Translating Guidelines Into Practice: Interpreting the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk.

OBJECTIVE: In 2016, the American College of Cardiology released a decision pathway, based on expert consensus, to guide use of non-statin agents in the management of atherosclerotic cardiovascular disease risk. The purpose of this article is to assist practitioners, health systems and managed care entities with interpreting this consensus statement in order to simplify implementation of the recommendations into patient care. METHODS: Major themes from the consensus statement are briefly summarized and explained. Drug therapy recommendations are condensed into a single algorithm, while tables correlate each recommended regimen with the appropriate patient population from both a patient-level and systems-level perspective. Finally, a patient case with evidence-based decision support is explored. RESULTS: These tools allow practitioners to make appropriate patient-specific decisions about the use of non-statin pharmacotherapy and enable health systems and managed care entities to more readily identify guideline-appropriate use of these agents upon review of patient profiles or prescribing patterns. CONCLUSION: This article provides resources for healthcare providers that facilitate uptake of these recommendations into clinical practice.

What's next for dyslipidemia management? The 2013 ACC/AHA Guidelines, the NLA recommendations, and beyond.

OBJECTIVES: To compare and contrast the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines and the 2014/2015 National Lipid Association (NLA) Recommendations for Management of Dyslipidemia in the context of evolving evidence. DATA SOURCES: Guidelines from the National Cholesterol Education Program (NCEP), ACC/AHA, and NLA; recent clinical trials involving non-statin therapies. STUDY SELECTION: Not applicable. DATA EXTRACTION: At the authors' discretion, preference was given to references focusing on guidelines and recent clinical trials involving dyslipidemia management. RESULTS: In late 2013, the ACC/AHA released guidelines on the treatment of blood cholesterol to reduce risk for atherosclerotic cardiovascular disease (ASCVD) in adults. Reflecting contemporary evidence-based literature, low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) numeric treatment goals were eliminated, and a new method of risk assessment (the Pooled Cohort Equations) was recommended. The guidelines emphasized lipid lowering in 4 patient populations proven to benefit from statin therapy, recommending moderate to high-intensity statin dosing, with no additional drug therapies and limited ongoing monitoring. Clinical controversies ignited by these guidelines led to the publication of recommendations by the NLA in 2014 and 2015. Part 1 of the NLA recommendations incorporated parts of both the ATP III guidelines and the 2013 ACC/AHA guidelines along with updated original recommendations. These recommendations provided numeric LDL-C, non-HDL-C, and apolipoprotein B treatment goals and potential additional ASCVD risk factors, with stepwise risk assessment based on traditional cardiac risk factors and multiple assessment tools. In addition to statins, the 2014 NLA recommendations highlighted the benefit of additional or alternative lipid-lowering therapies. Part 2 of the NLA recommendations expanded the guidance for treatment of special populations and prioritized ezetimibe as a non-statin agent based on recent evidence. Finally, the US Food and Drug Administration recently approved 2 medications from a new class, the PCSK9 inhibitors, although their role in therapy remains unclear pending outcomes data. CONCLUSION: We aim to highlight the core recommendations of recent guideline publications and to discuss similarities and differences in the context of the future management of dyslipidemia.

Lisinopril-Induced Alopecia: A Case Report.

The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines consider angiotensin-converting enzyme (ACE) inhibitors as one of the mainstay therapies in the management of heart failure. The widespread use of ACE inhibitors has been associated with several notable adverse effects such as hyperkalemia and an increased serum creatinine. There are no previous reports of alopecia associated with lisinopril use; however, a few previous cases of alopecia associated with other ACE inhibitors exist. This report discusses a case of lisinopril-induced alopecia of a 53-year-old male presenting to our outpatient heart failure clinic with a chief complaint of a new onset of alopecia. Upon evaluation, it was suspected that the patient's alopecia was likely medication induced by lisinopril; therefore, lisinopril was discontinued and switched to an angiotensin receptor blocker (ARB), losartan potassium. Alopecia resolved in 4 weeks after the therapeutic intervention. Our report suggests that the patient likely experienced a medication-induced alopecia, which was successfully resolved through proper identification and removal of the causative agent. Causality assessment between lisinopril and alopecia was determined using the Naranjo Adverse Drug Reaction Probability Scale-a total score of 6 was achieved and thus identified the adverse drug reaction as probable. Clinicians should be aware of the possibility that lisinopril may be an offending agent in a patient with unexplained alopecia.

Cangrelor: a novel intravenous antiplatelet agent with a questionable future.

Current percutaneous coronary intervention (PCI) guidelines recommend the use of a P2Y12 inhibitor with aspirin and an injectable anticoagulant. However, available oral P2Y12 inhibitor therapy is limited by significant drug interactions, unclear oral absorption in selected clinical conditions, and delayed onset and offset of activity that may be cumbersome for patients requiring coronary artery bypass graft (CABG) surgery. Cangrelor, a novel intravenous P2Y12 inhibitor, offers potential advantages compared with currently available oral agents, particularly in regard to rapid onset and offset of platelet inhibition. The Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition (CHAMPION) trials compared cangrelor versus an oral loading dose of clopidogrel, given before or after PCI, in patients with both stable and acute coronary syndromes. The results were conflicting, but some evidence demonstrated a lower rate of stent thrombosis compared with clopidogrel and lower rates of a composite cardiovascular end point, with comparable bleeding rates. The BRIDGE study assessed cangrelor as a replacement for oral P2Y12 inhibitors in patients awaiting CABG surgery and demonstrated that cangrelor maintained platelet inhibition during the preoperative period and enabled a rapid return to baseline platelet function upon cessation of the infusion. A new drug application was submitted to the Food and Drug Administration (FDA) for use during PCI to prevent thrombotic events and as bridging therapy for patients awaiting surgery who require therapy with P2Y12 inhibitors. In February 2014, the FDA's Cardiovascular and Renal Drugs Advisory Committee recommended against approval due to concerns over an appropriate risk-benefit ratio for use during PCI and a lack of evidence supporting the bridging indication. On April 30, 2014, the FDA issued a Complete Response letter for the PCI and bridging indications, denying approval and requesting further data. The future of this once promising novel intravenous antiplatelet agent is now in question.