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4th edition of clinical practice guidelines management of dyslilidemia 2011

4th edition of clinical practice guidelines management of dyslilidemia 2011



Malaysia CPG 2011

Malaysia CPG 2011



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    4th edition of clinical practice guidelines management of dyslilidemia 2011 4th edition of clinical practice guidelines management of dyslilidemia 2011 Document Transcript

    • I
    • II
    • STATEMENT OF INTENTThis guideline was developed to be a guide for best clinical practicein the management of dyslipidaemia. It is based on the bestavailable evidence at the time of development. Adherence to thisguideline does not necessarily lead to the best clinical outcomein individual patient care. Thus, every health care provider isresponsible for the management of his/her unique patient basedon the clinical presentation and management options availablelocally.REVIEW OF THE GUIDELINEThis guideline was issued in 2011 and will be reviewed in 2016 orearlier if important new evidence becomes available.CPG SecretariatHealth Technology Assessment UnitMedical Development DivisionLevel 4, Block EI, Parcel EGovernment Offices Complex62590 Putrajaya, MalaysiaAvailable on the following websites:http://www.malaysianheart.orghttp://www.moh.gov.myhttp://www.acadmed.org.my 1
    • SUMMARY• Total cholesterol (TC) and High Density Cholesterol (HDL-C) can be measured in the fasting and non fasting states. Triglycerides (TG) is best measured in a fasting sample. Low Density Cholesterol (LDL-C) is calculated using the Friedwald’s equation. When TG > 2.3mmol/l, non HDL-C is a better indicator of total atherogenic burden.• Dyslipidaemias may be primary or secondary.• Target of therapy: • LDL-C should be the primary target of therapy I,A • Non HDL-C should be an alternative primary target of therapy in patients with TG > 4.5 mmol/l I,A• Individuals should be risk stratified. I,C (See Table 1, pg 3 and Fig 1A & B, 2A & B, pg 30-31)• Diabetes is a Coronary Heart Disease (CHD) risk equivalent. I,A• Target lipids levels will depend upon the individual’s global risk. – CVD and CHD risk equivalents LDL-C < 2.6 mmol/L with Risk): (High an option of <2.0 mmol/L1,A – Individuals with a 10 year risk score of 10 – 20% (Intermediate Risk): LDL-C < 3.4 mmol/L1,A – Individuals with a 10 year risk score of < 10% (Low Risk): LDL-C < 4.1 mmol/lL IIa,C• Therapeutic Lifestyle Changes (TLC) should be an integral component of lipid management in all patients.1,B (Table 3, pg 4)• Individuals with Cardiovascular Disease (CVD) and CHD risk equivalents should be treated aggressively with drug therapy from the outset.1,A (Table 1&2, pg 3; Flowcharts I-IV, pg5-8) • Statins are the drug of choice for reducing LDL-C.1,A • Fibrates and nicotinic acid may be considered for increasing HDL-C and reducing TG after LDL-C treatment goal has been achieved. IIa, B • Some individuals may require combination therapy to achieve lipid target goals.• Control of glycaemia alone is inadequate in preventing cardiovascular (CV) events.1,A Concomitant treatment of dyslipidaemia, hypertension and other metabolic abnormalities are also important. 1,A 2
    • Table 1: Major Risk Factors for CVD (other than LDL Cholesterol) Positive Risk Factors • Male ≥ 45 years of age • Female ≥ 55 years of age or premature menopause without hormonal replacement therapy • Hypertension • Current cigarette smoking • Family history of myocardial infarction or sudden death prior to age 55 in a male parent or male first degree relative and prior to age 65 in a female parent or other female first degree relative • HDL-C < 1.0 mmol/L Negative Risk Factors • HDL > 1.6 mmol/LTable 2 : Recommendations for Drug Therapy for Dyslipidaemia Medications Grades of Comments recommendation/ Levels of evidenceStatins I, A Reduction of LDL-C. Increase dose till target levels are achieved or till toleratedEzetimibe IIa, B As an addition to statins if target LDL-C is not achieved IIa, C As monotherapy in statin intolerant individualsFibrates IIa,B As monotherapy to increase HDL-C and/or lower TG in individuals with mildly raised LDL-C IIa, B As part of combination therapy with statins to increase HDL-C and lower TG after LDL-C target is achieved or almost achievedNicotinic IIa,B As monotherapy to increase HDL-CAcid and/or lower TG in individuals with mildly raised LDL-C IIa, B As part of combination therapy with statins to increase HDL-C and lower TG after LDL-C target is achieved or almost achieved 3
    • Table 3 : Recommendations for Therapeutic Lifestyle Changes Grade of Comments Recommendation Level of EvidenceDietSaturated Fats and I, B < 7% of calorie intakeTrans-fatty acidsCholesterol I,B < 200 mg /dayMonounsaturated I,B Up to 10% of caloriesfatsPolyunsaturated fats I,B Up to 20% of caloriesDietary Fiber I,B 20-30 gm/dayPlant stanols IIb, B 2-3 gm /daySoy protein IIb, B 25-50 gm/dayOmega 3 fatty acids IIa, B A dose of 3-9 gm/day to lower TG levels IIb,B A dose of 0.75-1 gm/day as secondary prevention to prevent sudden deathTotal fats I,B 25-35% of caloriesCarbohydrates I,B 50-60% of caloriesProteins I,B About 15% of caloriesAnti-oxidants III,A AvoidWeight Reduction I,C Assess BMI and waist circumferenceGoal: at each visit.BMI : 18.5- <23 kg/ I,B Encourage a weight reduction ofm2 0.5-1kg/week in the overweightWaist circumference and obese. The initial goal should>90 cm in males and be to reduce body weight to < 10%< 80 cm in females of baseline.Exercise I,B Encourage aerobic exercises such asGoal: brisk walking, jogging, cycling and30-45 min per ses- swimmingsion, at least 5 timesa weekSmoking I,B Enquire about smoking status atGoal: each visit and encourage completeComplete cessation I,C cessation. Avoid exposure to environmental tobacco smoke at work and at home 4
    • FLOWCHART I: HIGH RISK INDIVIDUALS LIPID MANAGEMENT OF PERSONS WITH CVD OR CHD RISK EQUIVALENTS (Adapted and modified from ATPIII)139 In these high risk individuals the recommended LDL-C goal is < 2.61,A mmol/L with an optional goal < 2.0 mmol/L1,A CVD + CHD Risk Equivalents LDL-C < 2.6mmol/L LDL-C ≥ 2.6mmol/L TLC + Control Other Risk Factors * 3 months LDL-C < 2.6mmol/L LDL-C ≥ 2.6mmol/LTLC – Therapeutic Lifestyle Changes* Start statins to achieve LDL-C target goal < 2.0 mmol/L1,A** Consider LDL-C target goal < 2.0 mmol/L in very high risk individuals eg individuals with ACS, recurrent cardiac events, CHD with T2DM and those with multiple poorly controlled risk factors1,A*** Other therapeutic options include increasing the dose of statin, changing to high intensity statin or combination therapy, intensifying diet therapies, weight reduction, exercise or adding drugs to lower TG and / or increase HDL-C. 5
    • FLOWCHART II: INTERMEDIATE RISK INDIVIDUALS LIPID MANAGEMENT OF PERSONS WITH MULTIPLE RISK FACTORS, 10-YEAR RISK 10-20 PERCENT (Adapted and modified from ATPIII)139The LDL-C goal is < 3.4 mmol/L. I,A Drugs can be considered after a trial of TLC if the LDL-C level is ≥ 3.4 mmol/L. LDL-C < 3.4mmol/L LDL-C ≥ 3.4mmol/L Control other Risk TLC Factors Healthy lifestyle* Reevaluate in 1 year 3 months LDL-C < 3.4mmol/L LDL-C ≥ 3.4mmol/LTLC – Therapeutic Lifestyle ChangesThe LDL-C goal is < 3.4 mmol/L. Drugs can be considered after a trial of TLC if theLDL-C level is ≥ 3.4 mmol/L.* In patients at intermediate risk of CVD, the presence of high risk features such as a family history of premature CVD, evidence of subclinical atherosclerosis or high hs-CRP may warrant statin therapy to lower LDL-C target < 2.6 mmol/L. 6
    • FLOWCHART III: LOW RISK INDIVIDUALS LIPID MANAGEMENT OF PERSONS WITH MULTIPLE (2+) RISK FACTORS, 10-YEAR RISK < 10 PERCENT (Adapted and modified from ATPIII)139 In these individuals the LDL-C goal is < 3.4mmol/L. Drug therapy can be considered if LDL-C level is ≥ 4.1 mmol/L after a trial of TLC. LDL-C < 3.4mmol/L LDL-C ≥ 3.4mmol/L Control other Risk TLC Factors Healthy lifestyle* Reevaluate in 1 year 3 months LDL-C < 4.1mmol/L LDL-C ≥ 4.1mmol/LTLC – Therapeutic Lifestyle Changes* Patients at low risk of CVD with at least 2 other risk factors but with evidence of subclinical atherosclerosis, high hs-CRP or positive family history of premature CVD should be considered an LDL-C goal of < 2.6 mmol/L. 7
    • FLOWCHART IV: LOW RISK INDIVIDUALS LIPID MANAGEMENT OF PERSONS WITH 0-1 RISK FACTOR (Adapted and modified from ATPIII)139In these individuals, the LDL-C goal is < 4.1 mmol/L. Drug therapy can be considered if the LDL-C level is ≥ 4.9 mmol/L after a trial of TLC. If LDL-C is 4.1-4.9 mmol/L, drug therapy is optional depending on clinical judgment. 0-1 Risk Factors 10-yr risk usually <10%LDL-C < 4.1mmol/L LDL-C ≥ 4.1mmol/L Control other Risk Factors LDL-C < 4.1 TLC Healthy lifestyle* mmol/LReevaluate in 1 year 3 months LDL-C 4.1-< 4.9mmol/L LDL-C ≥ 4.9mmol/L* Patients at low risk of CVD with 0 to 1 risk factor but with evidence of subclinical atherosclerosis should be considered for a lower LDL-C target < 2.6 mmol/L. 8
    • 9
    • MESSAGE FROM THE AMERICAN COLLEGE OF CARDIOLOGYThe American College of Cardiology heartily congratulates theNational Heart Association of Malaysia along with the Ministry ofHealth of Malaysia and the Academy of Medicine for the creationof this important Clinical Practice Guideline for the managementof dyslipidemias.Appreciating that in Malaysia cardiovascular disease is theleading cause of death in both men and women and thatdyslipidemia is both readily identifiable and treatable offers theideal opportunity to translate known cardiovascular science tothe “bedside”. This CPG focusing on lipid management shouldbecome a cornerstone for practitioners in Malaysia in theirmission to combat cardiovascular disease. Seminal work by Fordreported in the New England Journal of Medicine points out thatboth primary risk factor modifications along with adherenceto secondary prevention measures has markedly decreasedmortality and morbidity of cardiovascular disease.1 Risk factormodification has a much greater impact on population health thaninvasive or interventional cardiac procedures. Evidence based lipidmanagement is a major component of the worldwide success indecreasing mortality and morbidity of cardiovascular disease alongwith hypertension control, tobacco cessation, diabetic care alongwith increasing exercise and successful treatment of obesity.I again congratulate my Malaysian colleagues and encourageenthusiastic application of this seminal work to improve the healthof the great people of Malaysia.Sincerely,Ralph Brindis, MD, MPH, MACC, FSCAIImmediate Past President, American College of CardiologyReference:1. Ford ES, Ajani UA, Croft JB et al “Explaining the Decrease in U.S. Deaths from Coronary Disease, 1980-2000.” N Engl J Med 2007;356:2388- 2398. 10
    • Members of the Expert PanelChairperson:Dr Robayaah Zambahari Consultant Cardiologist, Institute Jantung Negara, Kuala LumpurSecretary :Dr R. Jeyamalar Consultant Cardiologist, Sime Darby Medical Center, Subang Jaya, SelangorMembers (in alphabetical order)Dr Abdul Rashid Rahman Consultant Physician, Cyberjaya University College of Medical Sciences, Cyberjaya, Selangor Dr Chan Siew Pheng Consultant Endocrinologist, Sime Darby Medical Center, Subang Jaya, SelangorDr Khoo Kah Lin Consultant Cardiologist Pantai Medical CenterDr Rosli Mohd Ali Consultant Cardiologist Institute Jantung Negara, Kuala LumpurDr Sree Raman Consultant Physician, Hospital Tuanku Jaafar, Seremban (HTA trained)Dr Sim Kui Hian Consultant Cardiologist, Sarawak General Hospital, KuchingDr Wan Azman Consultant Cardiologist, University Malaya Medical CenterDr Zanariah Hussein Consultant Endocrinologist, Hospital Putrajaya, Putrajaya 11
