Active Low-Carber Forums
Atkins diet and low carb discussion provided free for information only, not as medical advice.
Home Plans Tips Recipes Tools Stories Studies Products
Active Low-Carber Forums
A sugar-free zone


Welcome to the Active Low-Carber Forums.
Support for Atkins diet, Protein Power, Neanderthin (Paleo Diet), CAD/CALP, Dr. Bernstein Diabetes Solution and any other healthy low-carb diet or plan, all are welcome in our lowcarb community. Forget starvation and fad diets -- join the healthy eating crowd! You may register by clicking here, it's free!

Go Back   Active Low-Carber Forums > Main Low-Carb Diets Forums & Support > Low Carb Health & Technical Forums > Cholesterol, Heart Disease
User Name
Password
Register FAQ Members Calendar Mark Forums Read Search Gallery My P.L.A.N. Survey


Reply
 
Thread Tools Display Modes
  #1   ^
Old Tue, Nov-13-18, 11:43
JEY100's Avatar
JEY100 JEY100 is offline
To Good Health!
Posts: 11,343
 
Plan: Keto/DrWestman/IF/DrFung
Stats: 222/172/169 Female 5' 9"
BF:45%/25.3%/24%
Progress: 94%
Location: NC
Default AHA new Revised Guidelines - 2018

The AHA last revised guidelines in 2013. The new 2018 guidelines released with more inclusion of the CAC score.

https://www.dietdoctor.com/manageme...st-got-personal

Management of blood cholesterol just got personal
by Dr. Bret Scher, MD


Quote:
Don’t look now, but the updated clinical practice cholesterol guidelines from the American College of Cardiology, the American Heart Association and others are getting personal. Although the guidelines still contain their familiar approach — that I consider too aggressive with drug therapy — the latest 2018 version of the guidelines now includes an impressive update to emphasize lifestyle intervention, plus a more individualized approach for risk assessment.

MedPage Today: AHA: Revised Lipid Guide Boosts PCSK9s, Coronary Calcium Scans

Could this be the start of a progressive trend away from shotgun statin prescriptions? I sure hope so.

Prior guidelines emphasized the 10-year ASCVD risk calculator as the main determining factor for statin therapy. In the 2018 update, the guidelines acknowledge that the calculator frequently overestimates the risk in those individuals who are more involved with prevention and screening. (In other words, those patients more interested in and proactive about their health; I find many in the low-carb world fall into this category.)

The ensuing discussion with a healthcare provider should then focus on:

[T]he burden and severity of CVD risk factors, control of those other risk factors, the presence of risk-enhancing conditions, adherence to healthy lifestyle recommendations, the potential for ASCVD risk-reduction benefits from statins and antihypertensive drug therapy, and the potential for adverse effects and drug–drug interactions, as well as patient preferences regarding the use of medications for primary prevention… and the countervailing issues of the desire to avoid “medicalization” of preventable conditions and the burden or disutility of taking daily (or more frequent) medications.
I appreciate the attention the new guidelines bring to the depth of the discussion that should ensue between doctor and patient. Considering the treatment burden is equally as important as the burden of disease, and possibly even more important in patients who have not been diagnosed with heart disease, these individualized discussions about trade-offs are critical to personalized care.

Also worthy of mention is the increased use of coronary artery calcium scores (CAC) to help individualize risk stratification. The updated guidelines specify CAC may be useful for those age 40-75 with an intermediate 10-year calculated risk of 7.5%-20%, who after discussion with their physician are unsure about statin therapy. They specify that a CAC of zero would suggest a much lower risk than that calculated by the ASCVD risk formula, and thus take statins off the table as a beneficial treatment option.

This is huge. I cheered when I read this! I have been critical of prior guidelines that focused on ways to find more people to place on statins. The mention of finding individuals unlikely to benefit from statins is a giant step in the right direction.

The guidelines go even further: they mention that a CAC either over 100 or greater than the 75th percentile for age increases the CVD risk and the likely benefit of a statin. A CAC between 1-99 and less than the 75th percentile does not affect the risk calculation much and it may be worth following the CAC in five years in the absence of drug therapy. I would still argue that a CAC >100 does not automatically equal a statin prescription and we need to interpret it in context, but I greatly appreciate this attempt at a more personalized approach.

The guidelines also go beyond the limited risk factors included in the ASCVD calculator by introducing “risk modifying factors” such as:

Premature family history of CVD
Metabolic syndrome
Chronic kidney disease
Chronic inflammatory conditions such as rheumatoid arthritis and psoriasis
Elevated CRP > 2.0 mg/L
Elevated Lp(a) > 50 mg/dL or 125 nmol/L
Elevated triglycerides > 175 mg/dL
Although they use these criteria to define an increased risk, the opposite would likely hold true. An absence of those criteria could define a lower risk situation.

