symptoms. • If an extended-release preparation is used, increase the dose of extended-release niacin from 500 mg to a maximum of 2,000 mg/day over 4 to 8 weeks, with the dose of extended-release niacin increasing not more than weekly. • If immediate-release niacin is chosen, start at a dose of 100 mg 3 times daily and up-titrate to 3 g/day, divided into 2 or 3 doses. Summary of Nonstatin Safety Recommendations I IIa IIb III C

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Safety of BAS 1. BAS should not be used in individuals with baseline fasting triglyceride levels ≥300 mg/ dL or type III hyperlipoproteinemia , because severe triglyceride elevations might occur. (A fasting lipid panel should be obtained before BAS is initiated, 3 months after initiation, and every 6 to 12 months thereafter.) 2. It is reasonable to use BAS with caution if baseline triglyceride levels are 250 to 299 mg/ dL , and evaluate a fasting lipid panel in 4 to 6 weeks after initiation. Discontinue the BAS if triglycerides exceed 400 mg/ dL . Safety of Cholesterol-Absorption Inhibitors 1. It is reasonable to obtain baseline hepatic transaminases before initiating ezetimibe . When ezetimibe is coadministered with a statin , monitor transaminase levels as clinically indicated, and discontinue ezetimibe if persistent ALT elevations >3 times ULN occur. Summary of Nonstatin Safety Recommendations I IIa IIb III B I IIa IIb III C I IIa IIb III B

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Safety of Fibrates 1. Gemfibrozil should not be initiated in patients on statin therapy because of an increased risk for muscle symptoms and rhabdomyolysis 2. Fenofibrate may be considered concomitantly with a low- or moderate-intensity statin only if the benefits from ASCVD risk reduction or triglyceride lowering when triglycerides are >500 mg/ dL , are judged to outweigh the potential risk for adverse effects. 3. Renal status should be evaluated before fenofibrate initiation, within 3 months after initiation, and every 6 months thereafter. Assess renal safety with both a serum creatinine level and an eGFR based on creatinine . • Fenofibrate should not be used if moderate or severe renal impairment, defined as eGFR <30 mL /min per 1.73 m2, is present. • If eGFR is between 30 and 59 mL /min per 1.73 m2, the dose of fenofibrate should not exceed 54 mg/day. • If, during follow-up, the eGFR decreases persistently to ≤30 mL /min per 1.73 m2, fenofibrate should be discontinued. Summary of Nonstatin Safety Recommendations I IIa IIb III B I IIa IIb III C I IIa IIb III B I IIa IIb III B

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Safety of Omega-3 Fatty Acids 1. If EPA and/or DHA are used for the management of severe hypertriglyceridemia , defined as triglycerides ≥500 mg/ dL , it is reasonable to evaluate the patient for gastrointestinal disturbances, skin changes, and bleeding. Summary of Nonstatin Safety Recommendations I IIa IIb III B

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Summary of Recommendations for Monitoring, Optimizing, and Insufficient Response to Statin Therapy Monitoring Statin Therapy 1.Adherence to medication and lifestyle, therapeutic response to statin therapy, and safety should be regularly assessed. This should also include a fasting lipid panel performed within 4 to 12 weeks after initiation or dose adjustment, and every 3 to 12 months thereafter. Other safety measurements should be measured as clinically indicated. Optimizing Statin Therapy 1.The maximum tolerated intensity of statin should be used in individuals for whom a high- or moderate-intensity statin is recommended, but not tolerated. I IIa IIb III A I IIa IIb III B