    • External Reviewers (in alphabetical order):Pn Che Zuraini Sulaiman Pharmacist Universiti Malaya Medical CentreDr Chia Yook Chin Consultant Primary Care Physician Universiti Malaya Medical CentreDr Ghazali Ahmad Kutty Consultant Nephrologist Hospital Kuala LumpurDr Hashim Noh General Practitioner, Klinik Young, Newton and Partners Kuala Lumpur/Petaling JayaDr Lee Chuey Yan Consultant Cardiologist Hospital Sultanah Aminah JohorDr Lee Fatt Soon Consultant Geriatrician Hospital Kuala Lumpur, Kuala LumpurDr Santha Kumari Consultant Physician Hospital Sultanah Rahimah, KlangDr V Paranthaman Family Medicine Specialist, Klinik Kesihatan Jelapang, Ipoh, PerakDr Wan Mohamad Consultant EndocrinologistWan Bebakar Hospital Universiti Sains Malaysia, Kota Baru, KelantanDr Wong Kai Fatt General Practitioner, LW Medical Associates Kuala Lumpur Dr Zurkarnai Yusof Consultant Cardiologist Hospital Universiti Sains Malaysia, Kota Baru, Kelantan 12
    • RATIONALE AND PROCESS OF GUIDELINE DEVELOPMENTRationale:In Malaysia, cardiovascular disease (CVD) is the leading cause ofdeath in both men and women1. CVD includes coronary heartdisease (CHD), cerebrovascular disease and peripheral arterialdisease. CHD is a spectrum ranging from stable angina to acutecoronary syndromes (ACS).Malaysians develop ACS at a younger age when compared topeople in Thailand, mainland China and western countries. Ourlocal NCVD-ACS Registry, showed that most patients (96.8%) hadat least one established cardiovascular risk factor–hypertension(72.6%), dyslipidaemia (55.9%) and /or diabetes (55%)3.In preventing CVD, efforts should be aimed at reducing globalrisks. The Clinical Practice Guideline (CPG) is on management ofdyslipidaemia. The last CPG (3rd edition) was published in 2004.Thus the need for an update.Objectives:The objective of this CPG is to:• provide guidance on the best treatment strategies for managing dyslipidemia utilizing and optimizing existing health resources.This CPG has been drawn up by a committee appointed by theNational Heart Association of Malaysia, Ministry of Health and theAcademy of Medicine. It comprises cardiologists, endocrinologistsand general physicians from the government and private sectorsas well as from the Universities.Process:Evidence was obtained by systematic review of current medicalliterature on dyslipidaemia using the usual search engines –PubMed, Medscape and Ovid. The other international guidelines(American and European) on the subject were also studied. Aftermuch discussion, the draft was then drawn up by the membersof the Expert Panel and submitted to the Technical AdvisoryCommittee for Clinical Practice Guidelines, Ministry of HealthMalaysia and key health personnel in the major hospitals of theMinistry Of Health and the Private Sector for review and feedback.The clinical questions were divided into major subgroups andmembers of the Expert Panel were assigned individual topics. The 13
    • group members met several times throughout the development ofthe guideline. All retrieved literature were appraised by individualmembers and subsequently presented for discussion during groupmeetings. All statements and recommendations formulated wereagreed collectively by members of the Expert Panel. Where theevidence was insufficient the recommendations were derived byconsensus of the Panel. The draft was then sent to local externalreviewers for comments. It was also sent to the American Collegeof Cardiology and the European Society of Cardiology for feedback.The level of recommendation and the grading of evidence used inthis guideline was adapted from the American Heart Associationand the European Society of Cardiology (ACC/ESC) and outlinedon page 15. In the text, this is written in black on the left handmargin. In the Summary and Key Recommendations, it is writtenas a superscript immediately after the therapeutic agent or at theend of the statement as applicable.Clinical Questions Addressed:• What is the current evidence on the management of patients with dyslipidaemia?• Which management and recommendations are most applicable to our local setting?Target Group:This guideline is directed at healthcare providers including generalpractitioners, medical officers, pharmacists, general and familyphysicians, cardiologists and endocrinologists.Target Population: All individuals.Period of Validity of the Guidelines:This guideline needs to be revised at least every 5 years to keepabreast with recent developments and knowledge.Applicability of the Guidelines:This guideline was developed taking into account our local healthresources. Blood chemistry for lipid profiles, liver and renalfunction tests can be done in all government health facilities. Themedications recommended are approved for use in Malaysia.This guideline aims to educate health care professional onstrategies to optimize existing resources in the management ofdyslipidemia. 14
    • Implementation of the Guidelines:The implementation of the recommendations of a CPG is part ofgood clinical governance. To ensure successful implementation ofthis CPG we suggest:• increasing public awareness of CVD and its prevention• continuing medical education and training of healthcare providers.• monitoring lipid levels in the population through National health surveys which will now be conducted every 5 years and through the NCVD ACS/PCI registry.• clinical audit at hospital level- documentation of target LDL-C levels. GRADES OF RECOMMENDATIONS AND LEVELS OF EVIDENCE GRADES OF RECOMMENDATION Conditions for which there is evidence and/or general agree- I ment that a given procedure/therapy is beneficial, useful and/ or effective. Conditions for which there is conflicting evidence and/or diver- II gence of opinion about the usefulness/efficacy of a procedure/ therapy. Weight of evidence/opinion is in favor of its usefulness/ef- II-a ficacy. II-b Usefulness/efficacy is less well established by evidence/opinion Conditions for which there is evidence and/or general agree- III ment that a procedure/therapy is not useful/effective and in some cases may be harmful. LEVELS OF EVIDENCE Data derived from multiple randomized clinical trials or meta A analyses Data derived from a single randomized clinical trial or large B non randomized studies Only consensus of opinions of experts, case studies or standard C of care Adapted from the American Heart Association/American College of Cardiology (AHA/ACC) and the European Society of Cardiology (ESC) 15
    • TABLE OF CONTENTSStatement of Intent 1Summary 2Flowcharts I,II,III and IV 5-8Message from Director General of Health 9Members of the Expert Panel 11External Reviewers 12Rationale and Process of Guideline Development 13-15Grades of Recommendation and Levels of Evidence 151. Introduction 17 2. Measurement of Lipids and Apoproteins 17-193. Classification of Dyslipidaemias 19-224. Dyslipidaemia as a Risk factor for CVD 22-24 5. Other Risk Factors for CVD 24-27 6. Global Cardiovascular Risk Assessment 27-34 6.1 Risk Stratification 27-32 6.2 Diabetes mellitus and Dysglycaemia as CHD 32-34 risk equivalents 6.3 Targets of therapy 347. Prevention of CVD 358. Management of Dyslipidaemia 36-47 8.1 Therapeutic Lifestyle Changes 36-39 8.2 Lipid lowering Drug Therapy 40-47 8.3 LDL Apheresis 479. Management in Specific Conditions 47-60 9.1 Specific Lipid Disorders 47-52 9.2 Diabetes Mellitus 52-54 9.3 Coronary Heart Disease 54-56 9.4 Hypertension 56-57 9.5 Stroke 57 9.6 Renal Disease 58-6010. Management in Specific Groups 61-63 10.1 Women 61 10.2 Children and Adolescents 61-62 10.3 Elderly 62-6311. Adherence, Compliance and Quality Assurance 63-6412. References 65-7913. Appendixes 80-84 14. Acknowledgement 8515. Disclosure Statements 8516. Source of Funding 85 16
    • 1. INTRODUCTIONIn 2009, cardiovascular disease (CVD) was the leading cause ofdeath in both men and women1. CVD includes coronary heartdisease (CHD), cerebrovascular disease and peripheral arterialdisease. CHD is a spectrum ranging from stable angina to acutecoronary syndromes (ACS).The peak incidence of ACS in Malaysia was in the 51-60 year agegroup and the male to female ratio was 3:12. The mean age in thelocal NCVD-ACS Registry 2006 was 58.1 years.3 This is youngerthan that noted in neighbouring countries such as Thailand (65years) 4, China (63 years) 5 and in the western population (GRACERegistry- 66 years6, Canada- 68 years7).In the NCVD-ACS Registry, most patients (96.8%) had at least oneestablished cardiovascular risk factor – hypertension (72.6%),dyslipidaemia (55.9%) and/or diabetes (55%)3.In the prevention of CVD, efforts should be aimed at reducingglobal risks. This guideline emphasizes:• a multifactorial approach that addresses all risk factors. This is because the benefits of modifying several risk factors simultaneously are synergistic.• that preventing CVD should be directed at global CVD burden rather than CHD alone.In the management of dyslipidaemia the following changes havebeen made:• identification of those at high risk – this includes individuals with established CVD, diabetes, multiple risk factors and established renal disease.• emphasizes the importance of a family history of premature CVD and familial dyslipidaemia• treatment targets.The objectives of this CPG is to:• provide guidance on the best treatment strategies for managing dyslipidemia utilizing and optimizing existing health resources. 17
    • 2. MEASUREMENT OF LIPIDS AND APOLIPOPROTEINSSerum lipid levels are affected by several factors:• acute stress or illness, eg fever, surgery, acute myocardial infarction.• drugs eg beta-blockers, thiazides, steroids.2.1 Lipids – TC, HDL-C, LDL-C and TGTotal cholesterol (TC) and high density lipoprotein cholesterol(HDL-C) can be measured both in the fasting and in the non fastingstates. Triglycerides (TG) however should be measured after 10-12 hours of fasting. TG levels are influenced by alcohol intake inthe preceding 24 hours and by smoking during the fasting state.Low density lipoprotein cholesterol (LDL-C) is calculated using theFriedewald equation:LDL-C (mmol/l) = TC – HDL-C - TG / 2.2If TG > 4.5mmol/L, this formula is not valid.LDL-C may also be measured directly although these methods arenot well standardized and not routinely performed.2.2 Lipids – non HDL-CMore recent data suggest that when TG > 2.3mmol/l, LDL-Ccalculation using the above formula may not be accurate.Cholesterol rich remnant lipoproteins - small Very Low DensityLipoprotein (VLDL) and Intermediate Density Lipoproteins(IDL) - are also significantly elevated.8,9 In this situation, LDL–Cmeasurement alone does not reflect the entire atherogeniclipoprotein fraction and Non-HDL-C is more representative ofthe atherogenic burden.10 This can be calculated by the followingformula:Non-HDL-C(mmol/l) = TC – HDL-CNon HDL-C levels can be calculated from a non-fasting serum. It isa target of therapy in patients with TG > 4.5mmol/l. 18
    • Measurements made from whole blood differs slightly from thatobtained from plasma or serum. TC, TG and HDL-C measured usingdesktop machines are acceptable when performed according tospecifications.Lipid levels especially TG show biological variability. Because ofthis and laboratory variability more than one measurement isrequired in borderline cases.2.3 Apolipoproteins (Appendix I, pg 80)Apoproteins are proteins attached to lipid particles to formlipoproteins. There are several apolipoproteins. Apo B is abetter indicator of CVD risk than LDL-C alone.11-14 It is found inchylomicrons, VLDL, IDL, LDL and Lp(a) particles. Since each of theseparticles contains a single Apo B molecule, measurement of Apo Brepresents the total atherogenic burden. Apo B measurement hasbeen standardized, automated and can be done in the non-fastingstate. It is not routinely measured. Key messages: • TC and HDL-C can be measured in the fasting and non fasting states. TG is best measured in a fasting sample. LDL-C is calculated using the Friedwald’s equation. • When TG > 2.3mmol/l, non HDL-C is a better indicator of total atherogenic burden.I,A3. CLASSIFICATION OF DYSLIPIDAEMIASDyslipidaemia is defined as lipid values outside the norm. Basedon therapeutic considerations, dyslipidaemias may be classified asfollows (Table 4): Table 4: Classification of Dyslipidaemias Lipoprotein Serum Lipid Hypercholesterolemia  LDL ­C T Mixed Hyperlipidemia ­LDL + ­ LDL V  TC and­ TG ­  TG and Hypertriglyceridemia ­ VLDL   or HDL-C TC and Low HDL Cholesterol  HDL or  TG 19
