assessing and managing - intermountain healthcare

copy2014 ndash 2017 INTERMOUNTAIN HEALTHCARE ALL RIGHTS RESERVED 1

The Cholesterol Management Development Team under the guidance of Intermountainrsquos Primary Care and Cardiovascular Clinical Programs developed this care process model (CPM) to guide the effective consistent management of cholesterol levels for patients across the Intermountain system This CPM is based on the 2013 American College of Cardiology and the American Heart Association (ACC AHA) Guideline on the Assessment of Cardiovascular Risk

GOF the 2013 ACC AHA Guideline on Lifestyle Management to Reduce Cardiovascular RiskECK

ECKEC and the 2017 ACC Expert DocumentLLO

Why Focus ON CHOLESTEROL MANAGEMENTbull More than 30 of US adults have high LDL cholesterol Of these about

half are being treated for it

CDC

bull High cholesterol is a leading risk factor for atherosclerotic cardiovascular disease (ASCVD) heart attack and stroke

bull New guidelines published in 2013 by a joint task force of the ACC AHA provides higher quality randomized controlled trial (RCT) evidence for cholesterol‑lowering drug therapy to reduce ASCVD riskGOF ECK In addition the ACC endorsed updated guidelines incorporating new evidence in 2017

bull People with diabetes who are currently taking statins will be added as a STARS measure effective in 2019

Key points from the updated guidelinesbull Lifestyle modification remains the foundation of ASCVD risk reduction

Heart‑healthy lifestyle habits are recommended for all patients whether or not they are on statin therapy

bull ldquoTreat to targetrdquo has been reevaluated The 2013 ACC AHA guidelines do not endorse treating to specific levels and instead support appropriate intensity of statin therapy and percent or LDL‑C reductions Other guidelines including the National Lipid Association (NLA) American Association of Endocrinology (AACE) the 2017 Expert Consensus Document (as well as many experts within Intermountain) feel there may be a role for levels in certain instances (see page 4)JAC JEL LLO

bull Four groups of individuals are identified as most likely to benefit from statin therapy These include those diagnosed with clinical ASCVD those age 40 to 75 with diabetes patients with a baseline LDL gt 190 mg dL and those with a calculated 10‑year ASCVD risk of gt 75 See page 2

bull The new Pooled Cohort Risk Calculator evaluates 10‑year and lifetime risk of ASCVD and more accurately identifies higher‑risk patients who may benefit from statin therapy This can be found in iCentra in the Calculators section under the title ACC AHA 2013 Cardiovascular Risk Assessment

bull Shared decision making on statin therapy is recommended for primary prevention in patients at lower risk but who have additional risk factors

A S S E S S I N G A N D M A N A G I N G

Cardiovascular Risk and Cholesterol

C a r e P r o c e s s M o d e l D E C E M B E R 2 0 1 7

WHATrsquoS INSIDEALGORITHM RISK ASSESSMENT 2

ADDITIONAL TREATMENT 4

HEART-HEALTHY LIFESTYLE 5

RESOURCES 6

EVALUATION 7

REFERENCES 7

GOALS amp MEASUREMENTS

As a result of implementing this CPM Intermountain aims to

bull Educate physicians on current guidelines and make them easy to implement

bull Increase appropriate use of statins

Taken together these goals are designed to assist Intermountain in reducing the rate of atherosclerotic cardiovascular disease associated with dyslipidemia

Throughout this CPM this symbol indicates an Intermountain measure consistent with these goals For more information see Evaluation on page 7

C A R D I O VA S C U L A R R I S K A N D C H O L E S T E R O L D E C E M B E R 2 0 17


ALGORITHM ASSESSMENT AND MANAGEMENT OF CHOLESTEROL LEVELS AND ASCVD RISK

CONSIDER moderate-intensity statin

(Note High-intensity statin may be indicated if higher risk greater LDL reduction desired or additional

risk factors) (e) (f)

Age 40 to 75

CONSIDER additional factors (e) in select individuals to inform

treatment decision making

yes

to statinYES

ASCVD Risk Reduction For All Patients (a)

SCREEN all adults age ge 20 years with full lipoprotein panel (fasting preferred) once every 5 years

yesno Clinical ASCVD (b)bull PRESCRIBE high-intensity

statin (c)

bull CONSIDER adding ezetimibe and or PCSK9 if needed to achieve 50 LDL reduction or if LDL remains gt 70

