Download - NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
1/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
2/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
3/52
In patients without coronary heart disease
(CHD), the NCEP recommends screening
with a complete lipid profile after a 12
hours fast for all adults > 20 years of age
once every 5 years and as indicated
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
4/52
DETECTION, EVALUATIONand
TREATMENTof High BloodCholesterol in Adults
RISK ASSESSMENT in an effort to
reduce premature death and disabilityfrom CHD
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
5/52
1stNCEP
outlined a strategy for primary preventionof CHD in persons with high levels of LDL
>160mg/dL or those with borderline high
LDL (130-159 mg/dL) and multiple (2+) risk
factors
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
6/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
7/52
Expand the prior list of cardiovascular
events to include virtually all occlusive
vascular diseases of the heart as well as
the brain and peripheral arteries.
Focus on global risk assessment rather
than just lipid parameters
GRAquantitation of the 10 year risk of
developing CHD
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
8/52
Major New Feature:
Primary prevention in persons with
multiple risk factors
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
9/52
DMCHD risk equivalent
Thus, all diabetic px should be treated as
aggressively as px who have survived a
prior occlusive event of the heart, brain or
peripheral arteries
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
10/52
Modifications of Lipid and Lipoprotein
Classficiation
Identifies LDL
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
11/52
mg/dL
LDL Cholesterol
190 Very High
Total cholesterol
240 High
HDL Cholesterol
60 High
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
12/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
13/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
14/52
Any person with elevated LDL or other
form of hyperlipidemia should undergo
clinical or laboratory assessment to rule
out secondary dyslipidemia before initiationof lipid-lowering therapy.
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
15/52
Causes of secondary dyslipidemia:
Hypothyroidism
Obstructive Liver Disease
Chronic Renal Failure Drugs that inc LDL and dec HDL (progestins,
anabolic steroids, and corticosteroids
Once secondary causes have been excluded, or,
if appropriately treated, the goals for LDLlowering therapy in primary prevention areestablished according to a persons risk category
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
16/52
First step in risk management
Basic principle of prevention
1st
step in selection of LDL loweringtherapy to assess a persons risk status
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
17/52
Risk status in person without clinicallymanifest CHD or other clinical forms ofatherosclerotic disease is determined by a
2-step procedure First, the number of risk factors is counted
Second, for persons with multiple (2+) risk
factors, 10 yr risk assessment is carriedout with Framingham Scoring to identifyindividuals whose short term (10yr) riskwarrants consideration of intensive
treatment
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
18/52
Estimation of the 10 yr CHD risk adds a
step to risk assessment beyond risk factor
counting, but this step is warranted
because it allows better targeting ofintensive treatment to people who will
benefit from it.
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
19/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
20/52
Risk Category LDL Goal (mg/dL)
CHD and CHD riskequivalents
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
21/52
Healthcare providersasked to quantitatethe 10 yr risk of all primary prevention pxwith 2 or more risk factors using the
Framingham Risk Assessment System Sex
Age
Cholesterol status
HDL
Systolic BP
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
22/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
23/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
24/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
25/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
26/52
More robust for total cholesterol than LDL
Total cholesterol and HDL values should
be the average of at least 2 measurements
obtained from lipoprotein analysis
BP- obtained at the time of assessment,
regardless of whether the person is on
antihypertensive therapy
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
27/52
If absolute risk is 20% or greater, primary
prevention px should be treated as
aggressively as a patient who experience a
previous event
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
28/52
Primary prevention patient at high risk
due to multiple metabolic risk factorsor
metabolic syndrome
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
29/52
3 out of 5 factors:
Abdominal obesity (waist >101.6cm/40in in
men and >88.9cm/35in in women)
Low HDL levels (130 or diastolic
>85mmHg)
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
30/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
31/52
Large and usually more-than-additive
benefits in terms of risk reduction
Efficacy of drug therapy with statins is
enhanced
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
32/52
Reduced intake of saturated fats and
cholesterol
Therapeutic options for enhancing LDL
lowering such as plant stanols and sterols
and increased viscous fiber
Weight reduction
Increased physical activity
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
33/52
Saturated fat less than 7% of total calories
and cholesterol
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
34/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
35/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
36/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
37/52
3-hydroxy-3-methylglutaryl coenzyme A
reductase inhibitors
STATINS
Recommended by NCEP as the 1stline
drug of choice for virtually all pxs eligible
for lipid modification
Goal -> drug therapy + therapeutic lifestyle
changes
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
38/52
STATINS
lower TC, LDL, and TG and inc HDL
LDL reduction of approx 35% Meta-analysis
Primary and secondary prevention pxs
assigned at random to statins
22% reduction in cholesterol
30% reduction in LDL
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
39/52
STATINS
Beneficial changes were associated with
significantly reduced risks of:
MI,
stroke
vascular death total mortality
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
40/52
STATINS
Reduce LDL levels by at least 30-35%
Usual starting doses of atorvastatin,fluvastatin and simvastatin provide even
larger decreases
Starting dose of atorvastatin yield the
largest reduction
All statins have favorable safe profile
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
41/52
STATINS
Induced liver dysfunction and myopathy
RARE
Higher doses will provide an even greater
reduction in LDL with proportionately less
increases in HD
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
42/52
STATINS
Atorvastatin 10mg, 20mg, 4omg, 80mg:
10-80mg tab OD-HS
Simvastatin 10mg, 20mg, 40mg: 5-
40mg/day: start with 10mg OD HS
Rosuvastatin 5mg, 10mg, 20mg: 5-20mg
OD HS
Pravastatin 10mg, 20mg: 10-40mg OD HS
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
43/52
Fibrates
Gemfibrozil 300-600mg BID
Fenofibrate 100-300mg cap ODNicotinic Acid
Nicotinic acid 50mg, 100mg: 50mg OD then
inc up to 100mg TID
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
44/52
Combination Therapy
Statin + Niacin of fibratesyield greater
elevations of HDL and decrease in
Triglycerides but increased risk of myopathy
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
45/52
Progression of Drug Therapy
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
46/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
47/52
No level of HDL protects against HDL
Thus, there needs to be a wider usage of
statins in px with LDL despite the
presence of normal or HDL level
HDL with LDLat sufficient risk to
warrant lipid modification
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
48/52
Airforce/Texas Coronary Atherosclerosis
Prevention Study
Px with normal LDL but HDL -> statin ->
cardiovascular benefits
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
49/52
Adherence to the NCEP guidelines by both
patients and providers is a key to
approximating the magnitude of the
benefits demonstrated in clinical trials ofcholesterol lowering.
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
50/52
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
51/52
These guidelines are intended to inform,
not replace, the physicians clinical
judgment, which must ultimately determine
the appropriate treatment for eachindividual.
-
8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx
52/52