    • Table 5: Primary Dyslipidaemia Risk Risk of Plasma Plasma Serum Physical of Pancrea- Choles- Triglyce- signs CHD titis terol ride (if present)Common(“polygenic”) Corneal Arcus ­  ­  NHypercholes- XanthelasmaterolemiaFamilial Corneal ArcusCombined  ­  ­ or  ­ or  XanthelasmaHyper-lipidemia Tendon xanthomata,Familial (finger extensor,Hypercholes- ­ ­ ­   ­ ­ ­   ­ Achilles’ tendons)terolemia Corneal Arcus, Xanthelasma, Aortic stenosis Tuberous xanthomata,Remnant (elbows), striaeHypercholes- ­ ­ ­   ­ ­ ­  ­ ­  xanthomata,terolemia (palm creases) tendon xanthomata Eruptive xanthomata,Chylomic-  or (buttocks, elbows)ronemia ­ ­ ­ ­ ­ ­ ­  ­ retinal lipemia,Syndrome hepatospleno- megaly Eruptive xanthomata,Familial (buttocks, elbows)Hypertrigly- ­ ­ ­  ­ ­ ­  retinal lipemia,ceridemia hepatospleno- megalyHigh HDL-C   ­  -Low HDL-C ­     or  - 20
    • Dyslipidaemias may be primary or secondary in etiology. (Tables5 & 6).In the following situations, secondary causes of dyslipidaemiashould be considered:• When TC exceeds 7.0 mmol/l, exclude conditions such as primary hypothyroidism, nephrosis, obstructive liver disease.• Cushing’s syndrome (including subclinical disease) can lead to lipid abnormalities in 40-70% of patients.15 Patients on exogenous steroids may also develop secondary dyslipidemias. Hypothyroidism is another important cause.16 It is more prevalent in the elderly in whom a high index of suspicion may be necessary for diagnosis.17• When TG exceeds 4.5 mmol/l, exclude secondary causes such as alcoholism.• When there is high TG with low HDL-C, insulin resistance states such as type 2 Diabetes (T2DM) and metabolic syndrome have to be considered• Failure to respond to anti-lipid therapy.• In patients with a family history of T2DM or a past history of thyroid disease. Table 6: Causes of Secondary Dyslipidaemias DISORDER CHOLESTEROL TRIGLY- HDL- CERIDES CHOLESTEROL Metabolic / Endocrine Hypothyroidism ­­  ­   T2DM ­ ­  Metabolic Syndrome ­  ­­   Cushing’s Syndrome ­­  ­  Renal End stage renal disease  or  ­  Nephrotic syndrome ­ ­­  ­ ­  Hepatic Obstructive liver ­    disease ­ Primary biliary cirrhosis ­    Drugs Alcohol  ­  ­ Thiazide diuretics  ­­  ­  Beta blockers  ­  21
    • Key messages: • Dyslipidaemias may be primary or secondary to nephrotic syndrome, obstructive liver disease, hypothyroidism, Cushing’s syndrome, drugs, alcoholism and insulin resistance states such as T2DM and metabolic syndrome.4. DYSLIPIDAEMIA AS A RISK FACTOR FOR CVDDyslipidaemia has been identified as one of the main risk factorsfor CVD. Our local NCVD – ACS Registry showed that dyslipidaemiawas present in 55% of our patients3. Specific lipid abnormalitiesimplicated are:4.1. Elevated LDL-C levelsLDL-C has been shown to be atherogenic in epidemiologicalstudies. There is a direct relationship between levels of LDL-C(or TC) and the rate of new onset CHD in men and women whowere initially free from CHD.18-21 In people with established CHD,elevated LDL-C correlates with recurrent cardiac events.22,23 Thereis a near absence of clinical CHD in populations with very lowlevels of serum cholesterol throughout their life (TC<3.9mmol/Lor LDL-C< 2.6 mmol/L).24,25 The risk for CHD appears to increaseprogressively above these levels. At levels of LDL-C above 3.4mmol/L, atherogenesis proceeds at a significant rate particularlyin the presence of other major risk factors.26Randomized controlled trials have repeatedly shown that loweringof LDL-C reduces CVD events in both primary and secondaryprevention.27-34 Studies have also shown that LDL-C particleconcentration and size are important predictors of CVD.34,35,36However measurement of these are not widely available and arenot standardized.Thus LDL-C should be the primary target for cholesterol therapy.Meta- analysis have shown that reducing LDL-C by 1% reducesCHD risk by 1%.37 22
    • 4.2. Low HDL-C levelsThere is substantial data linking a low HDL-C level (< 1.0 mmol/L)with increased risk of CHD.18,38,39,40 A 1% decrease in HDL-C, inepidemiological studies, has been associated with 2-3% increasein CHD risk.40 Clinical trials using pharmacotherapy to increaseHDL-C levels have, however, showed mixed results. 41,42,434.3. Elevated TG levelsData suggest that a raised TG level indicates a modest but highlysignificant association with CHD.44,45,46 This suggests that someTG-rich lipoproteins are atherogenic. Weight reduction and drugtherapies (fibrates, nicotinic acid and statins) reduce remnantlipoproteins and are accompanied by a reduced risk for CHD.43,47,484.4. Elevated Non-HDL-C levelsNon HDL-C reflects the concentration of cholesterol within all li-poprotein particles considered atherogenic. Many studies havedemonstrated that non HDL-C is a better predictor of CV risk thanis LDL-C and may be especially true in statin-treated patients.49,50,514.5. Atherogenic DyslipidaemiaThis consists of low HDL-C, raised TG and small dense LDLparticles.52,53 The LDL-C levels are usually normal but there is ahigher proportion of small dense LDL particles which are moreatherogenic.Although epidemiological data indicates that the ratio of TC/HDL-C is a CVD risk marker, there have been no outcome studiesto support using this as a target of therapy.4.6 Lipoprotein Lp(a)Elevated levels of Lp(a) have been shown to be related tocardiovascular risk in some but not all studies.54,55 23
    • Key messages: • LDL-C should be the primary target of therapy I,A • Non HDL-C should be an alternative primary target of therapy in patients with TG > 4.5 mol/L I,A5. OTHER RISK FACTORS FOR CVDMore than 90% of CVD can be explained by 9 to 10 modifiablerisk factors – dyslipidaemia, hypertension, smoking, diabetes,abdominal obesity, psychosocial stress, low intake of fruits andvegetables, alcohol intake and physical inactivity.56,57(Appendix II,pg 80)5.1. AgeThe incidence of CVD increases with age.18 This is due to thecombined effects of age related changes in the vascular system aswell the duration of exposure to adverse risk factors.5.2. GenderThe incidence of CVD is about 3-4 times higher in men thanwomen in the middle decades of life and approximately twice ashigh in the elderly.185.3. HypertensionBoth elevated systolic and diastolic blood pressures are linkedwith increased CVD risk.58,59,60 From epidemiological data, elevatedsystolic blood pressure appears to be more important whencompared to diastolic blood pressure as a risk factor especiallyin middle aged and elderly individuals.61-64 The presence of leftventricular hypertrophy is associated with increased CV risk.5.4. SmokingThis is an important CV risk factor and cause of mortality in bothmen and women.65,66,67 The incidence and mortality of CVD is 2-3times as high in cigarette smokers compared to non smokers.68,69 24
    • The risk of developing CVD is directly related to the number ofcigarettes smoked.70,71 The relative risk of CV events is greaterin younger than in older patients although the absolute excessmortality related to smoking increases with age.68,70Smoking interacts in a multiplicative manner with other riskfactors ie the risk is higher than that would have resulted fromsimply adding together the independent risks.72,73In individuals who discontinue smoking, the risk decreases withina year or two of stopping and the curve flattens out within 4 yearsalthough the relative risk remains slightly higher compared tonever-smokers.74,755.5. Family History of Premature CVDFamilial and genetic factors may play an important role in thedetermination of some major risk factors, especially hypertension,lipid abnormalities and glucose intolerance. In addition thereappears to be a familial predisposition to CVD.76,77,78 The presenceof premature CVD in first degree male relatives below the age of 55years or female relatives below the age of 65 years is a recognizedindependent risk factor for CVD.79 This risk is greater when morefamily members are affected and the younger their age of onsetof CVD.5.6 OthersOther risk factors include:5.6.1 Lifestyle Risk Factors- Abdominal obesity: Risk for CVD is increased although a recent analysis seems to indicate that abdominal obesity just helps to identify high risk individuals with metabolic abnormalities. In Asians, a waist circumference of > 90 cm in men and > 80 cm in women has been found to be associated with increased CV risk.80-84 (Appendix III, pg 81) 25
    • - Physical Inactivity: Numerous studies have shown that physical inactivity is associated with increased mortality and CVD.85,86,87- Intake of fruits and vegetables: Low intake (less than 5 servings a day) increases CV risk.885.6.2.: Risk MarkersThe following risk markers maybe helpful in intermediate riskpatients to determine the intensity of therapeutic targets.- Inflammatory markers (hs-CRP) – Pathological studies strongly support a role for inflammation in the pathogenesis of the early stages of atherosclerosis, plaque progression and rupture. One such acute phase reactant is high sensitivity C-reactive protein (hs-CRP). Data show that an elevated level of hs-CRP identifies healthy individuals who are at an increased risk of an initial and recurrent cardiac events.89-93 Results of a recent trial indicated that healthy persons with LDL-C levels in the normal range but with elevated hs-CRP benefited from statins.94- Hemostatic markers – An elevated level of fibrinogen has been associated with an increased risk for coronary events.95,96- Subclinical atherosclerosis - Individuals with subclinical atherosclerotic disease are at increased risk for major coronary events.97 Subclinical atherosclerosis may be identified by the: • presence of abnormalities in the resting and / or stress ECG • measurement of the ankle / brachial blood pressure (ABI) (a level of less than 0.9 is significant) • measurement of carotid intima-medial thickness (IMT) by ultrasound (more than 75th percentile for age and sex) • measurement of coronary calcium score by computed tomography (CT) • non invasive imaging of the coronary arteries by CT angiography. 26
    • These tests may be used for risk stratification in individu- als at intermediate risk. Patients with subclinical athero- sclerotic disease may warrant a more aggressive preven- tive treatment strategy. Key messages: • Increasing age, male gender, hypertension, smoking and a family history of premature CVD are major independent risk factors for CVD. • Diabetes is a CHD risk equivalent I,A6. GLOBAL CARDIOVASCULAR RISK ASSESSMENTBased on the Malaysian National Health and Morbidity Survey2006, the prevalence of dyslipidaemia in Malaysians above the ageof 40 years was 28%98. All adults above the age of 40 years shouldhave a complete fasting lipid profile (TC, LDL-C, HDL-C, TG). If thelevels are normal, then screening should be done annually.Individuals who already have evidence of atherosclerosis or are athigh risk of developing CVD, should have a complete lipoproteinprofile earlier in life. This includes individuals with a family historyof premature CVD, genetic dyslipidaemias, metabolic syndrome,T2DM and abdominal obesity.6. 1 Risk StratificationIndividuals with CVD and CHD risk equivalents belong to thehighest risk category.The CHD risk equivalents are:• Other clinical forms of atherosclerotic disease (atherosclerosis in any vascular bed - aorta including abdominal aortic aneurysm, carotid, cerebral and peripheral vessels)• T2DM• Multiple risk factors that confer a 10 year risk for CVD > 20%These individuals are at high risk of developing CVD . They should bescreened for the traditional risk factors and treated appropriately. 27
