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NEW YORK, February 15, 2019 / PRNewswire / – The Association of Black Cardiologists, Inc. is co-signatory to the recently published ACC / AHA 2018 guideline on the management of blood cholesterol, a document carefully drafted by the editorial board and experts in the field; and intended to inform clinical decision-making among practitioners. The importance of this document is better understood after a brief history of the state of implementation of recommendations by clinicians and the emerging perspective on the implementation of recommendations. The guidelines for clinical practice have shifted from a document based on expert opinion over the past years to a predominantly evidence-based publication designed to facilitate the dissemination of the results of the scientific research and the evolution of clinical practice. Standardizing practice and maximizing healthy outcomes in a cost-effective manner are the expected goals of implementation and adherence to the guidelines. A new proposal adding to the clbad of recommendations and level of evidence, recently added to the guideline recommendations, is the inclusion of a monetary value for the treatment intervention. The impact of this component will have to be evaluated as it will be necessary to avoid unintended negative consequences. It is estimated that 30-40% of patients receive treatment that is not based on scientific evidence and that 20-25% of patients receive unspecified or potentially harmful treatment. These data are striking in that guideline-based treatments have been shown to reduce morbidity and mortality and are often cost-effective. In addition, it was estimated that it would take 10 years for the dissemination of recommendations for recommendations to have a significant impact on clinical practice. One can imagine the potential benefits for the general population and minority communities that could be achieved if these data were minimized. Barriers to the implementation of the guidelines are multifactorial and beyond the scope of this Communication. However, an important vendor-based component, focused on knowledge of recommendations, contextualization and dissemination of information, is essential.
The 2018 ACC / AHA guidelines address a multitude of clinical scenarios and provide guidance regarding the treatment of patients with familial or severe hypercholesterolemia, diabetes, high risk, intermediate and low cardiovascular disease atherosclerosis (ASCVD). The guidelines reaffirm the use of specific LDL-C values as treatment goals compared to the 2013 recommendations. These guidelines also address the appropriate use of the 10-in. ASCVD risk calculator. years, the application of calcium risk score in the coronary arteries and the value of shared decision-making. The guidelines also provide a rational, evidence-based approach to the use of PCSK-9 inhibitors and non-statin therapies (ezetimibe) in a stratified manner based on LDL-C responses and the cost ratio. -efficiency. The addition of the concept of comorbidities that increase the risk is particularly relevant for African Americans and other minorities because it is about patients with a metabolic syndrome, a rate LDL-C ≥ 160 mg / dL, apolipoprotein B ≥130 mg / dL, Lipoprotein (a) ≥ 50 mg / dL, triglyceride level ≥ 175 mg / dL, chronic renal disease, inflammatory disorders; such as rheumatoid arthritis, psoriasis, highly sensitive C reactive protein> 2 mg / L, lupus, HIV, premature menopause (<40 years), history of preeclampsia, cigarette use, a ankle-brachial index <0.9 and South Asian ancestry. Recent data supporting the use of a calcium risk score in the coronary arteries, which many consider a microvascular plaque rupture marker, can facilitate the process of shared decision-making. In some individuals, a zero score would eliminate the need for statin therapy; an intermediate score favors statin treatment; while a score greater than 100 Agatston would be an indication for lipid-lowering therapy with a statin.
The following statements are intended to provide examples of the recommendations of Directive 2018 for various treatment scenarios. Readers of this correspondence are urged to review the guideline in its entirety and to refer to it as often as necessary when dealing with their patients. A change in the healthy lifestyle for the heart is at the heart of any prevention intervention.
Secondary preventionPatients with known cardiovascular disease may receive maximum tolerable statin therapy, regardless of baseline LDL-C value. If LDL-C is not decreased by 50% or is not < 70 mg/dL, ezetimibe may be added. If LDL-C is decreased with the addition of ezetimibe but LDL-C is still > 70 mg / dL, a PCSK-9 inhibitor can be added.
Familial hypercholesterolemia: In patients with LDL-C ≥ 190 mg / dL, a 10-year risk calculation is not required. Maximum tolerated statin therapy is recommended. If the LDL-C level is not reduced by 50% (high-intensity treatment) or if the LDL-C is greater than 100 mg / dL, add ezetimibe. If the same goal is not achieved, an inhibitor of PCSK-9 can be added.
Primary prevention: In patients without atherosclerotic cardiovascular disease or diabetes, therapeutic intervention will require the use of the ASCVD risk calculator. If the LDL-C level is> 70 mg / dL and if the 10-year risk score is ≥ 7.5%, statin therapy can be started and the goal of treatment for LDL-C followed.
diabetics: An ASCVD risk calculation is not necessary. All diabetic patients aged 40 to 75 years with LDL-C above 70 mg / dL should receive moderate-intensity statin therapy. If several risk factors are present, treatment with a high-intensity statin is indicated (LDL-C reduction of 50%). Further titration of the treatment is done based on the response of LDL-C to the initial treatment.
High risk patients: In patients with a 10-year risk of ASCVD ≥ 20%, statin therapy is a clbad 1 indication.
children: Children of family members with familial hypercholesterolemia can be tested as early as 2 years of age, but treatment should be suspended until the age of 10 years if the values of LDL-C are above the 75th percentile for normal adults.
For the prevention and treatment of cardiovascular diseases to be effective, it is essential, to the extent possible, to implement a medical treatment based on recommendations, in order to reduce morbidity and mortality in all patients and eliminate disparities between minority populations. The recent decline in the decline in cardiovascular mortality since 2015 is alarming and demonstrates the urgency needed to address the various risk factors badociated with the manifestation of cardiovascular disease.
About ABC
Founded in 1974, the CBA is a non-profit organization that brings together more than 1,800 international members of the health sector, non-professional professionals, businesses and institutions. The mission of the ABC is to promote the prevention and treatment of cardiovascular disease, including stroke, among blacks and other minorities, and to achieve health equity for all thanks to the elimination of disparities. For more information on the Black Cardiologists Association, visit http://www.abcardio.org.
SOURCE Association of Black Cardiologists, Inc.
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