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Insufficient Response to Statin Therapy 1. In individuals who have a less-than-anticipated therapeutic response or are intolerant of the recommended intensity of statin therapy, the following should be performed: • Reinforce medication adherence. • Reinforce adherence to intensive lifestyle changes. • Exclude secondary causes of hyperlipidemia . 2. It is reasonable to use the following as indicators of anticipated therapeutic response to the recommended intensity of statin therapy. Focus is on the intensity of the statin therapy. As an aid to monitoring: • High-intensity statin therapy† generally results in an average LDL–C reduction of ≥50% from the untreated baseline; • Moderate-intensity statin therapy generally results in an average LDL–C reduction of 30 to <50% from the untreated baseline; • LDL–C levels and percent reduction are to be used only to assess response to therapy and adherence. They are not to be used as performance standards. Summary of Recommendations for Monitoring, Optimizing, and Insufficient Response to Statin Therapy I IIa IIb III A I IIa IIb III B

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Summary of Recommendations for Monitoring, Optimizing, and Insufficient Response to Statin Therapy 3. In individuals at higher ASCVD risk receiving the maximum tolerated intensity of statin therapy who continue to have a less-than-anticipated therapeutic response, addition of a nonstatin cholesterol-lowering drug(s) may be considered if the ASCVD risk-reduction benefits outweigh the potential for adverse effects. Higher-risk individuals include: • Individuals with clinical ASCVD‡ <75 years of age. • Individuals with baseline LDL–C ≥190 mg/ dL . • Individuals 40 to 75 years of age with diabetes mellitus. Preference should be given to nonstatin cholesterol-lowering drugs shown to reduce ASCVD events in RCTs. 4.In individuals who are candidates for statin treatment but are completely statin intolerant, it is reasonable to use nonstatin cholesterol-lowering drugs that have been shown to reduce ASCVD events in RCTs if the ASCVD risk-reduction benefits outweigh the potential for adverse effects. I IIa IIb III C I IIa IIb III B

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2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults:

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Summary of Recommendations for Obesity Identifying Patients Who Need to Lose Weight (BMI and Waist Circumference) 1a. Measure height and weight and calculate BMI at annual visits or more frequently. 1b. Use the current cutpoints for overweight (BMI >25.0-29.9 kg/m2) and obesity (BMI ≥30 kg/m2) to identify adults who may be at elevated risk of CVD and the current cutpoints for obesity (BMI ≥30) to identify adults who may be at elevated risk of mortality from all causes. 1c. Advise overweight and obese adults that the greater the BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. I IIa IIb III C I IIa IIb III B I IIa IIb III B

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Summary of Recommendations for Obesity 1d. Measure waist circumference at annual visits or more frequently in overweight and obese adults. Advise adults that the greater the waist circumference, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. The cutpoints currently in common use (from either NIH/NHLBI or WHO/IDF) may continue to be used to identify patients who may be at increased risk until further evidence becomes available. I IIa IIb III B

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Summary of Recommendations for Obesity Matching Treatment Benefits With Risk Profiles 2. Counsel overweight and obese adults with CV risk factors (high BP, hyperlipidemia and hyperglycemia), that lifestyle changes that produce even modest, sustained weight loss of 3%-5% produce clinically meaningful health benefits, and greater weight losses produces greater benefits. a. Sustained weight loss of 3%-5% is likely to result in clinically meaningful reductions in triglycerides, blood glucose, HbA1C, and the risk of developing type 2 diabetes; b. Greater amounts of weight loss will reduce BP, improve LDL–C and HDL–C, and reduce the need for medications to control BP, blood glucose and lipids as well as further reduce triglycerides and blood glucose. I IIa IIb III A I IIa IIb III A

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Summary of Recommendations for Obesity Diets for Weight Loss (Dietary Strategies for Weight Loss) 3a. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention. Any 1 of the following methods can be used to reduce food and calorie intake: a. Prescribe 1,200–1,500 kcal/day for women and 1,500–1,800 kcal/day for men (kcal levels are usually adjusted for the individual’s body weight); b. Prescribe a 500 kcal/day or 750 kcal/day energy deficit; or c. Prescribe one of the evidence-based diets that restricts certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake. 3b. Prescribe a calorie-restricted diet, for obese and overweight individuals who would benefit from weight loss, based on the patient’s preferences and health status and preferably refer to a nutrition professional* for counseling. A variety of dietary approaches can produce weight loss in overweight and obese adults, as presented in CQ3, ES2. I IIa IIb III A I IIa IIb III A

