Chronic stable angina treatment lipid management

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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [5] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [6]; Associate Editors-In-Chief: John Fani Srour, M.D.; Jinhui Wu, MD

ACC / AHA Guidelines for cardiovascular risk factor reduction- Lipid management (DO NOT EDIT)

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Class I 1. Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), transfatty acids, and cholesterol (to less than 200 mg per day). (Level of Evidence: B) 2. Recommended lipid management includes assessment of a fasting lipid profile: (Level of Evidence: A) a. LDL-C should be less than 100 mg per dL. (Level of Evidence: A) b. If baseline LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in LDL-C levels.. (Level of Evidence: A) c. If on-treatment LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be intensified. (Level of Evidence: A) d. If triglycerides are 200 to 499 mg per dL, non–HDL-C‡ should be less than 130 mg per dL. (Level of Evidence: B) e. If triglycerides are greater than or equal to 500 mg per dL, therapeutic options to lower the triglycerides to reduce the risk of pancreatitis are fibrate or niacin; these should be initiated before LDL-C lowering therapy. The goal is to achieve non–HDL-C‡ less than 130 mg per dL if possible. (Level of Evidence: C) 3. Drug combinations are beneficial for patients on lipid lowering therapy who are unable to achieve LDL-C less than 100 mg per dL. (Level of Evidence: C) Class IIa 1. Dietary therapy with the addition of plant stanol/sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C. (Level of Evidence: A) 2. Recommended lipid management includes assessment of a fasting lipid profile: (Level of Evidence: A) a. Reduction of LDL-C to less than 70 mg per dL or high-dose statin therapy is reasonable. (Level of Evidence: A) b. If baseline LDL-C is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL. (Level of Evidence: B) c. Further reduction of non–HDL-C‡ to less than 100 mg per dL is reasonable, if triglycerides are greater than or equal to 200 to 499 mg per dL. (Level of Evidence: B) d. Therapeutic options to reduce non–HDL-C are: (Level of Evidence: B) i. Niacin can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C–lowering therapy)§ or, (Level of Evidence: B) ii. Fibrate therapy as a therapeutic option can be useful to reduce non–HDL-C‡ (after LDL-C–lowering therapy). (Level of Evidence: B) 3. The following lipid management strategies can be beneficial: (Level of Evidence: C) a. If LDL-C less than 70 mg per dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. b. When LDL-C less than 70 mg per dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of greater than 50% in LDL-C levels by either statins or LDL-C–lowering drug combinations. Class IIb 1. For all patients, encouraging consumption of omega-3 fatty acids in the form of fish* or in capsule form (1 g per day) for risk reduction may be reasonable. For treatment of elevated triglycerides, higher doses are usually necessary for risk reduction. (Level of Evidence: B)

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Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

References

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