Some changes deserve mention from a controversy standpoint as well. For instance, the new guidelines recommend checking lipid levels as early as two years old in some circumstances. Two!

They also recommend statin therapy for just about everyone with diabetes with no mention of attempting to reverse diabetes before starting a statin, a drug that has been shown to worsen diabetes and insulin resistance. In addition, the new guidelines do not mention the likely discordance between LDL-C and LDL-P in those with diabetes.

Last, the new guidelines define an LDL-C > 190 mg/dL as an absolute indication for statin therapy with a treatment goal of 190 mg/dL is in familial hypercholesterolemia populations (and even then has heterogenous outcomes). There is a clear lack of data supporting that same recommendation for metabolically healthy individuals with no other cardiac risk factors and no other characteristics of familial hypercholesterolemia. This is a clear example of when a guideline turns from “evidence based” to “opinion based.”

In summary, the guideline committee deserves recognition for its emphasis on an individualized care approach, its use of CAC, and its broader description of discussing potential drawbacks of drug treatment. It still combines opinion with evidence and believes all elevated LDL is concerning, but I for one hope it will continue its progression away from generalizations and someday soon see that individual risk variations exist, even at elevated LDL-C levels.

Thanks for reading,
Bret Scher MD FACC



MedPageAHA: Revised Lipid Guide Boosts PCSK9s, Coronary Calcium Scans
New recommendations aim to cut statins in low-risk primary prevention


Quote:
CHICAGO -- Updated national lipid guidelines present an algorithm for when to reach for a PCSK9 inhibitor and revise risk assessment in primary prevention.

The PCSK9 inhibitors were recommended by the American Heart Association (AHA) and American College of Cardiology (ACC) as "reasonable" for very high-risk atherosclerotic cardiovascular disease patients with multiple prior major events or a single such event plus multiple high-risk conditions when low-density lipoprotein (LDL) is 70 mg/dL or higher on maximally tolerated statin and ezetimibe (Zetia) therapy.

The class also got "may be considered" status for primary hypercholesterolemia regardless of 10-year atherosclerotic cardiovascular disease risk if LDL starts at 190 mg/dL or greater and doesn't drop below 100 mg/dL on a high-intensity statin plus ezetimibe and remains ≥100 mg/dL and the patient has multiple factors that increase risk.

"Ezetimibe is much less expensive, so we want people to try that first," noted Donald Lloyd-Jones, MD, of Northwestern University and a co-author of the guidelines released here at the AHA meeting and published simultaneously online in Circulation.

Click here for exclusive video comments from study authors and leading cardiologists on the AHA late-breaking trials.
The other big change in the guidelines was in risk assessment for lipid-lowering primary prevention in people without diabetes.

It's the same risk-pooled cohort equations and calculator that were so controversial when released in 2013, "but we use it in a much more sequential way that gets to much better answers," noted Lloyd-Jones in an interview with MedPage Today. "Between the risk-enhancing things and the coronary calcium scanning, we're going to be much smarter about who should and should not be on a statin."

He and his colleagues dug into concerns of overestimation of risk with those tools in a special report published alongside the guidelines in Circulation. They found nuance.
"In the broad clinical population, they actually seem to be well calibrated," he said. "In patients in groups where they are high socioeconomic status or they're very [sic...no idea dropped sentence?]

Thus, the guidelines recommended to personalize the discussion for adults ages 40 to 75 before starting statins for primary prevention, with review of major risk factors including 10-year atherosclerotic cardiovascular disease risk calculation, comorbidities and history that could play a role, potential for adverse effects, costs, and patient preferences and values.
Coronary artery calcium (CAC) scans got a boost from a 2b recommendation to now a 2a endorsement for an intermediate-risk group: adults 40 to 75 years of age without diabetes, with LDL in the 70 to 189 mg/dL range, at a 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 7.5% to 19.9%, if the decision about statin therapy is uncertain.

"If CAC is zero, treatment with statin therapy may be withheld or delayed, except in cigarette smokers, those with diabetes mellitus, and those with a strong family history of premature ASCVD," the document said.

That's actually about half of this large indeterminate group, Lloyd-Jones noted.
While the U.S. Preventive Services Task Force opted earlier this year not to back CAC scans for cardiovascular risk assessment in asymptomatic people due to insufficient evidence supporting a clinical endpoint benefit, the observational evidence was enough for the AHA/ACC. "We know what statins can do for those people in terms of reducing risk," Lloyd-Jones said.

"My personal hope is that that will push payers to start to cover this, because that has been a long time coming."

