use of the lipid optimization tool (lot) to … · if initial ldl at target, raise hdl and lo wer...
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USE OF THE LIPID OPTIMIZATION TOOL (LOT) TO ACHIEVE VARIOUS LDL TARGETS IN COMMUNITY PRACTICE
Statin Cost Efficacy
Statin Cost Efficacy
© Continuing Medical Implementation® Inc. May 2006 www.cvtoolbox.com
Lipid Optimization Tool
© Continuing Medical Implementation® Inc. March 2005 www.cvtoolbox.com
Lipid Optimization Tool
© Continuing Medical Implementation® Inc. March 2005 www.cvtoolbox.com
Revised March 2006
PROVE-IT/TNT/IDEAL/AtoZ ASTEROID
PATIENT: _________________________________ PHARMACY: _________________________________
Responsible for Lipid Management: Family Physician Cardiologist Endocrinologist
LIPID FLOW SHEET 1 – Use the following Table to Guide Intervention:NB: UPPER STRATUM* exceeds CWG on Hypercholesterolemia and other Dyslipidemias Recommendations
1. Count Risk Factors: Age M > 45 F > 55 Family Hx CAD Smoking HPT DM LVH HDL < 0.9 mmol/l
2. Identify Metabolic Syndrome ( > 3 parameters):Abdominal obesity (Waist circumference: Male >102 cm (40 in.) / Female > 88 cm (34.6 in.) TG > 1.7 mmol/L HDL < 1 mmol/L (male)/< 1. 3 mmol/L (female) BP > 130/85 FBG 6.2-7 mmol/L
3. Identify secondary causes: Diabetes Hypothyroidism Renal disease Liver disease Drugs & Alcohol4. Record Indication: Risk Factors CAD: _ angina, _ post MI, _ post PTCA, _ post CABG Cerebrovascular Disease PVD
1 Monitor lipid profile, ALT and CK at baseline, 2 months then every 6 to 12 months2 Diabetes carries the same CV risk as manifest CAD. DM+CAD impart much higher risk for subsequent CV events.3 Chronic Kidney Disease
Authors: J. Niznick, C. Boutin, Suzanne DugasOttawa Cardiovascular Centre (OCC), Ottawa, Ontario, Canada
Background (Objectives)Lipid optimization has the potential to signi�cantly reduce cardiovascular events and CHD death in various at risk populations. Failure to reach LDL target is commonplace and compromises cardiovascular outcomes. Our objective was to audit the effectiveness of the Lipid Optimization Tool as available on www.cvtoolbox.com, in achieving dyslipidemia control measured as LDL target achievement, in the high volume community practice at OCC.
MethodsOCC provides comprehensive follow-up to approximately 27,000 cardiovascular patients and structured lipid management and Telemonitoring for approximately 7000 dyslipidemia patients. The LOT has been used to guide lipid management at OCC since 1999. LOT �ow sheets for patients of the 9 OCC specialists (6 cardiologists and 3 internists) were sequentially analyzed from July to December 2005. LDL control rates were calculated for the current Canadian Working Group (CWG) targets of 4.5 mmol/L for low risk (LR), 3.5 mmol/L for moderate risk (MR) and 2.5 mmol/L for high risk (HR) patients as well as the antici-pated revised CWG LDL HR target of 2.0 mmol/L and the optional very high risk (VHR) NCEP ATP-III LDL target of 1.8 mmol/L.
ResultsData was collected on 963 patients; 78 LR, 87 MR, 62 HR and 736 VHR. LDL control rates were LR 94% (target < 4.5 mmol/L), MR 77% (target < 3.5 mmol/L), HR 68% (target < 2.5 mmol/L) and VHR 81% (target < 2.5 mmol/L), 59% (target < 2.0 mmol/L) and 46% (target 1.8 mmol/L).
ConclusionsUse of the LOT management protocol in contempory community practice at OCC achieves amongst the best lipid control rates in the world.
Funding: Dyslipidemia management at OCC is supported by unrestricted grants from AstraZeneca, Merck Frosst and P�zer.
Secondary Prevention: % LDL (mmol/L) change to reach LDL target by risk category.