Indicates an Intermountain measure

LDL-C ge 190 mg dL

Diabetes(For patients age 20 to 39 or gt 75 see sidebar on page 4)

no

yes

no

no

to statinNO

ENGAGE patient in shared decision-making discussion regarding statin use

bull EMPHASIZE lifestyle and MONITOR adherence

bull MANAGE other risk factors bull EMPHASIZE lifestyle and MONITOR adherence and response with serial lipid-panel measurements

bull INITIATE statin at appropriate intensity and MONITOR adherence

bull MANAGE other risk factors

EVALUATE 10-year risk

bull ESTIMATE 10-year ASCVD risk every 5 years beginning at age 20 using Pooled Cohort Equation

bull SUPPORT primary prevention (d)

10-year ASCVD risk lt 75 10-year ASCVD risk ge 75

Age le 75yes

no

PRESCRIBE moderate-intensity statin (c)

yes

bull PRESCRIBE high-intensity statin (c)

bull CONSIDER adding ezetimibe if ndash Needed to achieve 50 LDL reduction OR ndash LDL remains gt 100 OR ndash Non-HDL remains gt 130



(e) Additional ASCVD risk factors (beyond those included in the pooled cohort equation) When unsure whether or not to prescribe a statin CONSIDER

bull Family history of premature ASCVD bull Chronic kidney disease stage 3 or 4 bull Coronary artery calcium (CAC) score ge 300 Agatston units or ge 90th percentile for age and sex

bull Ankle brachial index (ABI) lt 09 bull hs-CRP ge 20 mg L bull Metabolic syndrome or prediabetes

(a) ASCVD risk reduction for all patients

The 2013 AHA ACC Lifestyle Management Guidelines recommend the following lifestyle habits (see page 5)ECK

bull Heart-healthy diet to manage LDL-cholesterol and if necessary blood pressure (DASH Mediterranean or Cardiac diet)

bull Physical activity Moderate- to vigorous-intensity physical activity totalling 150 minutes per week (about 30 minutes most days)

bull Tobacco cessation Quit all tobacco products and avoid second-hand smoke

bull Weight management Reach and maintain a normal weight

(c) Statin Therapy Recommendations

GOF (Do not prescribe if patient is pregnant or lactating)

High-intensity statin therapyPatients with ANY of these bull Clinical ASCVD AND lt 75 years bull LDL-C gt 190 bull Diabetes AND 40 to 75 years bull ge 75 10-year ASCVD risk

Moderate-intensity statin therapyPatients with ANY of these

bull Clinical ASCVD AND gt 75 years bull Diabetes AND age 20 to 39 OR gt 75 years bull 10-year ASCVD risk is ge 75

Low-intensity statin therapyPatients with ANY of these

bull lt 75 10-year ASCVD risk AND other risk factors bull Diabetes AND age 20 ndash 39 with a 30 ndash 40 lifetime ASCVD risk bull Intolerance to higher-intensity statins

Daily dose lowers LDL-C on average by approximately 50 or more

Daily dose lowers LDL-C on average by approximately 30 to 50

Daily dose lowers LDL-C on average by up to 30

bull atorvastatin (40) to 80 mg bull rosuvastatin 20 (40) mg

bull atorvastatin 10 (20) mg bull simvastatin 20 mg to 40 mg bull pravastatin 40 (80) mg bull lovastatin 40 mg bull fluvastatin XL 80 mg bull fluvastatin 40 mg bid bull pitavastatin 2 mg to 4 mg bull rosuvastatin (5) 10 mg

bull pravastatin 10 mg to 20 mg bull lovastatin 20 mg bull simvastatin 10 mg bull fluvastatin 20 mg to 40 mg bull pitavastatin 1 mg

Notes

Boldface type indicates preferred drug

Prior to initiating drug therapy evaluate patient for secondary causes of dyslipidemia which include diabetes hypothyroidism obstructive liver disease nephrotic syndrome CKD malnourishment anorexia or drugs that increase LDL-C and decrease HDL-C (progestins anabolic steroids and corticosteroids)

Beware of drug interactions with atorvastatin (80 mg) and simvastatin (40 mg) including clarithromycin erythromycin amiodarone calcium channel blockers or fluconazole

Individual responses to statin therapy should be expected to vary in clinical practice There may be a biologic basis for less-than-average response Evidence from one RCT only down-titration if unable to tolerate atorvastatin 80 mg in IDEAL PED

(d) Primary prevention in patients without diabetes and with LDL-C 70 ndash 189 mg dL

bull EMPHASIZE adherence to a heart-healthy lifestyle bull CHECK fasting lipid profile every five years bull For patients age 40 to 75 years ESTIMATE 10-year ASCVD risk every five years beginning at age 20 and CHOOSE appropriate statin therapy Use the Pooled Cohort Equations available at toolscardiosourceorgASCVD-Risk-Estimator

bull For patients lt 40 years or gt 75 years and LDL-C lt 190 mg dL CONSIDER additional factors and MAKE SHARED DECISION on statin use

