 benefits and betes,andsmokingstatusasriskfactorsinthepredictionmodeland harms of screening for dyslipidemia in children and adolescents. Specific recommendations from other organiza- ofbenefitthataninterventionwithdemonstratedefficacycanhave tions for such individuals are discussed in the “Recommendations in a specific population directly depends on the incidence of dis- of Others” section. This is one of optimal intervals for cardiovascular risk assessment are uncertain. StatinRegimensUsedinAvailableTrials Dose, mga Statin Low Moderate High Atorvastatin 10-20 40-80 Fluvastatin 20–40 40 twice daily Fluvastatin extended release 80 Lovastatin 20 40 aDosecategoriesarefromthe AmericanCollegeof Pitavastatin 1 2-4 Cardiology/AmericanHeart Pravastatin 10-20 40-80 Association2013guidelinesonthe Rosuvastatin 5-10 20-40 treatmentofbloodcholesterolto reduceatherosclerotic Simvastatin 10 20-40 24 cardiovascularriskinadults. Thedegreeofcholesterolreductionmaybeattributable, shared decision making that weighs the potential benefits and in part, to interindividual variability in response to statins, not just harms, the uncertainty about risk prediction, and individual statin dosage. There Suggestions for Practice Regarding the I Statement may be individual clinical circumstances that warrant consider- for Initiating Statin Therapy for Primary Prevention ation of use of high-dose statins; decisions about dose should be based on shared decision making between patients and clinicians. Anotherstudyusing Burden of Disease datafromtheMedicalExpenditurePanelSurvey,whichdidallowfor In 2011, an estimated 375 000 adults died of coronary heart dis- thedifferentiationofindividualswithandwithoutvasculardisease easeand130 000diedofcerebrovasculardisease. Themediandurationoffollow-upwas3years, Other Considerations and 3 trials were stopped early because of observed benefits in the Research Needs and Gaps interventiongroup. Research is needed to Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm) evaluate the optimal frequency of cardiovascular risk assessment, trials10,40 because of their large sample sizes, the estimate was including serum lipid screening. After6months harms of initiating statin use for the primary prevention of cardio- to 6 years of follow-up, statin use was associated with a decreased vascular events in adults 76 years and older. However, in the available estimates when trials were stratified according to dose. Nostudieswere tent across different clinical and demographic subgroups (even identifiedthatdirectlycomparedtreatmentwithstatinstitratedto among adults without marked dyslipidemia). Becausetheab- Harms of Statin Use soluteunderlyingriskislower,feweradultswhosmokeorhavedys- In randomized trials of statin use for the primary prevention of lipidemia,diabetes,orhypertensionanda7. As such, any decision to ini- withdrawal because of adverse events compared with placebo, tiateuseofalow-tomoderate-dosestatininthispopulationshould and there were no statistically significant differences in the risk of involve shared decision making that weighs the potential benefits experiencing any serious adverse event. It should also take into consideration the personal prefer- levels with statin use. Some comments requested clarification regarding the op- foundnoassociationwithstatinuse,41butananalysisfromtheWo- timal dose of statins. Thesepersonsshouldbescreenedandtreatedinaccordancetoclini- Recommendations of Others cal judgment for the treatment of dyslipidemia. Thetreatmentstrat- ment is no longer relevant and has been replaced by a preventive egy is treatment-to-target rather than by therapy dose (eg, 50% medication framework. Total cardiovascularrisk:areportoftheAmerican AspirinUsetoPreventCardiovascularDiseaseand cholesterol and risk of mortality in the oldest old. The tables and figures in this Pocket Guide follow the numbering of the 2017 Global Strategy Report for reference consistency. These include genetic abnormalities, abnormal lung development and accelerated aging. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently. Spirometry is the most reproducible and objective measurement of airflow limitation. Despite its good sensitivity, peak expiratory flow measurement alone cannot be reliably used as the only diagnostic test because of its weak specificity. Spirometry should be performed after the administration of an adequate dose of at least one short-acting inhaled bronchodilator in order to minimize variability. Spirometry in conjunction with patient symptoms and exacerbation history remains vital for the diagnosis, prognostication and consideration of other important therapeutic approaches. In the refined assessment scheme, patients should undergo spirometry to determine the severity of airflow limitation (i. Finally, their history of exacerbations (including prior hospitalizations) should be recorded. This classification scheme may facilitate consideration of individual therapies (exacerbation prevention versus symptom relief as outlined in the above example) and also help guide escalation and de-escalation therapeutic strategies for a specific patient. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen. If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved. Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Stimulation of beta2-adrenergic receptors can produce resting sinus tachycardia and has the potential to precipitate cardiac rhythm disturbances in susceptible patients. Exaggerated somatic tremor is troublesome in some older patients treated with higher doses of beta2-agonists, regardless of route of administration. Antimuscarinic drugs  Antimuscarinic drugs block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in airway smooth muscle. Inhaled anticholinergic drugs are poorly absorbed which limits the troublesome systemic effects observed with atropine. Toxicity is dose-related, which is a particular problem with xanthine derivatives because their therapeutic ratio is small and most of the benefit occurs only when near-toxic doses are given. Results from withdrawal studies provide equivocal results regarding consequences of withdrawal on lung function, symptoms and exacerbations. Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed.
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