Dose response to Medication (statins & fibrates) % LDL Reduction
Protocol: Initiate lipid lowering immediately in high-risk patients (concomitant with dietary/therapeutic lifestyle modification).1. Target initial medication dose to attain LDL of < 2.5 mmol/l. Consider LDL target of < 1.8 mmol/L for established CVD or DM > age 30.
Initiate therapy with the medication dose required to achieve target LDL.• NB: Initiate rosuvastatin at 10 mg (5 mg in Asians/CKD3). *40 mg. contraindicted in Asian population.• NB: Caution with simvastatin 80 mg. A to Z Trial.
2. If initial LDL at target, raise HDL and lower triglycerides to target values with appropriate intervention: diet, exercise, weight loss, refined carbohydrate restriction, moderate alcohol intake or medication: niacin, fibrate or salmon oil (1gm TID).
3. If LDL and triglycerides high and HDL-C low, consider combination therapy (niacin or fibrate).4. If unable to raise HDL sufficiently, lower LDL to achieve TC/HDL < 4 and/or LDL/HDL< 3.5. If initial lipid profile normal look at other risk factors (LPa, homocysteine, apo-B and hs-CRP).6. Follow Total cholesterol, LDL, HDL, triglycerides, CK and ALT in 2 months then every 6 months.7. If LDL not at target increase statin dose to achieve target or switch to more potent statin. If LDL target not achievable on monotherapy add bile acid sequestrant
(cholestyramine or colesevelam) or cholesterol absorption inhibitor (ezetimibe). Doubling statin dose adds ~ 6% LDL reduction. See Statin Cost Efficacy Grid.
www.cvtoolbox.com
Lipid Optimization Tool
1) RT Yan et al. Guideline Oriented Approach in Lipid Lowering (GOALL)Rregistry data presented at CCC Symposium Oct 2005.2) MH Davidson et al. Results of the National Cholesterol Education (NCEP) Program Evaluation Project Utilizing Novel e-Technology (NEPTUNE) II Survey and Implications for Treatment Under the Recent NCEP Writing Group Recommendations. Am J Cardiol 2005 Aug 15;96(4):556-63. 3) A Langer et al. Targeted Dosing of Atorvastatin Achieves Cholesterol Targets Quickly in Subjects with Diabetes or the Metabolic Syndrome (The ACTFAST Studies). Can J Cardiol 2005; Vol 21 Suppl C: Abstract 826, 253C. 4) C Bourgault et al. Stain Therapy in Canadian Patients with Hypercholesterolemia: The Canadian Lipid Study – Observational (CALIPSO). Can J Cardiol 2005; 21(13):1187-1193.
Sta
tin
Cost
Effi
cacy
Sta
tinC
ost
Eff
icac
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PR
OV
E-I
T/T
NT
/ID
EA
L/A
toZ
AS
TE
RO
ID
Seco
ndar
y Pr
even
tion
: % L
DL
(m
mol
/L)
chan
ge t
o re
ach
LD
L t
arge
t by
ris
k ca
tego
ry.
Dos
e re
spon
se t
o M
edic
atio
n (s
tati
ns &
fib
rate
s) %
LD
L R
educ
tion
Prot
ocol
: Ini
tiate
lipi
d lo
wer
ing
imm
edia
tely
in h
igh-
risk
patie
nts
(con
com
itant
with
die
tary
/the
rape
utic
life
styl
e m
odifi
catio
n).
1. T
arge
t ini
tial m
edic
atio
n do
se to
att
ain
LDL
of <
2.5
mm
ol/l.
Con
sider
LD
L ta
rget
of <
1.8
mm
ol/L
for
esta
blish
ed C
VD
or
DM
> a
ge 3
0.
Initi
ate
ther
apy
with
the
med
icat
ion
dose
req
uire
d to
ach
ieve
targ
et L
DL.
• N
B: I
nitia
te r
osuv
asta
tin a
t 10
mg
(5 m
g in
Asia
ns/C
KD
3 ). *4
0 m
g. c
ontr
aind
icte
d in
Asia
n po
pula
tion.
• N
B: C
autio
n w
ith s
imva
stat
in 8
0 m
g. A
to
Z T
rial
.2.
If i
nitia
l LD
L at
targ
et, r
aise
HD
L an
d lo
wer
trig
lyce
ride
s to
targ
et v
alue
s w
ith a
ppro
pria
te in
terv
entio
n: d
iet,
exer
cise
, wei
ght l
oss,
refin
ed c
arbo
hydr
ate
rest
rictio
n, m
oder
ate
alco
hol i
ntak
e or
med
icat
ion:
nia
cin,
fibr
ate
or s
alm
on o
il (1
gm T
ID).