Additional groups that endorsed the recommendations were the American Association of Cardiovascular and Pulmonary Rehabilitation, American Academy of Physician Assistants, Association of Black Cardiologists, American College of Preventive Medicine, American Diabetes Association, American Geriatrics Society, American Pharmacists Association, American Society for Preventive Cardiology, National Lipid Association, and Preventive Cardiovascular Nurses Association.
Reply With Quote
Sponsored Links
  #2   ^
Old Tue, Nov-13-18, 11:59
Ms Arielle's Avatar
Ms Arielle Ms Arielle is offline
Senior Member
Posts: 13,104
 
Plan: atkins
Stats: 255/214/153 Female 5'8"
BF:
Progress: 40%
Location: Massachusetts
Default

WHile I need a cup of coffee to red all the good stuff above, I will point out this"

Quote:
Some changes deserve mention from a controversy standpoint as well. For instance, the new guidelines recommend checking lipid levels as early as two years old in some circumstances. Two!


In reality it not a blood test that is needed but a dietary intervention.

I will never forget many years ago sitting and waiting my turn among dozens of others at the hospital for a blood draw. ANd a toddler in her wheeler was beening fed CHeetos, one after another after another. HORRORS!! My kids didnt even know what those things were until school age. Later I had to tell myself that maybe this parent was suddenly stuck at the hospital unexpectedly and had nothing else. ( there is a reason moms pack a huge bag before leaving the house with kiddos) and the only choice was the vending machine full of junk. In the years since as I think back on this, which has enered my mind MANY times, understanding the pressure to eat junk food starts at an early age.

Now that my kids are teens, outside influences are still the greatest risk ......
Reply With Quote
  #3   ^
Old Tue, Nov-13-18, 12:36
Meme#1's Avatar
Meme#1 Meme#1 is offline
Posts: 11,801
 
Plan: Atkins DANDR
Stats: 210/188/160 Female 5'4"
BF:
Progress: 44%
Location: Texas
Default

The big diaper bag full of baby supplies, yes, me too!

I had a horrendous site when I saw a HUNGRY skinny baby being fed table food at a restaurant. I couldn't believe it. The baby probably only had a couple of teeth at that point. I guess she was swallowing it whole. She kept screaming too and the waitress had her eyes bugging out at the sound and sight of this situation.

Tell me that these parents couldn't afford baby food when they were out eating at a restaurant!
Reply With Quote
  #4   ^
Old Tue, Nov-13-18, 12:44
Ms Arielle's Avatar
Ms Arielle Ms Arielle is offline
Senior Member
Posts: 13,104
 
Plan: atkins
Stats: 255/214/153 Female 5'8"
BF:
Progress: 40%
Location: Massachusetts
Default

I never took my kids out to restaurants--- until they were old enough to have manners and not upset the other patrons. To this day I cannot handle a crying baby--- sets off my " mommy alert" response: crying babies are in trouble.

I can remember when a horse broke my right wrist that I could not cook for my kids. DH had to open a couple jars of baby food every day, and on the days he forgot, I was in tears. Providing for my kids is everything to me.

Fortunately for my kids I was reading DANDR before they were born. ANd I know I know more than the doctors about nurition. No matter how many times they tried to get me to feed skim milk or was it 2%?, I gave them whole milk.

Quote:
"In the broad clinical population, they actually seem to be well calibrated," he said. "In patients in groups where they are high socioeconomic status or they're very [sic...no idea dropped sentence?]
We do not tech nutrition in any meaningful way. WHen I am low on funds, I buy ONLY the most nutritious foods. Meats and vegies. It is about nutrient dense not junk food. ALso food pantries only, mostly, provide only canned goods and cereal products. Junk and worse junk.
Reply With Quote
  #5   ^
Old Wed, Nov-21-18, 21:25
jschwab jschwab is offline
Senior Member
Posts: 6,269
 
Plan: Atkins72/Paleo/NoGrain/IF
Stats: 285/214/200 Female 5 feet 5.5 inches
BF:
Progress: 84%
Default

Quote:
Originally Posted by Meme#1
The big diaper bag full of baby supplies, yes, me too!

I had a horrendous site when I saw a HUNGRY skinny baby being fed table food at a restaurant. I couldn't believe it. The baby probably only had a couple of teeth at that point. I guess she was swallowing it whole. She kept screaming too and the waitress had her eyes bugging out at the sound and sight of this situation.

Tell me that these parents couldn't afford baby food when they were out eating at a restaurant!


Wait. I don't understand this comment. Why wouldn't the kid be OK eating the same food as the parents. Baby food from a jar is absolute junk. My kids ate real food from the time they were old enough to eat solid food. Baby food is not normal.
Reply With Quote
Reply

Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

vB code is On
Smilies are On
[IMG] code is On
HTML code is Off



All times are GMT -6. The time now is 04:17.


Copyright © 2000-2020 Active Low-Carber Forums @ forum.lowcarber.org
Powered by: vBulletin, Copyright ©2000 - 2020, Jelsoft Enterprises Ltd.