    • Table 7: Major Risk Factors for CVD (Other than LDL Cholesterol) Positive Risk Factors • Male ≥ 45 years of age • Female ≥ 55 years of age or premature menopause without hormonal replacement therapy • Hypertension • Current cigarette smoking • Family history of myocardial infarction or sudden death prior to age 55 in a male parent or male first degree relative and prior to age 65 in a female parent or other female first degree relative • HDL-C < 1.0 mmol/L Negative Risk Factors • HDL > 1.6 mmol/LIn all other patients, their global CVD risk should be determined.There are several risk equations that may be used.99 (Appendix IV,pg 82). All have some limitations and difficulty to extrapolate toour local population.Until local data are available we recommend adopting the latest(2008) Framingham CV risk score.100 This estimates CVD risk whilethe earlier version (2002) provides a risk estimate of “hard” CHDevents ie cardiac death and nonfatal myocardial infarction.The intensity of risk reduction therapy is dependent on anindividual’s global risk of developing CVD. In determining CV riskthe following steps are taken:• Count the number of major risk factors for CVD (Table 7,pg 28).• In individuals with more than 2 risk factors, calculate the 10- year CVD risk using the Framingham score sheets (Figures 1A & B, 2A & B, pg 30-31).• The vascular age can also be determined (Figure 1C and 2C, pg 32)• In individuals with 0 – 1 risk factors, the CV risk score need not be calculated since the 10-year CVD risk is <10%. 28
    • Other risk factors not included in the general risk profile thatshould be taken into account in evaluating risk include:• Clinical features of insulin resistance such as abdominal obesity, elevated triglycerides, and dysglycaemia (See Section 6.2)• ECG evidence of left ventricular hypertrophy• hs-CRP levels• Evidence of subclinical atherosclerosis• Chronic kidney disease (GFR<60ml/min)• Chronic autoimmune inflammatory disorders such as systemic lupus erythematosis and rheumatoid arthritis• Chronic HIV infectionThese individuals are at high risk of developing CVD. Theyshould be screened for the traditional risk factors and treatedappropriately.Individuals with 0-1 risk factor almost always have a 10 year CVDrisk <10%.Individuals with 2 or more risk factors can fall into one of thefollowing risk categories for developing CVD over 10 years:• > 20%• 10-20 %• < 10%Those individuals with a 10-year risk of developing CVD of > 20%have a very high risk and are therefore considered as CHD riskequivalents. (see 6.1)Determining an individual’s global CVD risk will guide LDL-C targetgoal and management strategies. (Table 8, pg 34)The 10 year risk calculation is to be performed at the outset to helpguide the intensity of cholesterol lowering therapy. It cannot beused to track changes in risk over time as risk factors are modified.In calculating the risk scores (Figures 1A & B, 2A & B, pg 30-31), theTC and HDL-C should be the average of at least 2 measurements.The average baseline blood pressure (BP) must be obtained froman average of several readings. A “smoker” means any cigarettesmoking in the past month. 29
    • Figure 1A: Estimation of 10 year CVD Points for MEN (Framingham Point Scores) 100Points Age,y HDL-C TC SBP SBP Smoker Diabetes (not (treated) treated) -2 1.6+ <120 -1 1.3-1.6 0 30-34 1.2-<1.3 <4.2 120-129 <120 No No 1 0.9-<1.2 4.2-<5.2 130-139 2 35-39 <0.9 5.2-<6.3 140-159 120-129 3 6.3-<7.4 160+ 130-139 Yes 4 >7.4 140-159 Yes 5 40-44 160+ 6 45-49 7 8 50-54 9 10 55-59 11 60-64 12 65-69 13 14 70-74 15 75+ Pointsallotted Grand Total :_____________points Figure 1B: CVD Risk for Men100 Total Points 10 year Risk % Total Points 10 year Risk % <-3or less <1 8 6.7 -2 1.1 9 7.9 -1 1.4 10 9.4 0 1.6 11 11.2 1 1.9 12 13.2 2 2.3 13 15.6 3 2.8 14 18.4 4 3.3 15 21.6 5 3.9 16 25.3 6 4.7 17 29.4 7 5.6 18+ >30 30
    • Figure 2A: Estimation of 10 year CVD Points for WOMEN (Framingham Point Scores) 100Points Age,y HDL-C TC SBP (not SBP Smoker Diabetes treated) (treated) -3 <120 -2 1.6+ -1 1.3-1.6 <120 0 30-34 1.2-<1.3 <4.2 120-129 No No 1 0.9-<1.2 4.2-<5.2 130-139 2 35-39 <0.9 140-149 120-129 3 5.2-<6.3 130-139 Yes 4 40-44 6.3-<7.4 150-159 Yes 5 45-49 >7.4 160+ 140-149 6 150-159 7 50-54 160+ 8 55-59 9 60-64 10 65-69 11 70-74 12 75+ Pointsallotted Grand Total :_____________points Figure 2B: CVD Risk For Women100 Total Points 10 year Risk % Total Points 10 year Risk % <-2 <1 10 6.3 -1 1.0 11 7.3 0 1.2 12 8.6 1 1.5 13 10.0 2 1.7 14 11.7 3 2.0 15 13.7 4 2.4 16 15.9 5 2.8 17 18.5 6 3.3 18 21.5 7 3.9 19 24.8 8 4.5 20 28.5 9 5.3 21+ >30 31
    • Figure 1C : Heart Age/ Vascular Age for Men100 Points Heart age, y <0 <30 0 30 1 32 2 34 3 36 4 38 5 40 6 42 7 45 8 48 9 51 10 54 11 57 12 60 13 64 14 68 15 72 16 76 >17 >80Figure 2C : Heart Age/ Vascular Age for Women100 Points Heart age, y <1 <30 1 31 2 34 3 36 4 39 5 42 6 45 7 48 8 51 9 55 10 59 11 64 12 68 13 73 14 79 15+ >80 32
    • 6.2. Diabetes mellitus and Dysglycaemia as CHD risk equivalentsPatients with type 2 diabetes mellitus (T2DM) and impairedglucose tolerance(IGT) have an increased risk of cardiovascular events.101,102 Thesepatients have higher mortality and a higher incidence of recurrentcardiac events.103The two main types of DM (type 1 and type 2) have differentpatterns of dyslipidaemia. Type 2 diabetes (T2DM) may beassociated with insulin resistance, as in some individuals with themetabolic syndrome.The current definition of metabolic syndrome (2009) includes any3 or more of the following (including those on treatment)*:• Elevated Waist circumference (Asian cut-off) : - females >80cm - males >90cm• Elevated TG > 1.7 mmol/L• Reduced HDL-C < 1.3 mmol/L (female) or < 1.0 mmol/L (male)• Elevated blood pressure (BP): - Systolic BP > 130 and / or diastolic BP > 85 mmHg• Disorders of glycaemia: - T2DM, or - impaired glucose tolerance (IGT) [Fasting plasma sugar < 7.0 mmol/L and 2 hours after 75 gm glucose load: 7.8 – 11.1 mmol/L], or - impaired fasting glucose (IFG) [Fasting plasma sugar: 6.1 – 7.0 mmol/L]*Adapted from Joint Interim Statement (Joint Interim Statement of InternationalDiabetes Federation Task Force on Epidemiology and Prevention, National Heart LungBlood Institute (NHLBI), American Heart Association (AHA), World Heart Federation(WHF), International Atherosclerotic Society (IAS and International Association forStudy of Obesity (IASO) Circulation 2009:120:1640-1645Proatherogenic risk markers like elevated Lp(a), prothromboticrisk markers eg. raised PAI-1, increased fibrinogen and endothelialdysfunction are found in insulin resistance states and contributeto the increased CV risk. These associated abnormalities of insulinresistance can be present for up to 10 years before detection ofthe glycaemic disorder. 33
    • Individuals with type 1 diabetes are more likely to have elevated TC, with rise in LDL-C and increased TG. These lipid abnormalitiesI,A can be fully corrected with good glycaemic control with insulin. Individuals with T2DM have the atherogenic dyslipidaemia. Im- provement of glycaemic control may not fully correct this dys- lipidaemia.104 Some studies show better correlation of non HDL-C than LDL-C to coronary mortality.10 (see 4.4. & 4.5) 6.3. Target Lipid LevelsI,A LDL-C is the primary target for therapy.I,A The target LDL-C level will depend on the individual’s global risk. (see Table 8) Table 8: Target LDL-C levels Global Risk LDL-C levels to Target LDL–C initiate Drug therapy levels (mmol/l) 0-1 risk factor a ≥ 4.9 c < 4.1 2 or more risk 3.4 c ≤ 3.4d factors b ≥ 2.6 < 2.6e CVD and CVD risk 2.0 to < 2.6 < 2.0f Equivalents a Almost all individuals with 0-1 risk factor have a 10 year risk < 10%, thus 10 year risk assessment in individuals with 0-1 risk factor is not necessary. b These include individuals with multiple risk factors but a 10 year risk of CVD of < 20%. c After 8-12 weeks of TLC. d An optional target of <2.6mmol/L in certain high risk individuals. See flowchart II & III, pg 4 e The lower the LDL-C achieved, the greater the CV benefits seen. f Consider LDL-C target goal < 2.0 mmol/LI,A in very high risk individuals eg individuals with ACS, recurrent cardiac events, CHD with T2DM and those with multiple poorly controlled risk factors See Flowcharts I-IV, pg 5-8. Key messages: • Individuals should be risk categorized I,C (Table 7, pg 28, Fig 1A & B, 2A & B, pg 30-31). • Target lipids levels will depend upon the individual’s global risk. • Individuals with CVD and CHD risk equivalents should be treated aggressively with drug therapy I,A (Table 8, pg 34; Flowcharts I-IV, pg 5-8). 34
    • 7. PREVENTION OF CVDPrevention can be divided into:• Primary prevention is the prevention of occurrence of CVD events in people without CVD.• Secondary prevention is the prevention of progression of CVD and its complications in people with established CVD or CVD risk equivalents.Strategy of primary preventionThe strategy is based on a:• Population based strategyThis strategy is aimed at educating the public concerning CVD,its presentation and complications, cardiac risk factors, and theimportance of maintaining a healthy lifestyle, which is a healthydiet, weight control, increased physical activity and the avoidanceor cessation of smoking. These measures should be started earlyin life. Mass screening for dyslipidaemia is not advocated as it isnot cost effective and there may be inadequate follow-up andcounseling.• Individual based strategyThe aim is to identify individuals at risk of developing CVD andmodifying their risk factors. This would include all individualsabove the age of 40 years. (See Section 6).Strategy of secondary preventionThis is aimed at individuals with established CVD or with CVD riskequivalents. In these high-risk persons, drug therapy should beinitiated together with therapeutic lifestyle changes (TLC). 35
    • 8. MANAGEMENT OF DYSLIPIDAEMIA 8.1. THERAPEUTIC LIFESTYLE CHANGES Introduction Therapeutic lifestyle changes (TLC) refer to dietary modification, weight reduction, regular physical activity, cessation of smoking and alcohol restriction. TLC is an integral component of the treatment of dyslipidaemia. It should precede or be initiated together with drug therapy and is directed especially at individuals who are obese, who smoke and who seldom exercise. For patients without CVD or CVD risk equivalents, emphasis should be placed on TLC. 8.1.1. Dietary Modification I,B This is aimed at optimizing lipid levels while maintaining a balanced diet. It is encouraged to refer an individual to a dietician for medical nutrition therapy. Dietary therapy can lower TC by 10-15% and occasionally >20%.105 Dietary therapy is continued indefinitely. (Appendix V, pg 83) I,B The intake of food high in cholesterol content must be reduced.106-109 A high intake of saturated fatty acids (SFA) and trans fatty acids (TFA) raise LDL-C levels while a high intake of monounsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) lower LDL-C and reduce CV risk.106,110,111 Thus both PUFA and MUFA should be encouraged in place of SFA and TFA. SFA should not be replaced with carbohydrates. I,B A high intake of carbohydrate (> 60% of total caloric intake) results in a reduction of HDL-C and a rise in TG levels.112,113 In individu- als with the metabolic syndrome a lower carbohydrate intake is important.IIa,B The use of viscous (soluble) forms of dietary fibre (oats, pectin, guar and psyllium) of at least 5–10 gm per day is encouraged as they have been shown to reduce LDL-C levels.114,115,116 36
    • IIb,B Plant stanol/sterol esters (2–3 gm/day) also have a LDL-C lowering effect117 which is dose related but there is inter-individual varia- tion in their response. Plant sterols and stanols are not routinely recommended for the prevention of CVD since there are no CV outcome data.IIb,B High intake of soy protein (25-50 gm/day) can cause small reduc- tions in LDL-C.106 8.1.2. Weight Reduction I,B This is important in overweight and obese individuals particularly those with the metabolic syndrome. Weight reduction helps to lower TG and increase HDL-C levels, in addition to enhancing the cholesterol (TC and LDL-C) lowering effects of dietary modifica- tion.118 I,B A weight reduction of 0.5-1.0 kg per week is recommended. Ac- cording to the Asia Pacific Western Pacific Regional World Health Organization, the recommended BMI in Asians is 18.5 - < 23 kg/ m2 and a waist circumference < 90 cm for males and < 80 cm for females.81 8.1.3. Physical Activity I,B Physical activity and weight reduction enhance the lipid-lowering effects of dietary therapy. They also improve cardiovascular fit- ness, lower BP, increase insulin sensitivity, increase HDL-C levels and decrease TG levels.119,120 Such activities include aerobic exer- cises such as brisk walking, jogging, cycling, swimming. Exercise needs to be regular and adequate (30-45 minutes per session at least 5 times a week). 8.1.4. Cigarette Smoking I,A Smoking is one of the major risk factors for CVD and must be stopped. Even passive smokers are at high risk of developing CVD. The decline in CVD risk begins within a year or two after smoking cessation.74,75 37