(f) Shared decision making on statin use

Prior to initiating statin therapy DISCUSS with patient bull Potential for ASCVD risk reduction benefit from statin therapy bull Potential for adverse effects and drug interactions from statin therapy bull Role of therapeutic lifestyle change bull Management of other risk factors such as blood pressure diabetes and abdominal obesity

bull Risk of pregnancy bull Patient preferences

(b) Clinical ASCVD

Clinical ASCVD is defined as one or more of the following bull Acute coronary syndromes bull History of MI bull Stable or unstable angina bull Coronary or other arterial revascularization bull Atherosclerotic stroke bull Atherosclerotic TIA bull Atherosclerotic peripheral artery disease bull Abdominal aortic aneurysm

ALGORITHM NOTES



DOCUMENTING STATIN INTOLERANCE IN iCENTRAFor patients who cannot take a statin due to intolerance (not allergy) the proper way to document this is to add one of the following diagnoses to the problem list (not allergy list)

bull G720 Drug-induced myopathy

bull G722 Myopathy due to other toxic agents

bull G729 Myopathy unspecified

bull M6282 Rhabdomyolysis

bull M791 Myalgia

bull Z789 Statin Intolerance

Treatment fundamentals for patients with clinical ASCVDA = Aspirin antiplatelet therapyB = Blood pressure controlC = Cholesterol control and Cigarette smoking cessationD = Diet and weight management AND Diabetes and blood glucose controlE = Exercise

DIABETES AND AGE 20 TO 39 OR gt 75 INTERMOUNTAIN RECOMMENDATIONSFor patients with diabetes who are outside the 40 ndash 75 age range the AHA ACC did not have enough data to make clear recommendations Intermountain experts in cardiology and primary care recommend shared decision making with patients in these categories considering the patientrsquos cumulative risk factors and patient preference in making the final decision

bull For nonpregnant patients age 20 ndash 39 ndash If lifetime ASCVD risk is 30 to 40 consider a low-intensity statin

ndash If lifetime ASCVD risk is gt 40 consider a moderate-intensity statin

bull For patients gt 75 consider a moderate-intensity statin

ADDITIONAL TREATMENTEzetimibe (Zetia) reduces the amount of cholesterol that is absorbed by the body It is recommended as second-line treatment for patients who have difficulty achieving control with a statin alone cannot take statins due to allergy or intolerance or have ASCVD with certain comorbidities (diabetes ASCVD event in the last 12 months or chronic kidney disease)

A PCSK9 inhibitor could be considered as a second- or third-line agent for patients with clinical ASCVD or with a baseline LDL gt 190 Providers should review the patientrsquos insurance coverage before prescribing a PCSK9

Managing lipid levelsThe NLA AACE and the 2017 ACC Expert Consensus Document (as well as certain experts at Intermountain) acknowledge there may be a role for treating to lipid levels especially in certain high‑risk patients such as those with ASCVD In these circumstances consider the following LDL guidelines

bull Primary prevention LDL lt 100 mg dL (especially in diabetics)bull Secondary prevention ASCVD or baseline LDL lt 70 mg dL non‑HDL lt 100 mg dL

Intermountain also recommends treating triglycerides if they are over 500 mg dL to reduce the risk of pancreatitis There is uncertain evidence of cardiovascular risk reduction from this treatment

Medications Other classes of lipid‑lowering medications include

bull Fibrates

ndash Gemfibrozil Do not initiate in patients who are already on statin therapy because of an increased risk for muscle symptoms and rhabdomyolysis

ndash Fenofibrates To prevent pancreatitis consider prescribing concurrently with a low‑ or moderate‑intensity statin only if the benefits are judged to outweigh the risks and primarily when triglycerides remain gt 500 mg dL

bull Bile acid sequestrants Consider using colesevelam for statin‑intolerant patients

bull Omega-3 fatty acids (fish oil supplements) May be used to lower triglycerides below 500 mg dL to reduce risk of pancreatitis Not recommended for reducing the risk of ASCVD

bull Niacin Not recommended

Monitoring It may be appropriate to perform the following testing to aid in monitoring treatment or compliance

bull Lipid panel ndash At baseline and 4 to 12 weeks after treatment initiation or dose adjustment ndash Annually thereafter

bull Liver function testing As a baseline prior to initiating treatment and as clinically indicated thereafter



HEART-HEALTHY LIFESTYLE MANAGEMENT

Lifestyle modification is the foundation for ASCVD risk-reduction effortsLifestyle modification is a critical component of health promotion and ASCVD risk reduction mdash both prior to and in conjunction with the use of cholesterol‑lowering drug therapies The recommendations below combine ACC AHA Guidelines of Lifestyle Management to Reduce Cardiovascular Risk and the AHA Diet and Lifestyle RecommendationsECK

