CHOLESTEROL ACC/AHA GUIDELINES - 2018 (NEW) UNDERSTANDING & IMPLEMENTING Joe Sky, MD, FACC Cardiologist

2018 (NEW)
                    CHOLESTEROL
                      ACC/AHA
Joe Sky, MD, FACC    GUIDELINES
     Cardiologist

                     UNDERSTANDING &
                      IMPLEMENTING

The views expressed in this presentation are Dr Sky’s and do not
reflect an endorsement or the official policy of the the U.S.
Government, the Department of Defense, or the U.S. Air Force.

Disclosures:
1. Boston Heart Diagnostics, speaker.
2. Blue Zones, speaker.

Outline:
1. Important changes
2. ACC/AHA slide set
3. Coronary calcium history
4. Lipoprotein (a), apoB & HS-crp
5. Implementation ~ resources needed

Changes

1. Lifestyle is has major role – now with
monitoring

2. Cholesterol targets are back

3. Work towards patient goals
   ~ using shared decision making

Changes

4. Serial monitoring
~ Net effect of lifestyle & meds emphasized

5. Team approach (pharmacy, educators, patient)

6. Medications others than statins are back

2013

Statins
                      Risks

          Lifestyle
              &
            Diet

We Can Do Better –
Improving the Health of the American People
              Steven A. Schroeder, M.D.

20%         20%

Medical                 80%
Care              80%   Ourselves

          Our Health

2018
                 Statins
                    &
                 Other
Lifestyle      Medications
    &
  Diet

              Risks

             Enhanced

Lifestyle & Diet

Lifestyle & Diet

Lifestyle & Diet

2018 ACC / AHA Guidelines

http://tools.acc.org/ldl/ascvd_risk_estimator/index.html#!/calulate/estimator/

2018 ACC / AHA Guidelines

See separate ACC/AHA slides

Coronary Calcium

CALCIUM SCORE

• Strength of calcium scoring ~ identification of risk
      • Key tool for strict safety goals of military aviation, NASA, etc

• Outcomes ~ entirely dependent on f/u prevention strategies
• Calcium score should lead to more successful outcomes
• 2018 cholesterol guidelines offer opportunity

CALCIUM SCORE

CALCIUM SCORE ~                        DELAYS IN ACCEPTANCE

1.    Over promised with financial profiteering
         ~ Skepticism in scientific community ~ resentment

2.    Use by researchers and clinicians required resources / change
          ~ Clinical scores didn’t require testing

3.    Radiation, incidental findings, etc

CALCIUM SCORE ~ A 2 ND CHANCE?

The 2018 ACC/AHA guidelines represent an opportunity

   ~ Use by researchers and clinicians is shifting
   ~ Radiation, incidental findings, etc not validated as problems
    ~ Inclusion in guidelines, perhaps a needed reset in thinking?

OTHER THAN CHOLESTEROL TESTING

 Lipoprotein (a), apoB & HS-crp

 ~ National Lipid Association influence

 ~ Recognition that other tests help delineate
   risk in patients with “normal" cholesterol

 ~ Continued debate

OTHER THAN CHOLESTEROL TESTING

                         Negative          Positive

                                 Disease

                                     Disease

WHEN CHOLESTEROL TESTING FAILS PATIENTS?

                    75% < 130mg/dL

     23%

IMPLEMENTATION ~                       RESOURCE NEEDS

Time & Personnel changes:
Shared decision making & risk-enhancing factors discussions
  1. Additional testing: Calcium scoring, labs other than cholesterol
  2. Collaborate with the patient for therapy and follow-up
    ~ Additional professionals, especially clinical pharmacists
  3. Healthy lifestyle with relevant advice, materials, or referrals with
      laboratory monitoring of meds & lifestyle.

Examples of Patient
                                 Shared Decision Making
What You Can Do:
1. Ask about your 10-year risk score if you don’t already have heart disease

2. Talk about other factors that might increase your risk (called “risk enhancers”)

3. If there’s any doubt, ask if CAC scoring could help

After initial visit:
1. Have ongoing discussions about your risk for heart disease, heart attack or stroke keeping in mind risk
   and available therapies change over time

2. If you are prescribed medication(s), take it as directed, and share any concerns before stopping.

3. Stick to a heart-healthy lifestyle. Enlist your family and others to help support you.

Examples of Patient
Shared Decision Making

IMPLEMENTATION

Patient resources recommended in new guidelines:
https://www.cardiosmart.org/
https://www.heart.org/en/professional/workplace-health/lifes-simple-7
https://www.lipid.org/practicetools/tools/tearsheets/practicetools/careers/
jobdescriptions
https://www.lipid.org/CLMT
http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
https://statindecisionaid.mayoclinic.org

MY PRINCIPLES   Customized care that reflect
FOR PREVENTIVE   patient's need, values & choices
                 ~ constructive follow-up.
     CARE
                   Screening for risks. Serial
                   follow up testing for
                   motivation!

                       Medications and treatments
                       after diet and lifestyle and
                       patient selected interventions.

                           Seek answers ~ evidence
                           based approach to best
                           medicine, diet and lifestyle

Questions