Dyslipidemia guideline review : the transatlantic differences


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ESC and ACC/AHA dyslipidemia guidelines

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Dyslipidemia guideline review : the transatlantic differences

  1. 1. Dyslipidemia guidelines update By Ashraf Reda, MD, FESC Prof and head of Cardiology Dep. Menofiya University
  2. 2. LDL-C Goals for High Risk Patients Recommended LDL-C treatment goals ATP III Update 20041 <100 mg/dL: Patients with CHD or CHD risk equivalents (10 year risk >20%)1 <70 mg/dL: Therapeutic option for very high risk patients1 AHA/ACC guidelines for patients with CHD*,2 <100 mg/dL <70 mg/dL 2006 Update <100 mg/dL: Goal for all patients with CHD†,2 <70 mg/dL: A reasonable goal for all patients with CHD2 • If it is not possible to attain LDL-C <70 mg/dL because of a high baseline LDL-C, it generally is possible to achieve LDL-C reductions of >50% with more intensive LDL-C–lowering therapy, including drug combinations. * And other forms of atherosclerotic disease.2 † Factors that place a patient at very high risk: established cardiovascular disease plus: multiple major risk factors (especially diabetes); severe and poorly controlled risk factors (e.g., cigarette smoking); metabolic syndrome (triglycerides ≥200 mg/dL + non–HDL-C ≥130 mg/dL with HDL-C <40 mg/dL); and acute coronary syndromes.1 1. Grundy SM et al. Circulation 2004;110:227–239. 2. Smith SC Jr et al. Circulation 2006; 113:2363–2372.
  3. 3. ADA/ACC 2008 Consensus Statement: Treatment Goals for Patients With Cardiometabolic Risk and Lipoprotein Abnormalities Goals LDL-C Highest-Risk Patients Non–HDL-C Apo B <70 mg/dL <100 mg/dL <80 mg/dL <130 mg/dL <90 mg/dL • Known cardiovascular disease (CVD) • Diabetes plus ≥1 additional major CVD risk factor High-Risk Patients <100 mg/dL • No diabetes or known CVD but ≥2 major CVD risk factors • Diabetes but no other major CVD risk factors “In individuals on statin therapy who continue to have low HDL-C or elevated non–HDL- C, especially if Apo B levels remain elevated, combination therapy is recommended. The preferred agent to use in combination with a statin is nicotinic acid…” Reprinted from Brunzell JD, et al. J Am Coll Cardiol. 2008;51:1512–1524, with permission from Elsevier.
  4. 4. ESC/EAS 2011 • Life style intervention should be tried first • If not effective statin is the first choice • Addition of Ch. Absorption inhibitors, bile acid Seq. or niacin if not at goal
  5. 5. Calculating the risk: SCORE • Very high, high, moderate or low risk • Total and HDL-c are incorporated • Relative risk charts for young apparently low risk individuals • Charts for low and charts for high risk region • Charts for different HDL levels
  6. 6. LDL levels are the main target of lipid management • Less than 115 mg/dl in moderate risk • Less than 100 mg/dl in high risk • Less than 70 mg/dl in very high risk • If target can’t be achieved………50% reduction • Non-HDL-c and Apo-B potential targets in DM2, Met.S and combined dyslipidemia
  7. 7. Atherogenic Lipoproteins Non-HDL; Apo B100-containing Non-HDL Includes All Atherogenic Lipoprotein Classes Very low-density lipoprotein VLDL – Made in the liver – TG >> CE – Carries lipids from the liver to peripheral tissues Intermediate-density lipoprotein IDL LDL Lp(a) HDL – Formed from VLDL due to loss of TG – Also known as a VLDL remnant Low-density lipoprotein – Formed from IDL due to loss of TG – CE>>TG Lipoprotein (a) – Formed from LDL w/ addition of apo (a)? – Very atherogenic High-density lipoprotein – Removes cholesterol from peripheral tissues
  9. 9. Non-HDL-c and Apo-B targets • The goal for non HDL-c is 30 mg above LDL goal • Apo-B goal less than 80 mg/dl in very high and less than 100 mg/dl in high risk • Especially considered as 2ry target in atherogenic dyslipidemia with average LDL
  10. 10. American Diabetes Association (2009) Treatment recommendations and goals • Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients: – with overt CVD – without CVD who are over the age of 40 and have one or more other CVD risk factors. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009 Level of Evidence A A
  11. 11. American Diabetes Association (2009) Treatment recommendations and goals • In individuals without overt CVD, the primary goal is an LDL cholesterol 100 mg/dl. • In individuals with overt CVD, a lower LDL cholesterol goal of 70 mg/dl, using a high dose of a statin, is an option. • If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 30–40% from baseline is an alternative therapeutic goal. DIABETES CARE, VOLUME 32, SUPPLEMENT 1, JANUARY 2009 Level of Evidence A B A
  12. 12. Although there are no specific goals , however Trigs., and HDL are important risk determinant
  13. 13. Lipid Management in high TG: Recommendation l lla llb lll B l lla llb lll B l C lla llb lll If TG are 200–499 mg/dL, non-HDL-C should be <130 mg/dL Further reduction of non-HDL-C to <100 mg/dL is reasonable Therapeutic options to reduce non-HDL-C: More intense LDL-C–lowering therapy I (B) or Niacin (after LDL-C–lowering therapy) IIa (B) or Fibrate (after LDL-C–lowering therapy) IIa (B) If TG are >500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy, Achieve non-HDL-C <130 mg/dL, if possible TG=Triglycerides; HDL-C=high-density lipoprotein cholesterol Smith SC Jr et al. Circulation 2006;113:2363–2372.
  14. 14. Elevated Triglycerides Non-HDL Cholesterol: Secondary Target • Primary target of therapy: LDL cholesterol • Achieve LDL goal before treating non-HDL cholesterol • Therapeutic approaches to elevated non-HDL cholesterol – Intensify therapeutic lifestyle changes – Intensify LDL-lowering drug therapy – Nicotinic acid or fibrate therapy to lower VLDL
  15. 15. Genetic dyslypidemia • Familial combined hperlipidemia is not rare: 1% of population • Often unrecognized and untreated • Early detection and management
  16. 16. The issue of non-adherence • Important barrier to dyslipidemia management • Responsibility of Pt. Dr., and health care system
  17. 17. Implication of the new American guidelines: which one should we follow? • ATP III 2002 JAMA (NHLBI) • The new one (ACC/AHA/ NHLBI) • The hottest in AHA 2013 • Key feature: from specific lipid goal to % reduction
  18. 18. The new American guidelines: Key features: Statin leeagable sub groups • • • • Clinical Atherosclerotic CVD LDL> 190 mg/dl Type 1 or 2 DM & LDL> 70 mg/dl 10 year risk > 7.5% & LDL >70 mg/dl (New risk calculator)
  19. 19. The new American guidelines: Sub groups with doughtful benefits from statin • > 75 yrs without clinical Atherosc. CVD • A need for hemodialysis • Heart filure
  20. 20. The American guidelines: key features • High or moderate intensity statin therapy when lipid lowering is indicated • Diminished role of non statin lipid lowering agents alone or in combination • Avoid LL drugs in certain group • No routine LDL assessment • New risk calculator and extended use in primary prevention
  21. 21. Guidelines are important but they are just guidelines
  22. 22. Conclusions • • • • • More aggressive approach Early screening and management Incorporation of Tgs. And HDL in risk evaluation LDL is still the primary target Non HDL-c is a secondary target in DM2, Met.S and combined dyslipidemia • Is it the end of non statin LL agents and combination?