Lifestyle management to reduce cardiovascular risk

AHA ACC

Lifestyle modification Recommendation Notes

Adhere to a heart-healthy eating pattern

Advise all patients to consume a diet that bull Is rich in vegetables fruits and whole grains bull Includes low-fat dairy products poultry fish legumes nontropical vegetable oils and nuts

bull Limits sweets sugar-sweetened beverages and red meats

Advise adults who would benefit from LDL-C lowering to bull Consume lt 6 of daily calories from saturated fat

bull Reduce percent of calories from trans fat to 1 or less

Advise adults who would benefit from BP lowering to bull Consume le 2400 mg of sodium day bull Further reduce sodium intake to le 1500 mg day (associated with even greater reduction in SBP) Note that even when desired daily sodium intake is not achieved a reduction of 1000 mg day from baseline provides some benefit

Achieve this pattern by following plans such as the DASH or Mediterranean diet

Adapt dietary pattern to appropriate calorie requirements personal and cultural food preferences and nutrition therapy for other conditions including diabetes

Increase physical activity

Advise all patients to engage in regular aerobic physical activity such as brisk walking at least 150 minutes week (30 minutes day most days of the week) HHS

This recommendation is consistent with Intermountainrsquos Lifestyle and Weight Management CPM

Quit tobacco Complete tobacco cessation

Maintain a normal weight

Weight loss and maintenance are critical for prevention and control of CVD risk factors

Limit alcohol consumption

Limit alcohol to le 2 drinks day in most men (le 1 drink day if 65 or older) or le 1 drink day in women and lighter-weight persons One drink = 12 oz beer 5 oz wine or 15 oz liquor hard alcohol

SUPPORT FROM AN RDN

Primary care providers are not expected to provide comprehensive nutrition education A registered dietitian nutritionist (RDN) is the best person to provide detailed information and coaching especially in patients with multiple chronic conditions

Consultation with an RDN is part of the required preventive coverage in the Affordable Care Act Commercial health plans cover three to five visits per year for diet-related conditions including high cholesterol

KEY RECOMMENDATIONSbull Advise all patients to adhere to

a heart-healthy lifestyle both prior to and in conjunction with drug therapies

bull Refer to a registered dietitian nutritionist (RDN) for detailed nutrition education and coaching



RESOURCESProvider tools

Care Process ModelsTo find this CPM and all other supporting CPMs go to intermountainphysicianorgclinicalprograms (see below) Select the Cardiovascular Clinical Program from the list at left and then the topic from the A to Z list at bottom

Flash CardsAccess related Best Practice Flash Cards by clicking the link below

Reference LinkRISK ASSESSMENT

ADULT B E S T P R A C T I C E F L A S H C A R D

CV Risk and Cholesterol

copy2014ndash2015 Intermountain Healthcare CPM078fca - 1215 Reference CPM078Not intended to replace physician judgment with respect to individual variations and needs

Heart-healthy lifestyle

Screen adults age ge 20 every 5 years

no

ESTIMATE 10-year ASCVD risk every 5 years using Pooled Cohort Equations toolscardiosourceorgASCVD-Risk-Estimator

yesClinical ASCVD

Diabetes and age 40ndash75 and LDL 70ndash189

LDL-C ge 190 mgdL

Age le 75 High-intensity statin

Moderate-intensity statin


Estimated 10-year ASCVD risk ge 75

High-intensity statin


bull Emphasize lifestyle and monitorbull Manage other risk factors

bull Emphasize lifestylebull Initiate statinbull Monitor adherencebull Manage other risk factors

Shared decision on statin use

no to statin

yes

yes

no

no

no

yes

no

Age 40ndash75

no

yes

yes

Consider additional factors

to statinyes

For recommendations based on lifetime risk including for patients who do not meet the above criteria refer to the CPM

10-year risk lt 5

10-year risk 5ndash75

10-year risk ge 75

Consider moderate- intensity statin

Consider high- or moderate-intensity statin

CV Risk and Cholesterol Flash Card

Evaluation toolsThe Intermountain Primary Care Clinical Program maintains a database of patients with certain risk factors who should be on a statin (HEDIS and STARS measures) The purpose of the database is to improve clinical care

The Diabetes Statin Report and the ASCVD Statin Report assess the percentage of patients with these conditions who are on a statin Using this information providers can identify patients who arenrsquot on a statin but could potentially benefit from being on a statin