3. I
f LD
L a
nd tr
igly
ceri
des
high
and
HD
L-C
low
, con
sider
com
bina
tion
ther
apy
(nia
cin
or fi
brat
e).
4. I
f una
ble
to r
aise
HD
L su
ffici
ently
, low
er L
DL
to a
chie
ve T
C/H
DL
< 4
and/
or L
DL/
HD
L< 3
.5.
If i
nitia
l lip
id p
rofil
e no
rmal
look
at o
ther
risk
fact
ors
(LPa
, hom
ocys
tein
e, a
po-B
and
hs-
CR
P).
6. F
ollo
w T
otal
cho
lest
erol
, LD
L, H
DL,
trig
lyce
rides
, CK
and
ALT
in 2
mon
ths
then
eve
ry 6
mon
ths.
7. I
f LD
L no
t at t
arge
t inc
reas
e st
atin
dos
e to
ach
ieve
targ
et o
r sw
itch
to m
ore
pote
nt s
tatin
. If L
DL
targ
et n
ot a
chie
vabl
e on
mon
othe
rapy
add
bile
aci
d se
ques
tran
t(c
hole
styr
amin
e or
col
esev
elam
) or
cho
lest
erol
abs
orpt
ion
inhi
bito
r (e
zetim
ibe)
. Dou
blin
g st
atin
dos
e ad
ds ~
6%
LD
L re
duct
ion.
See
Sta
tin
Cos
t Ef
fica
cy G
rid
PAT
IEN
T:__
____
____
____
____
____
____
____
___
PH
AR
MA
CY:
____
____
____
____
____
____
____
____
_
Res
pons
ible
for
Lipi
d M
anag
emen
t: Fa
mily
Phy
sicia
n
Car
diol
ogist
E
ndoc
rino
logi
st
LIP
IDFLO
WS
HE
ET
1–
Use
the
follo
win
g Ta
ble
to G
uide
Int
erve
ntio
n:N
B: U
PPE
R S
TR
ATU
M*
exce
eds
CW
G o
n H
yper
chol
este
role
mia
and
oth
er D
yslip
idem
ias
Rec
omm
enda
tions
1. C
ount
Ris
k Fa
ctor
s:
Age
M >
45
F >
55
Fam
ily H
x C
AD
Sm
okin
g
HPT
D
MLV
H
HD
L <
0.9
mm
ol/l
2. I
dent
ify
Met
abol
ic S
yndr
ome
( >
3 pa
ram
eter
s):
Abd
omin
al o
besit
y (W
aist
circ
umfe
renc
e: M
ale
>102
cm
(40
in.)
/ Fe
mal
e >
88 c
m (
34.6
in.)
T
G >
1.7
mm
ol/L
H
DL
< 1
mm
ol/L
(m
ale)
/< 1
. 3 m
mol
/L (
fem
ale)
B
P >
130/
85
FBG
6.2
-7 m
mol
/L3.
Ide
ntif
y se
cond
ary
caus
es:
Dia
bete
s
Hyp
othy
roid
ism
Ren
al d
iseas
e
Live
r di
seas
e
Dru
gs &
Alc
ohol
4. R
ecor
d In
dica
tion:
Risk
Fac
tors
CA
D: _
ang
ina,
_ p
ost M
I, _
post
PTC
A, _
pos
t CA
BG
C
ereb
rova
scul
ar D
iseas
e
PVD
1M
onito
r lip
id p
rofil
e, A
LT a
nd C
K a
t bas
elin
e, 2
mon
ths
then
eve
ry 6
to 1
2 m
onth
s2
Dia
bete
s ca
rrie
s th
e sa
me
CV
risk
as
man
ifest
CA
D. D
M+C
AD
impa
rt m
uch
high
er r
isk fo
r su
bseq
uent
CV
eve
nts.
3C
hron
ic K
idne
y D
iseas
e
.
Lipi
d Op
timiz
atio
n To
ol
Lipi
d Op
timiz
atio
n To
ol
Lip
id O
ptim
izat
ion
To
ol
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id O
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