dyslipidemia guideline review : the transatlantic differences
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ESC and ACC/AHA dyslipidemia guidelinesTRANSCRIPT
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Dyslipidemia guidelines update
ByAshraf Reda, MD, FESC
Prof and head of Cardiology Dep. Menofiya University
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LDL-C Goals for High Risk Patients
*And other forms of atherosclerotic disease.2
† Factors that place a patient at very high risk: established cardiovascular disease plus: multiple major risk factors (especially diabetes); severe and poorly controlled risk factors (e.g., cigarette smoking); metabolic syndrome (triglycerides ≥200 mg/dL + non–HDL-C ≥130 mg/dL with HDL-C <40 mg/dL); and acute coronary syndromes.1
1. Grundy SM et al. Circulation 2004;110:227–239.2. Smith SC Jr et al. Circulation 2006; 113:2363–2372.
<100 mg/dL
<70 mg/dL
Recommended LDL-C treatment goals
2006Update
• If it is not possible to attain LDL-C <70 mg/dL because of a high baseline LDL-C, it generally is possible to achieve LDL-C reductions of >50% with more intensive LDL-C–lowering therapy, including drug combinations.
ATP IIIUpdate 20041
<100 mg/dL:Patients with CHD or CHD risk equivalents(10 year risk >20%)1
<70 mg/dL:Therapeutic option for very high risk patients1
AHA/ACC guidelinesfor patients with CHD*,2
<100 mg/dL:Goal for all patients with CHD†,2
<70 mg/dL:A reasonable goal for all patients with CHD2
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Goals
LDL-C Non–HDL-C Apo B
Highest-Risk Patients <70 mg/dL <100 mg/dL <80 mg/dL
• Known cardiovascular disease (CVD)
• Diabetes plus ≥1 additional major CVD risk factor
High-Risk Patients <100 mg/dL <130 mg/dL <90 mg/dL
• No diabetes or known CVD but ≥2 major CVD risk factors
• Diabetes but no other major CVD risk factors
“In individuals on statin therapy who continue to have low HDL-C or elevated non–HDL-
C, especially if Apo B levels remain elevated, combination therapy is recommended. The preferred agent to use in combination with a statin is nicotinic acid…”
Reprinted from Brunzell JD, et al. J Am Coll Cardiol.2008;51:1512–1524 ,with permission from Elsevier.
ADA/ACC 2008 Consensus Statement:Treatment Goals for Patients With
Cardiometabolic Risk and Lipoprotein Abnormalities
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ESC/EAS 2011
• Life style intervention should be tried first• If not effective statin is the first choice• Addition of Ch. Absorption inhibitors, bile acid
Seq. or niacin if not at goal
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Calculating the risk: SCORE
• Very high, high, moderate or low risk• Total and HDL-c are incorporated• Relative risk charts for young apparently low
risk individuals• Charts for low and charts for high risk region• Charts for different HDL levels
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LDL levels are the main target of lipid management
• Less than 115 mg/dl in moderate risk• Less than 100 mg/dl in high risk• Less than 70 mg/dl in very high risk
• If target can’t be achieved………50% reduction• Non-HDL-c and Apo-B potential targets in
DM2, Met.S and combined dyslipidemia
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Non-HDL Includes All Atherogenic Lipoprotein Classes
Very low-density lipoprotein– Made in the liver– TG >> CE– Carries lipids from the liver to peripheral tissues
HDL
LDL
IDL
VLDL
Atherogenic
Lip
op
rote
ins
No
n-H
DL
; A
po
B1
00-
con
tain
ing
Intermediate-density lipoprotein– Formed from VLDL due to loss of TG– Also known as a VLDL remnant
Low-density lipoprotein – Formed from IDL due to loss of TG– CE>>TG
High-density lipoprotein– Removes cholesterol from peripheral tissues
Lp(a)Lipoprotein (a)
– Formed from LDL w/ addition of apo (a)?– Very atherogenic
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LIPID PROFILEEGYPTIAN RF AND LIPID PROJECT
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Non-HDL-c and Apo-B targets
• The goal for non HDL-c is 30 mg above LDL goal
• Apo-B goal less than 80 mg/dl in very high and less than 100 mg/dl in high risk
• Especially considered as 2ry target in atherogenic dyslipidemia with average LDL
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American Diabetes Association (2009)Treatment recommendations and goals
• Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients:– with overt CVD – without CVD who are over the age of 40 and
have one or more other CVD risk factors.
Level of Evidence
A
A
DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009
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American Diabetes Association (2009)Treatment recommendations and goals
• In individuals without overt CVD, the primary goal is an LDL cholesterol 100 mg/dl.
• In individuals with overt CVD, a lower LDL cholesterol goal of 70 mg/dl, using a high dose of a statin, is an option.
• If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 30–40% from baseline is an alternative therapeutic goal.
Level of Evidence
A
B
A
DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009
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Although there are no specific goals , however Trigs., and HDL are important risk determinant
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If TG are 200–499 mg/dL, non-HDL-C should be <130 mg/dL
Lipid Management in high TG: Recommendation
l lla llb lll
B
l lla llb lll
BFurther reduction of non-HDL-C to <100 mg/dL is reasonable
Therapeutic options to reduce non-HDL-C:More intense LDL-C–lowering therapy I (B) orNiacin (after LDL-C–lowering therapy) IIa (B) orFibrate (after LDL-C–lowering therapy) IIa (B)
l lla llb lll
CIf TG are >500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy, Achieve non-HDL-C <130 mg/dL, if possible
TG=Triglycerides; HDL-C=high-density lipoprotein cholesterolSmith SC Jr et al. Circulation 2006;113:2363–2372 .
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Elevated Triglycerides
Non-HDL Cholesterol: Secondary Target
• Primary target of therapy: LDL cholesterol• Achieve LDL goal before treating non-HDL
cholesterol• Therapeutic approaches to elevated non-HDL
cholesterol– Intensify therapeutic lifestyle changes– Intensify LDL-lowering drug therapy– Nicotinic acid or fibrate therapy to lower VLDL
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Genetic dyslypidemia
• Familial combined hperlipidemia is not rare: 1% of population
• Often unrecognized and untreated• Early detection and management
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The issue of non-adherence
• Important barrier to dyslipidemia management
• Responsibility of Pt. Dr., and health care system
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Implication of the new American guidelines: which one should we follow?
• ATP III 2002 JAMA (NHLBI)• The new one (ACC/AHA/ NHLBI)• The hottest in AHA 2013
• Key feature: from specific lipid goal to % reduction
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The new American guidelines: Key features: Statin leeagable sub groups
• Clinical Atherosclerotic CVD• LDL> 190 mg/dl• Type 1 or 2 DM & LDL> 70 mg/dl• 10 year risk > 7.5% & LDL >70 mg/dl (New risk
calculator)
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The new American guidelines: Sub groups with doughtful benefits from statin
• > 75 yrs without clinical Atherosc. CVD
• A need for hemodialysis
• Heart filure
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The American guidelines: key features
• High or moderate intensity statin therapy when lipid lowering is indicated
• Diminished role of non statin lipid lowering agents alone or in combination
• Avoid LL drugs in certain group• No routine LDL assessment• New risk calculator and extended use in
primary prevention
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Guidelines are important but they are just guidelines
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Conclusions
• More aggressive approach• Early screening and management• Incorporation of Tgs. And HDL in risk evaluation• LDL is still the primary target• Non HDL-c is a secondary target in DM2, Met.S
and combined dyslipidemia• Is it the end of non statin LL agents and
combination?