Throughout this CPM the icon indicates instances where data is collected about these patient cohorts Reports are updated monthly and are available to Intermountain‑employed providers through the Reports Center Affiliated providers receive their reports through SelectHealth If you have questions about your report please contact Stephen Smith at StephenCSmithimailorg



RESOURCES (CONTINUED)

Patient education

Access to patient materialsIntermountain education materials are designed to support your efforts to educate and engage patients and families They complement and reinforce cholesterol management team interventions by providing a means for patients to reflect and learn in another mode and at their own pace To access these materials

bull As the iCentra EMR system is implemented search for Intermountain items in the patient education module

bull Log in to Intermountainphysicianorg and search for the patient education library under A ndash Z Then search the item number and title in the appropriate area

bull Use Intermountainrsquos Online Education Library and Print Store for one‑stop access and ordering for all Intermountain‑approved education such as fact sheets booklets and trackers

Suggested patient education

Fact sheets

bull Understanding Cholesterol

bull Cholesterol Statin Medication Decision Guide

bull Statins

bull High Blood Pressure and the DASH Diet

bull Mediterranean Diet

bull Live Well Move More

Other patient education

bull Quitting Tobacco

bull Heart Care Handbook

F A C T S H E E T F O R P A T I E N T S A N D F A M I L I E S

1

What causes itMost commonly high blood pressure develops a little at a time over many years Certain things can increase your risk for high blood pressure These are called risk

factors Some you cannot change others you can Check your risk factors on the list below See the next two pages for tips on managing the risk factors you can control

What are the symptoms Rarely people with high blood pressure may have dizziness headaches or nose bleeds However most

people donrsquot have any signs or symptoms For this reason you should have your blood pressure checked regularly even if yoursquore feeling fine

High Blood Pressure and the DASH Diet

What is high blood pressureBlood pressure is the force of blood against the inside walls of your arteries When your arteries become narrow the pressure of the blood inside goes up This causes high blood pressure (also called hypertension)

High blood pressure can damage your arteries reduce blood flow to your organs and make your heart work harder If not controlled it can lead to heart disease stroke kidney disease blindness and other health problems

How is it diagnosed To measure your blood pressure your health care provider will wrap a special cuff around your arm The cuff is attached to a machine or gauge When the cuff is inflated it measures the pressure in your blood vessels in millimeters of mercury (mmHg)

Blood pressure is measured with 2 numbers for example ldquo120 over 80rdquo (written as 120 80) The first number is your systolic pressure (when your heart beats) The second number is your diastolic pressure (when your heart rests between beats) The table below shows the numbers for normal elevated and stage 1 and 2 for high blood pressure

Your health care provider will check your blood pressure several times to determine if you have high blood pressure on a regular basis

Important keys to blood pressure control are reducing the amount of sodium (salt) in your diet a healthy diet rich in fruits and vegetables regular physical activity and home monitoring

Risk factors you CANNOT change

Risk factors you CAN change

Family history

Age Risk increases as you age

Race Risk increases in African Americans

Physical inactivity Being overweight or obese

Diet Smoking and tobacco use

Stress Use of birth control pillsBP category Systolic Diastolic

Normal less than 120 and less than 80

Elevated 120 to 129 and less than 80

Stage 1 High 130 to 139 or 80 to 89

Stage 2 High 140 or higher or 90 or higher

11

LiVe WellF A C T S H E E T F O R P A T I E N T S A N D F A M I L I E S

Live Well Move MoreNo matter what your current weight or health condition is

being active will give you a better quality of life

All activities shown are examples mdash you can pick your own

What do I choose to do

Move more

Moderate

150 minutesper week

Thatrsquos about

30 minutes on most days

Vigorous

Running

Playing catch

Vigorous

75 minutes per week

Activity tips

Breathing a bit harder but still

able to talk

Breathing fast and cannot easily talk

Brisk walking

Easy cycling

Build

Weight lifting

Doing pushups or squats

Doing heavy chores

days per week

Dancing

Doing martial arts

Practicing yoga

Moderate

or

BalanceStrength

How much

Sit less

TV computer and other

screen time

Limit

How much

Less than 2 hours per day (outside of work or school)

Break up sitting timeEvery 20ndash30

minutes stand up and move around for

2ndash3 minutes (even at work)

How much

OR a mix of both

To lose weight get twice as

much activityx2

bullNone is bad some is good more is better

bullStart small and build up a little at a time bullJust 10 minutes at a time is enough to benefit you

Fast cycling

Playing basketball

Why is being active important to me

Improve your mood

Improve sleep

z

z z z z

Be there for friends and family

Maintain healthy weight

Avoid chronic illness

Do things I love to do

11


Statins

Statins are medications that lower ldquobadrdquo (LDL) cholesterol and raise ldquogoodrdquo (HDL) cholesterol