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Summary of Recommendations for Obesity Lifestyle Intervention and Counseling (Comprehensive Lifestyle Intervention) 4a. Advise overweight and obese individuals who would benefit from weight loss to participate for ≥6 months in a comprehensive lifestyle program that assists participants in adhering to a lower calorie diet and in increasing physical activity through the use of behavioral strategies. 4b. Prescribe on site, high-intensity (i.e., ≥14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist.† 4c. Electronically delivered weight loss programs (including by telephone) that include personalized feedback from a trained interventionist† can be prescribed for weight loss but may result in smaller weight loss than face-to-face interventions. 4d. Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss, provided there is peer-reviewed published evidence of their safety and efficacy. I IIa IIb III A I IIa IIb III A I IIa IIb III A I IIa IIb III A

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Summary of Recommendations for Obesity 4e. Use a very low calorie diet (defined as <800 kcal/day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high intensity lifestyle intervention can be provided. Medical supervision is required because of the rapid rate of weight loss and potential for health complications. 4f. Advise overweight and obese individuals who have lost weight to participate long-term (≥1 year) in a comprehensive weight loss maintenance program. 4g. For weight loss maintenance, prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (monthly or more frequent) with a trained interventionist† who helps participants engage in high levels of physical activity (i.e., 200-300 minutes/week), monitor body weight regularly (i.e., weekly or more frequent), and consume a reduced-calorie diet (needed to maintain lower body weight). I IIa IIb III A I IIa IIb III A I IIa IIb III A

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Summary of Recommendations for Obesity Selecting Patients for Bariatric Surgical Treatment for Obesity (Bariatric Surgical Treatment for Obesity) 5a. Advise adults with a BMI ≥40 or BMI ≥35 with obesity-related comorbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. 5b. For individuals with a BMI <35, there is insufficient evidence to recommend for or against undergoing bariatric surgical procedures. 5c. Advise patients that choice of a specific bariatric surgical procedure may be affected by patient factors, including age, severity of obesity/BMI, obesity-related comorbid conditions, other operative risk factors, risk of short- and long-term complications, behavioral and psychosocial factors, and patient tolerance for risk as well as provider factors (surgeon and facility). I IIa IIb III A I IIa IIb III NA I IIa IIb III C

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2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk:

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Lifestyle Management Recommendations LDL–C - Advise adults who would benefit from LDL–C lowering to: 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats. a. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus). b. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet. 2. Aim for a dietary pattern that achieves 5% to 6% of calories from saturated fat. 3. Reduce percent of calories from saturated fat. 4. Reduce percent of calories from trans fat. I IIa IIb III A

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BP - Advise adults who would benefit from BP lowering to: 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats. a. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus). b. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet. 2. Lower sodium intake. Lifestyle Management Recommendations I IIa IIb III A I IIa IIb III A

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3. a. Consume no more than 2,400 mg of sodium/day; b. Further reduction of sodium intake to 1,500 mg/day is desirable since it is associated with even greater reduction in BP; and c. Reduce intake by at least 1,000 mg/day since that will lower BP, even if the desired daily sodium intake is not yet achieved. 4. Combine the DASH dietary pattern with lower sodium intake. Lifestyle Management Recommendations BP - Advise adults who would benefit from BP lowering to: I IIa IIb III B I IIa IIb III A

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Lifestyle Management Recommendations Lipids 1. In general, advise adults to engage in aerobic physical activity to reduce LDL–C and non-HDL–C: 3 to 4 sessions a week, lasting on average 40 minutes per session, and involving moderate-to-vigorous intensity physical activity. PHYSICAL ACTIVITY BP 1. In general, advise adults to engage in aerobic physical activity to lower BP: 3 to 4 sessions a week, lasting on average 40 minutes per session, and involving moderate-to-vigorous intensity physical activity. I IIa IIb III A I IIa IIb III A

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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Prevention Guideline Clinical Cases.

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