    • 8.1.5. Alcohol I,B Restriction of alcohol is advised in patients with dyslipidaemia as it increases plasma TG levels.121,122 I,A Moderate alcohol consumption (not more than 14 units for males and 7 units for female per week) increases HDL-C and apo A-I and is associated with a reduction in all cause mortality.123-127 Over-consumption is however associated with a higher mortality rate. High intake of alcohol elevates BP and can precipitate acute pancreatitis in individuals with high TG levels. Nondrinkers should therefore not be encouraged to start alcohol consumption to improve their dyslipidaemia. (1 unit of alcohol is equivalent to 250 ml of beer, 100 ml of wine and 30 ml of whisky) 8.1.6. MiscellaneousIIa,B Omega–3 polyunsaturated fatty acids are useful in individuals with high TG and can be considered in addition to fibrates or nicotinic acid. For lowering TG, a dose of 3-9 gm/day of omega-3 fatty acids is requiredIIb,B In patients with CVD, omega-3 fatty acids (dose of 0.75 gm-1 gm/day) has been shown to reduce sudden cardiac death, CHD mortality and total mortality although a recent trial showed no benefit.128,129,130 It is recommended to increase intake of omega-3-fatty acids by eating more fish, walnuts, flaxseed oil and green, leafy vegetables.128,131III,B The importance of the following in treating dyslipidaemia remains uncertain : - trans-fatty acids, essential fatty acids (linoleic acid, linolenic acid), and lecithin.III,A The use of anti–oxidants (such as vitamin C, E, beta carotene, bioflavonoids) selenium and Coenzyme Q-10 has not been shown to be effective in preventing or treating CVD. Foods, vitamins and minerals which act as antioxidants include Co-enzyme Q10, ginkgo, green tea, Vitamin A (Beta-carotene), Vitamin C, Vitamin E.132,133 38
    • III,B None of the formulations of garlic have been shown to produce a statistically significant effect on the cholesterol level.134 Guggulipid has not been found to be effective in lowering LDL-C levels and may cause a hypersensitivity rash in some individuals.135 8.1.7. Assessing response to TLC The lipid profile should be measured 6-12 weeks after initiating TLC. Generally, TLC may reduce lipid levels (at best) up to 20%. For individuals who attain target lipid levels, they should continue these lifestyle changes life-long to maintain these effects. They can be assessed every 6 months with a full lipoprotein analysis. On the other hand, if these levels are not achieved, patient compliance should be re-assessed and TLC intensified. They are then reassessed after 6-12 weeks. There is a genetically determined inter-individual variability in the response to diet. Thus poor response to TLC is not always due to non-compliance. For individuals at low risk, failure to achieve a defined target value for LDL-C does not necessarily mean that dietary therapy be replaced by drug therapy. Whatever reduction that is achieved will help lower the risk of CVD especially with the concomitant adoption of a healthy lifestyle. When a decision has been made to start drug therapy, TLC must still be continued indefinitely because it provides substantial additive LDL-C lowering effects.136 Key messages: • A multifactorial lifestyle approach is recommended to reduce the risk of CVD. I,B • In patients without CVD or CHD risk equivalents, a period of at least 6-12 weeks is given to assess the effectiveness of TLC before considering drug therapy. I,C 39
    • 8.2. DRUG THERAPYI,A Therapeutic Lifestyle Change forms an integral component in the management of dyslipidaemia. In secondary dyslipidaemia, efforts should be made to correct the underlying cause. 8.2.1 Lipid Lowering Drugs In those with established CVD / CHD risk equivalents, drug treatment will need to be initiated in conjunction with TLC (Table 8, pg 33). There are 5 major groups of anti-lipid drugs. (Table 9, pg 41) HMG CoA Reductase Inhibitors (Statins) Statins are inhibitors of HMG CoA reductase , the rate limiting en- zyme in hepatic cholesterol synthesis. They are the most effective drug class and the treatment of choice in reducing LDL-C. They are suitable first-line agents in familial hypercholesterolemia, forI,A primary prevention of CVD, secondary prevention of CVD and CHD equivalents. They have moderate effect in lowering TG and in elevating HDL-C. Treatment is initiated at the recommended starting dose with the evening meal or at bed time except for long-acting statins that can be taken at any time. The dose is then adjusted accordingly to achieve target levels. Serum lipids and alanine aminotransferase should be measured at 6-8 weeks after starting treatment and thereafter as necessary especially when doses are increased.III,C Statin therapy is contraindicated in pregnancy and lactation. It should not be prescribed to women of child bearing potential un- less adequate contraception is taken. 40
    • Table 9: Major Anti Lipid Drug Classes (Adapted from ATPIII)139 Drug Class Lipid Effects Side Effects Contraindications HMG-CoA LDL-C 18-55% -Myopathy Absolute: Reductase HDL-C ­5-15% -Increased liver -Active or chronic liver Inhibitors TG  7-30% Enzymes disease (statins) Relative: -Concomitant use of certain drugs* Fibric-Acid LDL-C  5-20% -Dyspepsia Absolute: Derivatives HDL-C ­ 10-35%  -Gallstones -Severe hepatic (Fibrates) TG 20-50% -Myopathy disease -Severe renal disease Relative: -Concomitant use of certain drugs** Bile-Acid LDL-C 15-30% -GIT distress Absolute: Sequestrants HDL-C ­ ­ -5% 3 -Constipation -Dysbeta- (Resins) TG /  ­ -***Decreased lipoproteinemia absorption of -Tg > 4.5 mmol/l certain drugs Relative: -Tg > 2.3 mmol/l Nicotinic Acid LDL-C  5-25% -Flushing Absolute: (Niacin) HDL-C 15-35% -Hyperglycemia -Chronic-liver disease TG 20-50% -Hyperuricemia -Severe Gout (or gout) Relative: -Upper-GIT -Diabetes (high doses distress only) -Hepatotoxicity -Hyperuricemia -Peptic-Ulcer Disease Cholesterol LDL-C 18-25% -Headache Absorption HDL-C ­ -5% 3 -Abdominal pain Inhibitors**** TG 8-14% -Diarrhea* cyclosporin, macrolide antibiotics, various anti fungal agents and cytochrome P-450 inhibitors (fibrates and nicotinic acid should be used with appropriate caution)** gemfibrozil and repaglinide140*** Paracetamol, NSAIDs, anticoagulant, valproate, digitalis, thiazides, thyroxine, raloxifene, propranolol and tricyclic antidepressants.**** usually used in combination with statins.These data are derived from short-term clinical trials meant fordrug registration. In real life long term use, the amount of lipidchange achieved may be less than this. 41
    • Recent concern about statin and new onset diabetes has not been substantiated. In fact statins have been proven to prevent CV events in diabetics with no overt CVD.137,138 There is no evidence that patients on statins have increased risk of cancer, poor memory and renal toxicity. The routine use of Co enzyme Q 10 to prevent muscle toxicity is unproven and therefore not recommended. Recommended Dosages for Statins* Recommended Drug Usual dose range initiating dose 10-80 mg/day in single Lovastatin 20 mg or divided doses Pravastatin 20 mg 10-40 mg daily Simvastatin 20 mg 5-80 mg once daily 20-80 mg/day single Fluvastatin 20 mg or divided doses Atorvastatin 10 mg 10-80 mg once daily Rosuvastatin 10 mg 10-20 mg once daily * As stated in MIMS,Malaysia Fibric Acid Derivatives (Fibrates) Fibrates are Peroxisome Proliferator Activated Receptor (PPAR) –α agonist which in turn stimulates synthesis of fatty acid oxidation. Fibrates are particularly useful in individuals with combined (mixed) dyslipidaemia and hypertriglyceridaemia as they reduce serum TG levels and increase HDL-C effectively. Fibrates are alternative treatment in individuals with mild to moderate hypercholesterolemia who are statin intolerant.IIa,B In men with established CHD with low LDL-C and HDL-C, fibrates have been shown to improve CV outcome. In individuals with T2DM, fibrates reduced the composite endpoint of CV death, CV events and the need for coronary and carotid revascularization.43,47 42
    • IIa,B Doses of fibrates need to be adjusted in the presence of CKD. Serum alanine aminotransferase should be monitored when starting therapy or when doses are increased. Recommended Dosages for Fibrates* Drug Recommended Dosage Bezafibrate 200 mg daily increasing to a maximum dose of 200 mg tds (regular) or 400 mg daily (sustained release) Fenofibrate 300 mg daily or in divided doses (regular) or 200 mg daily (micronised) or 160 mg daily (supra) Gemfibrozil 600-1500 mg daily in divided doses (regular) or 900 mg daily (sustained release) Ciprofibrate 100 mg daily * As stated in MIMS,Malaysia Bile Acid Sequestrants (Resins)IIa,B Bile acid sequestrants bind to bile acids to promote their secretion into the intestines. They are effective in lowering LDL-C. Resins may increase TG and HDL-C slightly. Monotherapy has a modest effect on CHD in primary prevention. Resins are therefore not suitable as monotherapy in combined hyperlipidaemia. Combination with a statin may be necessary in severe hypercholesterolaemia. Other medications should be taken 1 hour before and / or 4 hours after resins. This class of drug is currently not available in the Malaysian market. Nicotinic Acid (Niacin) and its derivatives Nicotinic acid decrease mobilization of free fatty acids from adi-IIa,B pose tissues. It is very effective in increasing HDL-C and also ef- fectively lowers both TC and TG levels. It is also the first to show mortality reduction in individuals with CHD.48 43
    • However its side effects (particularly flushing and gastrointestinalside effects) tend to limit compliance. Acipimox is a derivativeof nicotinic acid which produces fewer side effects (especiallyless cutaneous flushing) and does not worsen glucose tolerance.Tredaptive is a combination of modified – release nicotinic acidand laropiprant (a prostaglandin inhibitor) which will reduce theflushing caused by nicotinic acid.Recommended Dosages:Nicotinic acid (Niacin) is available as capsules of 100 mg or 500mg,and sustained release form:- starting dose: 150-300 mg daily in divided doses, titration of doseup to 2g/day (Usual dose) It should be taken with meals to reducegastrointestinal side effects.Acipimox is currently not available in the Malaysian market. Cholesterol Absorption InhibitorsCholesterol absorption inhibitors selectively block intestinalabsorption of both dietary and biliary cholesterols and otherphytosterols. This leads to a reduction in hepatic cholesteroldelivery - a mechanism which complements the action of statins. Itis indicated as monotherapy for primary hypercholesterolemia inpatients who cannot tolerate statin or fibrate. It can also be used incombination with statins to further lower LDL-C. When used withstatins, the lipid lowering effects appears to be synergistic.Recommended Dose:• Ezetimibe 10 mg daily8.2.2. Recommended Drug Treatment for DyslipidaemiaThe choice of drugs will depend on the type of dyslipidaemia.(Table 10, pg 45) 44
