Taken 2008 Dual Audio 72013


Statin therapy is the most effective therapy for reducing cardiac morbidity and mortality in patients with coronary artery disease and ischemic stroke. This consensus statement emphasizes the importance of primary and secondary prevention by initiating statin therapy in symptomatic patients. It also recommends that statins be used for primary prevention in individuals with risk factors (including ASCVD) or a calculated 10-year ASCVD risk equivalent to a 10-year risk >7.5% based on the Pooled Cohort Risk Equation and in asymptomatic individuals with calculated ASCVD risk of 7.5% to 10.0%. The physician decision to initiate statin therapy should be based on an assessment of the patient’s 10-year ASCVD risk, but should also consider the cost of drug therapy and the risk of adverse events that may occur with statin use. Patients without other cardiovascular risk factors or a 10-year ASCVD risk equivalent <7.5% may also benefit from statin therapy in primary prevention, but there is little evidence to support this. In patients with renal dysfunction (eg, estimated glomerular filtration rate [GFR] <60 mL/min/1.73 m2) at the time of initiation of statin therapy, dosage may be modified depending on the level of GFR. In addition, the possibility of statin-induced myopathy should be considered in patients with a history of statin-induced myopathy or other muscle symptoms. Patients with advanced liver disease (eg, Child-Pugh Score B and C) may be at an increased risk of adverse events with statins, and so the decision to initiate statin therapy in this group should be made cautiously.




The Expert Panel did not find evidence for initiation or intensification of antiplatelet therapy in prevention of ASCVD (CQ4) or VTE (CQ5). Given the lack of trial data, there is no reliable scientific evidence to support initiation or intensification of antiplatelet therapy in primary or secondary prevention, and any decision to initiate or increase antiplatelet therapy should be based on risk stratification and personal preference rather than on trial data. For the prevention of VTE, it is reasonable to perform risk assessment and to consider initiation or intensification of antiplatelet therapy based on the estimated risk of VTE in the individual, but specific to the individual. Clinical practice guidelines have existed for many years. Since 2007, the American College of Cardiology / American Heart Association (ACC/AHA) have recommended initiating antiplatelet therapy after the percutaneous coronary intervention of an acute coronary syndrome to reduce the risk of ischemic events ( Table 6, Recommendation 13). Antiplatelet therapy may be considered to reduce ischemic events in individuals undergoing PCI and who are at high risk of bleeding, after the PCI of a stable coronary plaque, at the time of PCI of acute coronary syndromes, and/or after the acute coronary syndrome. In individuals in whom the indication for antiplatelet therapy is the treatment of acute myocardial infarction, the ACC/AHA Expert Consensus document notes a risk of bleeding. A recent study, the PROTECT (Perioperative Ischemic Evaluation by Antiplatelet Therapy) trial of 7,701 individuals undergoing noncardiac surgery, showed a 45% reduction in mortality in those patients who received antiplatelet therapy compared to those who did not; however, the rate of major bleeding events was increased in the antiplatelet arm, in part because of a higher rate of gastrointestinal bleeding. (11). Importantly, the observed outcomes were not different in randomized trials of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. Recent data demonstrate that the benefit of antiplatelet therapy after surgery is not established. Individualized risk of perioperative complications (bleeding, thrombotic risks, ischemic risks) in a given patient should be assessed before surgery. Prescribing antiplatelet therapy for noncardiac surgery is supported by low-level evidence, thus prescribing with caution ( 6 ). 5ec8ef588b


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