AHA / ACC[의학신문·일간보사=김자연 기자] New therapeutic guidelines and risk factors have been added to the guidelines of the American Heart Association and Society (AHA / ACC). A high-risk patient who had a heart attack or stroke recommends adding a new cholesterol treatment if cholesterol levels are not adequately reduced by statins.
Patients with high risk should first try statin therapy with Ezetimib and if they do not, a new PCSK9 inhibitor should be given, especially those with high risk or genetically elevated cholesterol levels.
For secondary prevention of patients with clinical atherosclerotic cardiovascular disease (ASCVD), treatment with maximum tolerance statin therapy should be considered if LDL-C decreases by more than 50% or falls below 70 mg / dL, C is 20 % minor However, the addition of a PCSK9 inhibitor is reasonable if LDL-C is> 70 mg / dL.
Patients with severe hypercholesterolaemia and familial hypercholesterolaemia should be treated with a maximum tolerance statin therapy. If LDL-C does not decrease more than 50% or remains above 100 mg / dL, consider the PCSK9 inhibitor.
The current PCSK9 inhibitors include Lefatta and Pralant, which were not used in the US. UU for more than $ 14,000 a year, but recently fell to $ 5,850 and $ 4,500 to $ 6,600, respectively.
In addition, the guidance added more data based on the population, including the calculation of the 10-year ASCVD risk score that was introduced in 2013 and added new health risks such as family history, chronic renal and chronic renal disease and early menopause . Especially, for primary prevention of ASCVD intermediate risk (7.5% to 20%), communication was emphasized so that the patient and the doctor decide the treatment together.
The promotional risk factors for these decisions include LDL-C higher than 160 mg / dL, C-reactive protein greater than 2 mg / L, Apolipoprotein B above 130 mg / dL and an increase in fat protein (a) E diseases concomitant, such as metabolic syndrome, chronic renal disease, chronic inflammatory disorder, precocious menopause, precocious family history of ASCVD and elevated risk of ASCVD.
Among these, treatment with statins is preferred as a class 2b recommendation if there is a risk factor for patients with ASCVD risk of 5 to 7.5%. Statin is recommended as a first degree recommendation with a risk of 7.5 to 20% If it is greater than 20%, it is recommended that statins of high resistance are first class.
However, it is advisable to measure coronary artery calcium (CAC) in cases where more confirmation is needed to determine whether statin treatment should be avoided, such as intermediate risk patients if the score is zero. In addition, the CAC score must be at least 100 (Agatston unit), and must be adjusted to the patient's age and sex. If the CAC score is greater than 75 percent, the risk of atherosclerosis is significant. If the CAC score is in the average range of 1 to 99, then the CAC may start after the statins start or two years later.
In addition, for all diabetic patients aged 40-75 years with LDL-C greater than 70 mg / dL, therapy with statins for moderate to severe anomalies is recommended without the need for a 10-year risk assessment of ASCVD and high risk statin therapy . It must be considered.
In addition, women are also recommended for the detection of conditions related to pregnancy, such as preeclampsia, hypertension induced by pregnancy and diabetes, low birth weight and preterm birth. Statin should be interrupted especially 1-2 months before pregnancy planned, even if an unplanned pregnancy is observed. Cholesterol testing for children 2 to 7 years of age is also recommended if there is a family history of high cholesterol or heart disease.
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