ATP IV Guideline for Treatment of Blood cholesterol level to reduce Atherosclerosis risk

1. New guideline on Treatment of
Blood Cholesterol
to reduce ASCVD risk
Dr. Kamal modi
Biochemistry dept.

2. Points of New ATP iv guidlines
Focus on ASCVD risk reduction
New perspective on LDL-C & Non-HDL-C
treatment goals
Global risk assesment for Primary prevention
Safety recommendation
Role of Biomarkers and Non-invasive tests
Future updates to the blood cholesterol guidelines

3. Focus on ASCVD risk reduction
Classified into 4 statin benefit groups:
1. Individuals with clinical ASCVD
2. Individuals with primary elevation of LDL–C > 190 mg/dl
3. Individuals 40- 75 years of age with diabetes with LDL-C 70-
189 mg/dl
4. Individuals without clinical ASCVD or diabetes who are 40 – 75
years of age with LDL-C 70-189 mg/dl and an estimated 10 year
ASCVD risk of 7.5 % or higher.

4. Statin therapy for ASCVD risk reduction

5. Statin therapy in individiual with clinical ASCVD

6. Statin therapy in individiual without clinical ASCVD

7. Role of Biomarkers and Non-invasive
tests
 For treatment decision in selected individuals
who are not included in the 4 statin benefit
groups.

8.  Other factors:
1. Primary LDL-C > 160 mg/dl
2. Genetic hyperlipidemias
3. Family history of premature ASCVD with onset
<55 years of age in first degree male relative or
< 65 years of age in first degree female relative
4. C-reactive protein > 2 mg/dl
5. CAC score > 300 Agaston units or > 75
percentile for age , sex and ethnicty
6. Ankle brachial index < 0.9
7. Elevated lifetime risk of ASCVD

9. Limitation
• Younger adults (< 40 years) who have low estimated
10 year ASCVD risk but high lifetime ASCVD risk
• Persons with serious comorbidities :
Rheumatologic or inflammatory disease,
HIV positive
Solid organ transplant
• No ASCVD risk reduction with statin therapy in
individuals with class ii – iv heart failure or
undergoing hemodialysis .

10. New perspective on LDL-C & Non-
HDL-C treatment goals
 Appropriate intensity of statin therapy should be
used.
 Non-Statin therapies do not provide acceptable
benefits compared to their adverse effects in
routine prevention of ASCVD.

12. Non-Statin drug therapy
• Niacin
• Bile acid sequestrants : cholestyramine, colestepol ,
colesevalam
• Fibric acid derivatives: gemfibrozil, fenofibrate,
clofibrate

13. Safety recommendation
 Identifies important safety considerations
 Facilitates understanding of the net benefit from
statin therapy
 Provides guidance on management of statin
associated adverse effects

14. Monitoring of therapeutic responce

15. Secondary causes

16. Global risk assessment for Primary
prevention
 Use of the new pooled cohort equation is
recommended to estimate 10 year ASCVD
risk in both white and black men and women
who do not have clinical ASCVD.
 Available at “my.americanheart.org”

17. Future updates to the blood cholesterol
guidelines
• To provide expert guidance on management of
complex lipid disorders and refinements in risk
stratification based on critical review of emerging
data.
 RCTs comparing alternate treatment stratigies are
needed in order to inform future evidence based
guidelines for optimum ASCVD risk reduction
approach.

18. • Guidelines for individuals with class ii – iv heart
failure or undergoing hemodialysis that might benefit
from statin therapy.
• Whether on treatment markers such as ApoB, Lp(a),
LDL particles are useful for guiding treatment
decisions
• How lifetime risk should be used to inform treatment
decisions and the optimal age for initiating statin
therapy to reduce lifetime risk of ASCVD.
• Efficacy and safety of statins in patents with HIV
positive or solid organ transplant.

19. Thank you…..