Statin therapy works best when itrsquos combined with a heart-healthy diet and an exercise program

What are statinsStatins are a class of prescription medications that lower ldquobadrdquo cholesterol (LDL) and raise ldquogoodrdquo cholesterol (HDL) There are several different statin medications available Examples include lovastatin (Mevacor) pravastatin (Pravachol) simvastatin (Zocor) atorvastatin (Lipitor) rosuvastatin (Crestor) pitavastatin (Livalo) and fluvastatin (Lescol) Combination medications are also available such as simvastatinezetimibe (Vytorin) and others Your doctor will recommend a specific medication based on your situation Statins should always be used with exercise and a heart-healthy diet (see page 2)

What do they doStatins work by blocking an enzyme involved in how the body makes cholesterol Blocking this enzyme helps your body achieve a better balance between ldquobadrdquo (LDL) cholesterol and ldquogoodrdquo (HDL) cholesterol Your doctor can check your cholesterol by doing simple lab tests

Why is this medication important for my health

bull Abnormal cholesterol is a risk factor for heart attack and stroke ldquoBadrdquo cholesterol (LDL cholesterol) can build up in the walls of your blood vessels and block the blood flow

bull Along with a heart-healthy diet and exercise statins are one of the most effective ways to lower ldquobadrdquo cholesterol Studies have shown that statins can lower your chances of a heart attack up to 37

bull If your doctor prescribes a statin itrsquos often because a lab test has shown that your cholesterol is abnormal It may also be prescribed mdash regardless of your initial cholesterol level mdash if you have diabetes or certain other chronic illnesses or if yoursquove had a heart attack or stroke

Guidelines for taking statinsYou should always follow your doctorrsquos specific instructions for taking any medication including statins But there are some general rules that will probably apply to you

bull Before you start a statin (and while taking it) eat a diet that helps to lower cholesterol (see page 2)

bull Be sure your doctor knows about anything else you take for your health like vitamins herbal supplements or other over-the-counter and prescription medications

bull If you have a history of liver problems tell your doctor Statins are broken down in the body by the liver Sometimes liver function tests may be needed while yoursquore taking statins

bull Take it exactly as instructed Most statins should be taken once a day in the evening If you forget to take a dose take it as soon as you remember If itrsquos already time for your next dose just take the usual amount Do not double your dose

bull Tell your doctor about any side effects you notice See page 2


copy2014ndash2017 INTERMOUNTAIN HEALTHCARE ALL RIGHTS RESERVED Patient and Provider Publications CPM078 - 1217 (approved 121217) 8

This CPM presents a model of best care based on the best available scientific evidence at the time of publication It is not a prescription for every physician or every patient nor does it replace clinical judgment All statements protocols and recommendations herein are viewed as transitory and iterative Although physicians are encouraged to follow the CPM to help focus on and measure quality deviations are a means for discovering improvements in patient care and expanding the knowledge base Send feedback to Mark R Greenwood Medical Director Primary Care Clinical Program MarkRGreenwoodimailorg

REFERENCESCDC Centers for Disease Control and Prevention High cholesterol facts Available at

httpswwwcdcgovcholesterolfactshtm Last updated March 17 2015 Accessed November 1 2017

ECK Eckel RH Jakicic JM Ard JD et al 2013 AHA ACC guideline on lifestyle management to reduce cardiovascular risk Circulation 2014129(25 Suppl 2)S76-S99

GOF Goff DC Lloyd-Jones DM Bennett G et al 2013 ACC AHA guideline on the assessment of cardiovascular risk A report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines Circulation 2014129(25 Suppl 2)S49-S73

JAC Jacobson TA Ito MK Maki KC et al National Lipid Association recommendations for patient-centered management of dyslipidemia Part 1 mdash Full Report J Clin Lipidol 20159(2)129-169

JEL Jellinger PS Handelsman Y Rosenblit PD et al American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease Endocr Pract 201723(4)479-497

LLO Lloyd-Jones DM Morris PB Ballantyne CM et al 2017 Focused update of the 2016 ACC expert consensus decision pathway on non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk A report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways J Am Coll Cardiol 201770(14)1785-1822

PED Pedersen TR1 Faergeman O Kastelein JJ et al Incremental Decrease in End Points through Aggressive Lipid Lowering (IDEAL) Study Group High-dose atorvastatin vs usual-dose simvastatin for secondary prevention after myocardial infarction The IDEAL study A randomized controlled trial JAMA 2005294(19)2437-2445

RAY Ray KK Kastelein JJ Boekholdt SM et al 2013 ACC AHA guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease in adults The good the bad and the uncertain A comparison with ESC EAS guidelines for the management of dyslipidaemias 2011 Eur Heart J 201435(15)960-968