    • Table 10: Suggested Drug Therapy for Dyslipidaemia Lipid Values Initial Drug Suggested Addition (in order of preference) LDL-C > 3.4 mmol/l Statins Resin TG < 2.3 mmol/l Ezetimibe Fibrates Nicotinic Acid LDL-C ≥ 3.4 mmol/l Statins Fibrates TG : 2.3-5.7 mmol/l Nicotinic Acid HDL-C < 1.0 mmol/l TG < 5.7 mmo/l If: LDL-C < 2.6 mmol/l Statins Fibrates Nicotinic Acid If: LDL-C > 2.6 mmol/l Statins Fibrates Nicotinic Acid TG > 5.7 mmol/L Fibrates Nicotinic Acid Statins Omega 3 FA I,A LDL-C reduction with statin treatment remains the cornerstone of lipid lowering therapy to reduce risk of CVD. If target lipid goals have not been achieved after 8-12 weeks of optimal monotherapy, combination therapy is suggested (Table 10, pg 45). CombinationIIa, B of statin and cholesterol absorption inhibitors have been shown to reduce CV events and renal outcomes in patients with CKD.141 Some combination therapies carry a potential for adverse effects, especially myositis (particularly combination of fibrates plus statins) although the incidence is still low (0.5 - 2.5%). For monotherapy, the incidence of myopathy is 0.1 - 0.5%.142,143 The combination of gemfibrozil and statin is discouraged. If used, caution and close monitoring should be stressed. 8.2.3. Monitoring and Duration of Therapy It should be stressed that these individuals will be on lifelong therapy. It is therefore important to assess them on a regular basis, 45
    • ie. in terms of response to treatment and to look out for possibleside-effects related to the drugs. After starting drug therapy, LDL-Clevel should be measured at 6-8 weeks and drug doses titratedif necessary. Once target lipid levels are achieved, a 4-6 monthlyfollow up is recommended.Monitoring of ALT is necessary if statins and fibrates are usedfor treatment. Liver function tests should be carried out beforeand within 1-3 months of starting treatment. Statins should bediscontinued if transaminase levels rise to at 3 times the upperlimit of normal. If the levels are elevated between 2 to 3 timesupper limit of normal, the trend should be monitored at monthlyintervals. If the levels are stable, they only need be checkedperiodically or if the dose of statin or fibrate is increased. If myositisis suspected, then creatine kinase levels should be measured. Ifthe level is more than 10 times the upper limit of normal, then thedrug should be discontinued.8.2.4 Pharmacoeconomics of Lipid Lowering TherapyThe economic implication of treating dyslipidaemia should notbe judged only by the direct out of pocket cost. Dyslipidaemialeads to major CV events which have economic implications. Theincidence of CVD and CKD in the country is on the rise and so isthe cost associated with it. As such the economic implication oftreating dyslipidaemia must be looked at from the perspective oftotal cost (direct and intangible cost) instead of just direct out ofpocket cost. Local data is lacking at this present time.Cost effective analysis of major lipid lowering trials have shown thatalthough direct short term cost may be higher, the incrementalcost effectiveness ratio (derived from the ratio of cost over QualityAdjusted Life Years) is favorable even for patented statins.144A substantial proportion of statin acquisition cost was offset byreduction in health care resource use as a consequence of lesserCV events. Even taking into consideration the cost of patentedstatin and measurement of hs- CRP, statin use is cost effective evenin primary prevention of medium risk individuals. 145 This is alsotrue for fibrate treatment in T2DM.146Cost effective analysis showed that prescribing generic statins maynot necessarily translate into the most cost effective option fortreating dyslipidemia.147 46
    • Key messages: • Statins are the drug of choice for reducing LDL-C in a wide range of dyslipidaemic patients. I,A • Fibrates and nicotinic acid may be considered for increasing HDL-C and reducing TG after LDL-C treatment goal has been achieved. IIa,B • Some individuals may require combination therapy to achieve lipid target goals 8.3 LDL-C APHERESISIIa,B LDL-C apheresis is indicated in patients with homozygous familial hypercholesterolemia (FH) who do not respond satisfactorily to maximum multiple drug therapy.148-153IIa,B This form of treatment may also be considered in individuals with severe heterozygous FH and progressive coronary artery disease who do not achieve target lipid levels with maximal drug therapy (high intensity statin at maximal dose with ezetimibe).148-153 In some patients with very high LDL-C levels, despite aggressive treatment with medications plus LDL-C apheresis, progression of atherosclerosis may occur but at a lesser extent.154,155 9. MANAGEMENT IN SPECIAL CONDITIONS 9.1. Specific Lipid Disorders 9.1.1. Elevated TG There is evidence of a strong association between TG levels and CVD.44,45,46 This may in part be due to its association with the other CV risk factors found in the metabolic syndrome. Very high serum TG (> 5.7 mmol/L) can give rise to acute pancreatitis and needs urgent and definitive treatment. High (2.3-5.7 mmol/L) and borderline high levels (1.7-2.3mmol/L) of TG are a common association with low HDL cholesterol, small dense LDL particles and insulin resistance. 47
    • Targets of therapyI,A In individuals with elevated TG, the primary target of therapy re- mains achieving LDL-C goal depending upon the individual’s global risk. (Table 8, pg 34)I,A In individuals where the TG > 2.3 mmol/L, non HDL-C is more rep- resentative of all atherogenic lipoproteins than LDL-C. (see also section 2 and 4.4) In these individuals, the secondary target of therapy is non HDL-C as listed in Table 11, pg 48. Another secondary target of therapy is TG < 1.7 mmol/L. Table 11: Targets of LDL-C and non HDL-C Global Risk Target LDL–C non HDL-C levels levels corresponding to (mmol/L) LDL-C goals (mmol/L) 0-1 risk factor < 4.1 < 4.9 2 or more risk < 3.4** < 4.1 factors* 2.0 to < 2.6 < 3.4 CHD and CHD risk < 2.0 < 2.6 Equivalents * These include individuals with multiple risk factors but a 10 year risk of CVD of < 20% ** Optional target <2.6mmol/L in certain high risk individuals. See Flowchart II & III Classification of TG (see Table 12, pg 48) With reference to Table 12, pg 50: • Factors contributing to elevated TG include: obesity and overweight, physical inactivity, cigarette smoking, excessive alcohol intake, high carbohydrate intake (>60% of energy intake), T2DM, chronic kidney disease, nephrotic syndrome, Cushing’s disease, lipodystrophy, pregnancy and various drugs {corticosteroids, beta-blockers, retinoids, oral estrogens (not transcutaneous estrogen), tamoxifen, protease inhibitors for AIDS}. 48
    • • Genetic disorders associated with high TG (familial combined hyperlipidaemia, familial hypertriglyceridaemia and familial dysbetalipoproteinaemia) Management of elevated TG (see Appendix VI, pg 78) In individuals with mixed hyperlipidaemia, the primary target ofI,A therapy is to achieve LDL-C goal. In those individuals with: • TG between 2.3 and 4.5mmo/l the secondary target of therapy is non HDL-C • TG > 4.5mmol/L, the primary target of therapy is non HDL-C. Once LDL-C target has been achieved, the next step is to target TG < 1.7 mmol/L. a) Borderline high TG (1.7–2.3 mmol/L) A target value of TG < 1.7 mmol/L can usually be achieved by: I,B • Lifestyle changes of weight reduction, low carbohydrate diet, control of diabetes or insulin resistance, exercise, reduction of alcohol intake and cessation of smoking.106,109,112,113,118-121 • Medications are rarely required. b) High TG ( 2.3–5.7 mmol/L) Treatment should include: I,B • Lifestyle changes as outlined above. I,B • Ensure diabetes if present is controlled. • Drug therapy should be considered in high risk individuals. There are two options to achieve targets139:I,A - intensifying statin therapy if LDL-C target not achieved156IIa,B - adding fibrates or niacin as a combination therapy to statin157,158,159 - caution should be exercised when gemfibrozil is used in combination with statins because of the significant risk of rhabdomyolysis.141,142 49
    • Table 12: Classification of TG (Adapted from ATPIII)139Classification Causes of elevated TG Clinical significanceof serum TGNormal TG(< 1.7mmol/L)Borderline • Acquired causes • Marker for atherogenicHigh TG - Overweight and obesity dyslipidemia(1.7-2.3 - Physical inactivity - elevated small LDLmmol/L) - cigarette smoking particles - excess alcohol intake - Low HDL-C - high carbohydrate intake • Marker for the (> 60% of total energy) metabolic syndrome • Secondary causes - elevated BP • Genetic causes - insulin resistance and various genetic glucose intolerance polymorphism - prothrombotic state - proinflammatory stateHigh TG • Acquired causes • Elevated atherogenic-(2.3-5.7 - same as for borderline remnantmmol/L) high TG (usually combined lipoproteins with foregoing causes) • Marker for other • Secondary causes components of • Genetic causes atherogenic - familial combined dyslipidemia (see above) hyperlipidemia • Marker for the -familial metabolic syndrome (see hypertriglyceridemia above) -polygeneic hypertriglyceridemia - familial dysbetalipoproteinemiaVery high TG • Usually combined causes • Metabolic syndrome,-(≥ - same as for high TG T2DM and5.7mmol/L) •Familial lipoprotein lipase increased risk for CHD deficiency • Increased risk for acute •Familial apolipoprotein pancreatitis C-11 deficiency • Chylomicronemia syndrome - eruptive skin xanthomas - hepatic steatosis - lipemia retinalis - mental changes - high risk for pancreatitis 50
    • There are no clinical trial evidence that show a reduction in CVD events with drug therapy in individuals with only elevated TG both c) Very high TG > 5.7 mmol/L: in primary and secondary prevention. (Appendix VI, pg 84) When TG is extremely high (>10mmol/L) treatment goal is to prevent acute pancreatitis. Treatment include: • Start with a fibrate or nicotinic acid I,B - Gemfibrozil and Fenofibrate lower TG by about 70%.43,47,160,161 I,B - Nicotinic acid is effective at doses of above 2gm per day.139,162 I,B • very low fat diets (< 15% of calorie intake) and lifestyle changes (See Section 8.1)106,111,139 • Severe hypertriglyceridaemia associated with uncontrolled diabetes warrants initiation of insulin therapy. The TG level will improve but may not normalize.IIa,B • Fish oils which contain long chain omega-3 polyunsaturated fatty acids can also lower TG. Doses of 3 to 9 gm per day can lower TG by up to 50%.139,163 They can be considered as an addition to fibrate or nicotinic acid. • Statins are not useful as a first line therapy in this situation. In these individuals, it is difficult to achieve target values of TG (< 1.7mmol/L). Levels of TG < 2.3 mmol/L are acceptable. 9.1.2. Low HDL-C and High TG: Low HDL-C and high TG are seen in insulin resistance states and very high carbohydrate intakes.I,A Treatment of this dyslipidaemia in individuals with CVD or CHD risk equivalents is aimed at lowering LDL-C to target.164 The choice of anti lipid drug will depend upon the level of LDL-C (Table 10, pg 45). If the HDL-C is still low despite adequate TLC then consider,IIa,B • fibrates or niacin if LDL-C is < 2.6mmol/L.43,47,160,161,162I,A • statin if LDL-C is > 2.6mmol/L 165,166 51
    • 9.1.3. Isolated Low HDL-C Individuals with isolated low HDL–C have HDL-C < 1.0 mmol/L and TG < 1.7 mmol/L. Low HDL-C is an independent major risk factor for CVD.18,38,39 The major causes are obesity, physical inactivity, cigarette smoking and genetic factors. There are however no large outcome studies to date showing that increasing HDL-C improves CVD outcomes. 164 Treatment for isolated low HDL-C is mainly aimed at those individuals with CVD or CHD risk equivalent.I,A Statin is still the mainstay of treatment even in patients with low LDL-C (<2.6 mmol/L). Statin trials have showed that lowering LDL- C in persons with isolated low HDL-C, significantly reduces CVD risk.166IIa,B Fibrates have also been shown to reduce major CVD events in persons with isolated low HDL-C.43,47,160,161 This benefit has been attributed in part to the HDL-C raising effects of fibrates. Key messages: • In patients with isolated hypertriglyceridemia, isolated low HDL-C or its combination, the primary goal of treatment is lowering LDL-C to target.I,A • The other targets of therapy are lowering non HDL-C (if TG > 2.3mmol/L) to target, maintaining TG < 1.7 mmol/L and HDL-C > 1.0 mmol/L. 9.2. Diabetes Mellitus (T2DM) Diabetes (T2DM) is a CHD risk equivalent. Recent long-term follow up studies showed that the benefits of intensive glucose control was not apparent early on but a legacy effect of a significant reduction in CV events was realized only 9-10 years after good glycaemic control.167,168 Despite this, the CV risk still remains high when compared to non-diabetics. Thus efforts must also be directed to control hypertension, lipids and other abnormalities. 169 52