USP US Preventive Services Task Force USPSTF A and B Recommendations Available at httpswwwuspreventiveservicestaskforceorgPageNameuspstf-a-and-b-recommendations April 2017 Accessed 102617

CPM DEVELOPMENT TEAM

Jeffrey L Anderson MD

Jonathan Anderson MPH (Data Analyst)

Matt Anderson BS (Data Analyst)

Eric Carter MD

Roy Gandolfi MD

Mark R Greenwood MD (Co-chair) Medical Director Primary Care Clinical Program

Sharon Hamilton RN MS APRN-BC Clinical Operations Director Primary Care Clinical Program

Donald Lappe MD (Co-chair) Medical Director Cardiovascular Clinical Program

David Larsen (SelectHealth)

Mariam Nassif MD

Cody Olsen PharmD

Jane Sims BA (Medical Writer)

Johanna Thompson PharmD BCPS

Jeffrey Twitchel MD



ALGORITHM ASSESSMENT AND MANAGEMENT OF CHOLESTEROL LEVELS AND ASCVD RISK

CONSIDER moderate-intensity statin

(Note High-intensity statin may be indicated if higher risk greater LDL reduction desired or additional

risk factors) (e) (f)

Age 40 to 75

CONSIDER additional factors (e) in select individuals to inform

treatment decision making

yes

to statinYES

ASCVD Risk Reduction For All Patients (a)

SCREEN all adults age ge 20 years with full lipoprotein panel (fasting preferred) once every 5 years

yesno Clinical ASCVD (b)bull PRESCRIBE high-intensity

statin (c)

bull CONSIDER adding ezetimibe and or PCSK9 if needed to achieve 50 LDL reduction or if LDL remains gt 70

Indicates an Intermountain measure

LDL-C ge 190 mg dL

Diabetes(For patients age 20 to 39 or gt 75 see sidebar on page 4)

no

yes

no

no

to statinNO

ENGAGE patient in shared decision-making discussion regarding statin use

bull EMPHASIZE lifestyle and MONITOR adherence

bull MANAGE other risk factors bull EMPHASIZE lifestyle and MONITOR adherence and response with serial lipid-panel measurements

bull INITIATE statin at appropriate intensity and MONITOR adherence

bull MANAGE other risk factors

EVALUATE 10-year risk

bull ESTIMATE 10-year ASCVD risk every 5 years beginning at age 20 using Pooled Cohort Equation

bull SUPPORT primary prevention (d)

10-year ASCVD risk lt 75 10-year ASCVD risk ge 75

Age le 75yes

no

PRESCRIBE moderate-intensity statin (c)

yes

bull PRESCRIBE high-intensity statin (c)

bull CONSIDER adding ezetimibe if ndash Needed to achieve 50 LDL reduction OR ndash LDL remains gt 100 OR ndash Non-HDL remains gt 130

























Notes











(b) Clinical ASCVD


ALGORITHM NOTES








bull M791 Myalgia













bull Fibrates














AHA ACC


















SUPPORT FROM AN RDN

















no


yesClinical ASCVD


LDL-C ge 190 mgdL










no to statin

yes

yes

no

no

no

yes

no

Age 40ndash75

no

yes

yes


to statinyes


10-year risk lt 5


10-year risk ge 75










Patient education






Fact sheets



bull Statins








1














Family history










11






Move more

Moderate

150 minutesper week

Thatrsquos about


Vigorous

Running

Playing catch

Vigorous

75 minutes per week

Activity tips


able to talk


Brisk walking

Easy cycling

Build

Weight lifting


Doing heavy chores

days per week

Dancing

Doing martial arts

Practicing yoga

Moderate

or

BalanceStrength

How much

Sit less


screen time

Limit

How much





How much

OR a mix of both


much activityx2



Fast cycling

Playing basketball


Improve your mood

Improve sleep

z

z z z z





11


Statins
































Eric Carter MD

Roy Gandolfi MD





Mariam Nassif MD

Cody Olsen PharmD



Jeffrey Twitchel MD

























Notes











(b) Clinical ASCVD


ALGORITHM NOTES








bull M791 Myalgia













bull Fibrates














AHA ACC


















SUPPORT FROM AN RDN

















no


yesClinical ASCVD


LDL-C ge 190 mgdL










no to statin

yes

yes

no

no

no

yes

no

Age 40ndash75

no

yes

yes


to statinyes


10-year risk lt 5


10-year risk ge 75










Patient education






Fact sheets



bull Statins








1














Family history










11






Move more

Moderate

150 minutesper week

Thatrsquos about


Vigorous

Running

Playing catch

Vigorous

75 minutes per week

Activity tips


able to talk


Brisk walking

Easy cycling

Build

Weight lifting


Doing heavy chores

days per week

Dancing

Doing martial arts

Practicing yoga

Moderate

or

BalanceStrength

How much

Sit less


screen time

Limit

How much





How much

OR a mix of both


much activityx2



Fast cycling

Playing basketball


Improve your mood

Improve sleep

z

z z z z





11


Statins
































Eric Carter MD

Roy Gandolfi MD





Mariam Nassif MD

Cody Olsen PharmD



Jeffrey Twitchel MD








bull M791 Myalgia













bull Fibrates














AHA ACC


















SUPPORT FROM AN RDN

















no


yesClinical ASCVD


LDL-C ge 190 mgdL










no to statin

yes

yes

no

no

no

yes

no

Age 40ndash75

no

yes

yes


to statinyes


10-year risk lt 5


10-year risk ge 75










Patient education






Fact sheets



bull Statins








1














Family history










11






Move more

Moderate

150 minutesper week

Thatrsquos about


Vigorous

Running

Playing catch

Vigorous

75 minutes per week

Activity tips


able to talk


Brisk walking

Easy cycling

Build

Weight lifting


Doing heavy chores

days per week

Dancing

Doing martial arts

Practicing yoga

Moderate

or

BalanceStrength

How much

Sit less


screen time

Limit

How much





How much

OR a mix of both


much activityx2



Fast cycling

Playing basketball


Improve your mood

Improve sleep

z

z z z z





11


Statins
































Eric Carter MD

Roy Gandolfi MD





Mariam Nassif MD

Cody Olsen PharmD



Jeffrey Twitchel MD






AHA ACC


















SUPPORT FROM AN RDN

















no


yesClinical ASCVD


LDL-C ge 190 mgdL










no to statin

yes

yes

no

no

no

yes

no

Age 40ndash75

no

yes

yes


to statinyes


10-year risk lt 5


10-year risk ge 75










Patient education






Fact sheets



bull Statins








1














Family history










11






Move more

Moderate

150 minutesper week

Thatrsquos about


Vigorous

Running

Playing catch

Vigorous

75 minutes per week

Activity tips


able to talk


Brisk walking

Easy cycling

Build

Weight lifting


Doing heavy chores

days per week

Dancing

Doing martial arts

Practicing yoga

Moderate

or

BalanceStrength

How much

Sit less


screen time

Limit

How much





How much

OR a mix of both


much activityx2



Fast cycling

Playing basketball


Improve your mood

Improve sleep

z

z z z z





11


Statins
































Eric Carter MD

Roy Gandolfi MD





Mariam Nassif MD

Cody Olsen PharmD



Jeffrey Twitchel MD












no


yesClinical ASCVD


LDL-C ge 190 mgdL










no to statin

yes

yes

no

no

no

yes

no

Age 40ndash75

no

yes

yes


to statinyes


10-year risk lt 5


10-year risk ge 75










Patient education






Fact sheets



bull Statins








1














Family history










11






Move more

Moderate

150 minutesper week

Thatrsquos about


Vigorous

Running

Playing catch

Vigorous

75 minutes per week

Activity tips


able to talk


Brisk walking

Easy cycling

Build

Weight lifting


Doing heavy chores

days per week

Dancing

Doing martial arts

Practicing yoga

Moderate

or

BalanceStrength

How much

Sit less


screen time

Limit

How much





How much

OR a mix of both


much activityx2



Fast cycling

Playing basketball


Improve your mood

Improve sleep

z

z z z z





11


Statins
































Eric Carter MD

Roy Gandolfi MD





Mariam Nassif MD

Cody Olsen PharmD



Jeffrey Twitchel MD




Patient education






Fact sheets



bull Statins








1














Family history










11






Move more

Moderate

150 minutesper week

Thatrsquos about


Vigorous

Running

Playing catch

Vigorous

75 minutes per week

Activity tips


able to talk


Brisk walking

Easy cycling

Build

Weight lifting


Doing heavy chores

days per week

Dancing

Doing martial arts

Practicing yoga

Moderate

or

BalanceStrength

How much

Sit less


screen time

Limit

How much





How much

OR a mix of both


much activityx2



Fast cycling

Playing basketball


Improve your mood

Improve sleep

z

z z z z





11


Statins
































Eric Carter MD

Roy Gandolfi MD





Mariam Nassif MD

Cody Olsen PharmD



Jeffrey Twitchel MD


















Eric Carter MD

Roy Gandolfi MD





Mariam Nassif MD

Cody Olsen PharmD



Jeffrey Twitchel MD

assessing and managing - intermountain healthcare

Documents