    • Optimal Lipid values in individuals with diabetes are: • Primary target :I,A - LDL-C < 2.6 mmol/L (<1.8 mmol/L for DM with established CVD) • Secondary target: - Non-HDL-C < 3.4 mmol/L (when TG > 2.3 mmol/L) - HDL-C > 1.0 mmol/L (male) and > 1.2 mmol/L (female) - TG < 1.7 mmol/L These targets are usually not achievable by TLC or glucose control. Improvement of glycaemic control alone will not fully correct the atherogenic dyslipidaemia. (See Table 13, pg 53) Table 13: Lipid Lowering Drug Therapy In Diabetics Lipid Goal Initial Drug Suggested Addition In order of preference Lower LDL–C Statins Fibrates Ezetimibe Resins Increase HDL-C Fibrates* or, Statins*** Nicotinic Acid** Lower TG Fibrates Treat Combined Statins*** Fibrates Hyperlipidemia Nicotinic Acid * statins should be the initial drug if LDL-C goal is not achieved. ** with careful monitoring and keeping the dose < 1.5 gm / day. *** high doses may be required.I,A Statins should be initiated for all individuals above the age of 40 years with T2DM regardless of baseline LDL-C.170I,A Target should be to LDL-C <2.6 or 30-40% below baseline LDL- C.169,170 For those with T2DM and with established CVD, LDL-C should be <1.8 mmol/L.169 53
    • I,B If drug-treated patients do not reach targets on maximal toler- ated statin therapy, a reduction in LDL cholesterol of 30–40% from baseline is an alternative therapeutic goal.170 I,B In patients with high TG, reduction of carbohydrate intake is em- phasized.112,113IIa,B Sub group analysis of recent outcome studies using combination therapy of statins and fibrates to achieve lipid targets have shown benefit in atherogenic dyslipidaemia.170 Key messages: • Control of glycaemia alone is inadequate in preventing CV events. Concomitant treatment of dyslipidaemia, hypertension and other metabolic abnormalities are also important.I,A • Target LDL-C goal in individuals with diabetes is <2.6 mmol/L. I,A In the presence of established CVD, LDL-C should be <1.8 mmo/L. I,A 9.3 Coronary Heart Disease (CHD) Patients with CHD may present as stable angina or as acute coronary syndromes (ACS). ACS is a spectrum of disease ranging from unstable angina (UA), non ST elevation myocardial infarction (NSTEMI) to ST elevation myocardial infarction depending on the acuteness and severity of the coronary occlusion. 9.3.1. Acute Coronary Syndromes (ACS)I,A Early initiation of statin therapy soon after admission for ACS is safe and improves outcome regardless of baseline LDL-C levels in patient with ACS.32,171-175 These benefits are independent of the lipid lowering effects of statins.I,A Patient with ACS should be treated with a higher intensity statins. More aggressive lipid lowering further lowers cardiovascular event rates.32,171,172,176-179 54
    • Lipid management includes: I,C Assessment of a fasting lipid profile for all patients, within 24 hours of hospitalization. I,A Statins, in the absence of contra-indications, regardless of baseline LDL-C and diet modifications, should be initiated soon after admission and continued indefinitely to provide life long benefits.180-182 Statin treatment should not be delayed until lipid levels are available or management of other modifiable risk factors. Lipids should be re-tested about 2-3 months after the start of statin therapy. I,A LDL-C level should be targeted <2.0mmol/L for most patients.IIa,B Patients with low HDL-C may benefit from fibrates or nicotinic acid.43,162 9.3.2. Coronary RevascularizationsIIa,B Pre-treatment with statins 7 days prior to elective PCI has been shown to reduce post-procedure MI.183IIa,B A loading dose of statins pre-procedure has also been shown to reduce post –procedure MI in individuals who are statin–naïve and those already on regular statins.184,185IIa,A All cardiac patients post-revascularization (CABG, PCI) should be on long term statin therapy, the dose being adjusted to achieve target lipid levels.186,187 9.3.3 Stable CAD Stable CAD refers to stable angina, asymptomatic myocardial ischemia and coronary atherosclerosis detected by coronary or CT Angiogram. In individuals with stable CAD, PCI did not confer additional CV benefits when added to optimal medical therapy as an initial management strategy.188. Those individuals who had undergone 55
    • PCI however, had improvement in their quality of life during follow up.189I,A Irrespective of the baseline LDL-C level, statin therapy reduces the risk of major CV events by 24%.29I,A Individuals with stable CAD should be treated with optimal medi- cal therapy using a combination of antiplatelet agents, statins, β-blockers and angiotensin converting enzymes inhibitors.190I,A Statin therapy should always be considered for individuals with stable coronary artery disease .I,A Therapy should aim at statin dosages documented to reduce morbidity and mortality in clinical trials. Key messages: • Statins should be started early in individuals with ACS, and on all post revascularisation individuals irrespective of their baseline cholesterol levels.I,A • In high risk individuals, high intensity statin treatment confers more benefit. I,A • Statins are an integral component of optimal medical therapy in CAD individuals. I,A 9.4. Hypertension CV risk depends not only on blood pressure but also on associated risk factors, clinical conditions and target organ damage.191I,A Hypertensive individuals without established CVD but with moderate to high CV risk (≥ 10% risk of events in 10 years) should also be considered for statin therapy irrespective of baseline LDL-C levels.192 The choice of antihypertensive agent should be individualized. Certain antihypertensive agents may have an adverse effect on lipid levels eg high dose thiazides increases TC, LDL-C and TG levels, β-blockers with no intrinsic sympathetic activity reduce HDL-C and increase serum TG. These effects are modest and should not affect the selection of an antihypertensive agent.139 56
    • Key messages: • Hypertension and elevated cholesterol levels often coexist and synergistically increase the risk of developing CVD and treatment of both conditions reduces CVD events. • Statins should be considered in high risk hypertensive individuals. I,A 9.5 Stroke Recent studies have shown an association between raised serum lipids and risk of ischaemic stroke.193I,B Statins have been shown to prevent ischaemic stroke in high risk individuals.29,194I,B Individuals with Ischaemic stroke or transient ischaemic attacks benefit from lipid modifying therapy.181,194,195 High intensity statins has been found to prevent recurrent stroke7. In-hospital lipid testing should be performed in individuals with ischaemic stroke and TIA.196,197I,A Statin therapy should be considered in individuals with LDL-C ≥2.6 mmol/L 198,199. Key messages: • Statins have been shown to reduce the incidence of ischaemic strokes when used in high risk individuals. I,B • Lipid lowering therapy with statins should be considered in all individuals with previous ischaemic stroke or transient ischaemic attack. I,B 57
    • 9.6. Renal disease Chronic Kidney Disease (CKD) is associated with significant CV morbidity and mortality.200,201 Mortality increases progressively with worsening renal function. The risk of death from CVD is higher than the risk of eventually requiring renal replacement therapy.202,203 Currently, there are differing views about recognizing CKD as a CHD Risk Equivalent although all stages of CKD including individuals with asymptomatic microalbuminuria are at increased CVD risk. 139,200,204-209 They should be screened for traditional risk factors and treated according to their determined risk. Dyslipidaemia occurs in all stages of CKD, on dialysis, after renal transplantation and in individuals with the nephrotic syndrome. In individuals with CKD and in those on dialysis, the main lipid abnormalities are elevated levels of TG, low levels of HDL-C and elevated levels of Lp (a).The TC is usually normal or low. A number of studies have shown that in these individuals, lower levels of TC are associated with increased mortality most likely due to the adverse effects of malnutrition and chronic inflammation.210-217 In the nephrotic syndrome both TC and LDL-C are elevated. The lipid abnormalities may improve or resolve following resolution of the nephrosis. If the dyslipidaemia still persists, drug therapy should be considered. Caution must be exercised when starting anti lipid drug therapy in individuals with renal insufficiency. The use of fibrates in these individuals carries a higher risk of rhabdomyolysis and there is no proven long term CV benefits.218IIb,B In individuals with very high TG levels (more than 5.7 mmol/L), low dose fibrates may be initiated cautiously to prevent pancreatitis.43,47,160,161IIa,B Omega 3 Fish oils (at a dose of 4 gm/day) may also be used.219IIa,B Statins have been shown to have differential effects on the kidney. Some statins reduce proteinuria and slow the rate of progression of renal disease while others have been neutral.220,221 58
    • I,B In individuals with CHD and mild to moderate CKD, statins have been shown to be beneficial.29,218IIa,B A recently presented large prospective trial in patients with stages 3-5 CKD without CHD, showed that the use of a statin and ezetimibe combination resulted in a significant reduction in atherosclerotic events.IIb,B A third of these patients were on dialysis and they did not show any benefit, a finding consistent with that of previous studies.141,222,223 The immunosuppresive drugs used post renal transplants or for underlying renal disease are associated with dyslipidaemia. Individuals receiving statins and fibrates in combination with cyclosporin should be closely monitored for myositis. The initiating dose of anti lipid drugs in patients with CKD should be lower. (Table 14, pg 60). Key messages: • Individuals with CKD have high CV Risk. • Statins have been found to be beneficial in individuals with CHD and mild to moderate CKD.I,B • In individuals on dialysis, the benefits of lipid lowering therapy are doubtful.IIb,B • Statins are safe in CKD.I,B • Fibrates should be used cautiously in individuals with CKD and very high TG.IIb,B 59
    • Table 14. Dosing Modifications for Lipid-Lowering Drugs in CKD224 Agent Mild Moderate Severe Notes GFR GFR GFR 60–90 15–59 ml/ <15 ml/ ml/ min/1.73 m2 min/1.73 min/1.73 m2 m2 STATINS Atorvastatin No No No Fluvastatin No Not defined Not dose to one-half defined at GFR <30 ml/ min/1.73 m2 Lovastatin No to 50% to 50% dose to one-half at GFR <30 ml/ min/1.73 m2 Pravastatin No No No Start at 10 mg/day for GFR <60 ml/ min/1.73 m2 Rosuvastatin No 5–10 mg Avoid Contraindicated for GFR <30 ml/ min/1.73 m2, max dose 10 mg/day Simvastatin No No to 50% Start at 5 mg if GFR <10 ml/min/1.73 m2 NONSTATINS Nicotinic acid No No to 50% 34% kidney excretion Cholestyramine No No No Not absorbed Colesevelam No No No Not absorbed Ezetimibe No No No Fenofibrate to 50% to 25% Avoid May serum creatinine Gemfibrozil No No No NLA recommends a dose of 600 mg/ day for GFR 15–59 ml/min/1.73 m2 and avoiding use for GFR <15 ml/ min/1.73 m2 60
    • 10. MANAGEMENT IN SPECIAL GROUPS 10.1. Women Women develop heart disease about 10 to 15 years later than men.225 There are no gender differences in the risk factors that predispose to CVD although women with T2DM are at higher risk of CVD than men.226-230 In premenopausal women, CVD tends to occur in those with T2DM and multiple risk factors. I,A In secondary prevention, women have similar benefits on CVD outcomes as men.29,33,231 Statins should be the drug of first choice.29,33,231III,C Statins should not be used in women who are pregnant, intend to become pregnant or who are breast feeding. IIb,B In women who have normal LDL-C but low HDL-C and high TG, fibrates may be used.47 I,B In primary prevention, the cornerstone of management is lifestyle modification with advice on a healthy diet and physical activity.IIa,C Women at high risk who do not achieve their target levels should be considered for pharmacological intervention although there is little data on the effect of lipid lowering therapy on CVD events for primary prevention in women. Current practice is to treat these women in the same manner as men based on extrapolation of benefit in men at similar risk.232 IIa,B Women with genetic dyslipidaemias such as familial hypercholes- terolemia with very high levels of TC or LDL-C may be considered for lipid lowering therapy from the outset. 10.2. Children & Adolescents Atherosclerosis begins in childhood, the rate of progression depending on the presence and number of risk factors and their severity.233-237 Risk factors for atherosclerosis in children include: 61
    • • obesity and the metabolic syndrome238 • T2DM • post organ transplantation • systemic lupus erythematosis • nephrotic syndrome • HIV infections These risk factors have been shown to persist into adult life and lead to premature CVD. Screening begins with an assessment of family history for CVD or genetic dyslipidaemia.239 In addition, obese and overweight children and those with the risk factors mentioned above should also have a full lipoprotein profile, BP measurement and a fasting glucose assessment. Children whose lipid levels are significantly elevated should be referred to specialists interested in this field. I,B The main approach is a healthy lifestyle with appropriate diet, maintenance of “desirable weight” and regular exercise. I,A In children with elevated cholesterol levels, statins are the drug of choice.240IIb,B There has been limited data on the use of niacin, fibric acid derivatives and ezetimibe in children. When prescribing drugs in children, the need for life long therapy and its associated health risks and drug exposure during unplanned pregnancy in individuals of child bearing age need to be considered. Patients should be extensively counseled prior to initiation of drug therapy. 10.3. Elderly (> 65 years) I,A Increasing age is a major risk factor for CVD and death. For secondary prevention, the elderly derive a greater absolute benefit from lipid lowering therapy.241,242 62
    • Thus, they should not be deprived from lipid lowering therapysolely on the basis of their age although there is limited clinicaltrial data in patients over the age of 80 years.Renal function should be assessed and drug dosages adjustedaccordingly.The benefits of lipid lowering therapy for primary prevention inelderly individuals with no other risk factors besides dyslipidaemiaare less well established. Global risk assessment using standardrisk factors as mentioned earlier is generally less reliable in olderpersons. Clinical judgement and consideration of co-morbidfactors, co-existing disease and functional age become essentialin deciding the need for drug therapy in this situation. (see Table8, pg 34) Key messages: • Women and the elderly with CHD and CHD risk equivalent should be treated in the same manner as man. I,A • Children with very high cholesterol levels benefit from statin therapy. I,A11. ADHERENCE, COMPLIANCE AND QUALITY ASSURANCEIt has been well documented that there is a lack of adherence tocardiovascular preventive therapy. This is due to both physicianfactors (not initiating treatment, not achieving treatment goals,not checking on drug compliance) and patient factors (noncompliance).Lack of adherence threatens the success of the guidelinerecommendation and implementation. Clinical trials have shownthat the amount of risk reduction achieved is related to thelevel of adherence to treatment.243,244,245 More importantly, lackof adherence leads to missed opportunity for the risk reducingbenefits of the treatment, thus creating enormous costs tothe health system for treating CV events that could have beenprevented. 63
    • To improve adherence and compliance the following arerecommended:• Patient factors - Simplify medication regimens using wherever possible drugs with a single daily or twice daily dosing - Give clear instructions - Encourage the support of the family - Involve patients in their care through self-monitoring - Remind patients that lipid lowering drugs are not a substitute for dietary and lifestyle interventions• Physician Factors - Teach physicians to implement lipid treatment guidelines - Educate patients to prompt preventive care - Remind patients of appointments and follow-up missed appointments• Health Delivery System - Involve pharmacists and other health care deliverers in patient education - Use mass media for patient education - Disseminate clinical guidelines and clinical pathways to health care providers - Standardize reference values in all laboratories to recommended Malaysian guidelinesAdherence to therapy should be checked periodically. Somesuggestedindicators as audit for lipid lowering therapy are:• Measurement of lipid values• Risk categorization of patients• Appropriate usage of drug therapy• Achieving primary lipid target goal: LDL-C to target• Achieving secondary lipid target goals: HDL-C and TG to target 64
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    • APPENDIX I: APOLIPOPROTEINS : MAJOR CATEGORIES MAJOR CLASSES SUBCLASSES/ISOFORMS Apo A apo A-I, apo-II, apo A-IV, apo A- V Apo B apo B-48, apo B-100 Apo C apo C-I, apo C-II, apo C-III, apo C-IV Apo D Apo E apo E-2, apo E-3, apo E-4 Apo H APPENDIX II: RISK FACTORS FOR MI AND STROKE IN THE INTERHEART AND INTERSTROKE STUDIES* INTERSTOKE INTERHEART (all stroke; 3000 (acute myocardial cases, 3000 infarction; 15152 controls)* cases, 14820 controls)** Hypertension 34.6% (30.4-39.1) 17.9% (15.7-20.4) Smoking 18.95 (15.3-23.1) 35.7% (32.5-39.1) Waist-to-hip 26.5% (18.8-36.0) 20.1% (15.3-26.0) (abdominal obesity) Diet Diet risk score 18.8% (11.2-29.7) Fruits and vegetables .. 13.7% (9.9-18.6) daily Regular physical activity 28.5% (14.5-48.5) 12.2% (5.5-25.1) Diabetes 5.0% (2.6-9.5) 9.9% (8.5-11.5) Alcohol intake 3.8% (0.9-14.4) 6.7% (2.0-20.2) Psychosocial factors All psychosocial .. 32.5% (25.1-40.8) factor 4.6% (2.1-9.6) .. Psychosocial stress .. Depression 5.2% (2.7-9.8) Cardiac causes 6.7% (4.8-9.2) .. Ratio of apolipoproteins 24.9% (15.7-37.1) 49.2% (43.8-54.5) B to A1* Yusuf S, Hawken S, Ounpuu S, on behalf of the INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004; 364:937-952.** ‘O Donnel MJ, Xavier D, Liu L et al on behalf of the INTERSTROKE Investigators. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010;376 : 112-123 80
    • APPENDIX III: BODY MASS INDEXCalculation of body mass index (BMI) is one way of determiningthe ideal weight for an individual. BMI is the relationship of bodyweight to height. Increased BMI is associated with increasedmortality and morbidity. The predictive value of BMI is enhancedby taking the waist circumference into consideration as well.Body Mass Index = (Weight in kg) (Height in m)2 CLASSIFICATION OF WEIGHT BY BMI CLASSIFICATION BMI (Kg / m2) Risk of co-morbidities Underweight < 18.5 Low (but increased risk of other clinical problems) Normal range 18.5-22.9 Average Overweight > 23.0 Pre-Obese 23.0-27.4 Increased Obese I 27.5-34.9 Moderate Obese II 35.0-39.9 Severe Obese III > 40.0 Very Severe(Adapted from Malaysian Clinical Practice Guidelines on theManagement of Obesity 2003. Assessed at www.acadmed.org.my) 81
    • APPENDIX IV: COMPARISON OF GLOBAL CORONARY AND CARDIOVASCULAR RISK SCORES94 Framingham SCORE PROCAM (Men) Reynolds (Women) Reynolds (Men) Sample size 5,345 205,178 5,389 24,558 10,724 Age (y) 30 to 74; 19 to 80; 35 to 65; >45; >50; Mean: 49 Mean : 46 Mean: 47 Mean: 52 Mean: 63 Mean follow-up ,y 12 13 10 10.2 10.8 Risk factors Age, sex, total Age, sex, Age, LDL Age, HbA1C (with Age, systolic blood considered cholesterol, HDL total-HDL cholesterol, HDL diabetes), smoking, pressure, total cholesterol, cholesterol cholesterol, systolic blood pressure, cholesterol, HDL smoking, systolic ratio, smoking, smoking, systolic total cholesterol, HDL cholesterol, smoking, blood pressure, systolic blood blood pressure, cholesterol, hsCRP, hsCRP, parental history82 antihypertensive pressure family history, parental history of MI at of MI at <60 y of age medications diabetes, <60 y of age triglycerides Endpoints CHD (MI and CHD Fatal CHD Fatal/nonfatal MI MI, ischemic MI, stroke, coronary death) or sudden cardiac stroke, coronary revascularization, death (CHD and revascularization, cardiovascular CVD combined) cardiovascular death (CHD and CVD death (CHD and CVD combined) combined) URLs for risk http://hp2010. http://www. http://www.chd- http://www. http://www. calculators nhlbihin.net/ heartscore. taskforce.com/ reynoldsriskscore.org/ reynoldsriskscore.org/ atpiii/calculator. org/pages/ coronary_risk_ asp?usertype=prof welcome.aspx assessment.html
    • APPENDIX V: LIPID LOWERING DIET PRINCIPLE AMOUNT COMMENT Decrease < 200 mg / day Reduce intake of organ meat (offal) eg dietary liver, heart, brains, kidney. Limit to 3 cholesterol oz once fortnightly. A small amount of prawn / crab / oysters / cockles may be taken once or twice a week if desired. Decrease < 30% of total Modify cooking methods – grill /steam total fat/oil energy / boil / bake / microwave to reduce use of oils and fats. Avoid oily / fatty food eg deep fat fried foods. Types: 7-10% (not Minimize the use of following – butter, a) saturated more than 10% hard margarine, full cream milk (including fat of total calorie condensed milk) cream, high fat cheese, intake) fatty meats, bacon and sausages, coconut oil, santan, products containing hydrogenated oil and some non dairy creamers. b)mononun- Not more Choices may include the following: saturated than 6 olive oil, sunflower oil, corn oil, and polyun- teaspoonsfuls palm oil, soybean oil, peanut oil and saturated per day to be polyunsaturated margarine. oils/marga- used in cooking rine or as a spread Increase 20-25 gm fiber Sources of complex carbohydrates/grains: intake of / day. Include rice, bread, pasta, noodles and tuber complex 2-3 servings Sources of fiber: fruits, vegetables, carbohydrate of fruit and pulses, legumes and unrefined cereals. / grains and 3-4 servings of fiber vegetables and 5 -7 servings per day of grains Choose food 2-3 servings Choices may include: chicken without high in per day skin, fish, Legumes and pulse (tofu, dhal, protein but green peas and beans), egg whites, lean low in meat, skim milk and milk products (low saturated fat fat milk may be used but some low fat milk may contain up to 50% of its original fat).Consuming an egg a day does not substantially increase CVD risk.246,247 The method of cook-ing the egg is important.*Adapted and modified from Lichtenstein AH, Appel LJ, Brands M et al. Diet and LifestyleRecommendations Revision 2006. A Scientific Statement From the American Heart Associa-tion Nutrition Committee Circulation 2006;114:82-96. 83
    • APPENDIX VI: CONVERSION TABLE (<1.14mmol/L) (<1.7mmol/L) (1.7-2.3mmol/L) (2.3-5.7mmol/L) (≥5.7mmol/L)*Adapted from Miller M, Stone NJ, Ballantyne C et al Triglycerides and Cardiovascular Dis-ease: A Scientific Statement from the American Heart Association. Circulation 2011; 123:2292-2333 84
    • ACKNOWLEDGMENTSThe committee of this guideline would like to express their grati-tude and appreciation to the following for their contribution:• Technical Advisory Committee, Clinical Practice Guidelines, Ministry of Health for their valuable input and feedback• Panel of external reviewers who reviewed the draftDISCLOSURE STATEMENTThe panel members have no potential conflict of interest to dis-close.SOURCES OF FUNDINGThis CPG was made possible by an unrestricted educational grantto NHAM from Pfizer (M) Sdn Bhd. There was total editorial inde-pendence and the funding body did not influence the content ofthis guideline. 85