Cardio updates 2019 power point template

Case of dyslipidemia
Haytham Soliman, MD, FSCAI
Fayoum University

is a 74-year-old-woman who presents to the office for routine follow-up. She had an anterior wall myocardial
infarction 1 year ago. She does not smoke. Her current medication regimen is well tolerated and also
includes aspirin, metoprolol, lisinopril (20 mg/day), and Simvastatin (20 mg/day). On examination, her blood
pressure is 140/100 mm Hg and her pulse is 68 beats/min. Her most recent laboratory values are:
- A1c: 6.2%,
Lipid profile
– TC 200 mg/dL
– LDL 110mg/dL
– HDL 41 mg/dL
– TG 240 mg/dL
eGFR:80 ml/min
ASCVD Case

Q: is every thing is OK in this
patient?
NO

is a 74-year-old-woman who presents to the office for routine follow-up. She had an anterior wall myocardial
infarction 1 year ago. She does not smoke. Her current medication regimen is well tolerated and also
includes aspirin, metoprolol, lisinopril (20 mg/day), and Simvastatin (20 mg/day). On examination, her blood
pressure is 140/100 mm Hg and her pulse is 68 beats/min. Her most recent laboratory values are: A1c:
6.2%,
Lipid profile
– TC 200 mg/dL
– LDL 110mg/dL
– HDL 41 mg/dL
– TG 240 mg/dL
eGFR:80 ml/min
ASCVD Case

2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce
cardiovascular risk (European Heart Journal 2019 -doi: 10.1093/eurheartj/ehz455)www.escardio.org/guidelines
Recommendations for the treatment of
dyslipidaemias in older people (aged >65 years)
©ESC
Recommendations Class Level
Treatment with statins is recommended for older people with ASCVD in
the same way as for younger patients.
I A
Treatment with statins is recommended for primary prevention, according to
level of risk, in older people aged ≤ 75.
I A
Initiation of statin treatment for primary prevention in older people aged
> 75 may be considered, if at high risk or above.
IIb B
It is recommended that the statin is started at a low dose if there is
significant renal impairment and/or the potential for drug interactions,
and then titrated upwards to achieve LDL-C treatment goals.
I C

In order to set goals for
treatment we must know the
risk of the patient

Treatment goals for low-density lipoprotein
cholesterol (LDL-C) across categories of total cardiovascular
disease risk
©ESC
Low
Moderate
High
Very-High
3.0 mmol/L
(116 mg/dL)
Treatment goal
for LDL-C
2.6 mmol/L
(100 mg/dL)
1.8 mmol/L
(70 mg/dL)
1.4 mmol/L
(55 mg/dL)
& ≥50%
reduction
from baseline
Low Moderate High very-High CV Risk
•SCORE <1%
•SCORE ≥1% and <5%
•Young patients (T1DM <35 years; T2DM <50 years) with DM
duration <10 years without other risk factors
•SCORE ≥5% and <10%
•Markedly elevated single risk factors, in particular TC >8 mmol/L (310
mg/dL) or LDL-C >4.9 mmol/L (190 mg/dL) or BP ≥180/110 mmHg
•FH without other major risk factors
•Moderate CKD (eGFR 30–59 mL/min)
•DM w/o target organ damage, with DM
duration ≥10 years or other additional risk factor
•ASCVD (clinical/imaging)
•SCORE ≥10%
•FH with ASCVD or with another major risk factor
•Severe CKD (eGFR <30 mL/min)
•DM & target organ damage: ≥3 major risk factors;
or early onset of T1DM of long duration (>20 years)

Recommendations for treatment goals for
low-density lipoprotein cholesterol (1)
©ESC
In secondary prevention patients at very-high risk , an LDL-C reduction ofc
at least 50% from baseline
are recommended.
d and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) I A
In primary prevention, for individuals at very-high risk but without FH , anc
LDL-C reduction of at least 50% from baseline
mmol/L (<55 mg/dL) are recommended.
d and an LDL-C goal of <1.4 I C
In primary prevention, for individuals with FH at very-high risk, an LDL-C
reduction of at least 50% from baseline and an LDL-C goal of <1.4 mmol/L
(<55 mg/dL) should be considered.
IIa C
c
For definitions see Table 1.
d
The term ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C lowering medication. In people who
are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based
on the average LDL-C-lowering efficacy of the given medication or combination of medications.

Follow up period
Recommendations for lipid-lowering therapy
in very-high-risk patients with acute coronary syndromes (1)
©ESC
In all ACS patients without any contra-indication or definite history of
intolerance, it is recommended to initiate or continue high dose statin as
early as possible, regardless of initial LDL-C values.
I A
Lipid levels should be re-evaluated 4–6 weeks after ACS to determine
whether a reduction of at least 50% from baseline and goal levels of LDL-
C <1.4 mmol/L (<55 mg/dL) have been achieved. Safety issues need to be
assessed at this time and statin treatment doses adapted accordingly.
IIa C
If the LDL-C goal is not achieved after 4–6 weeks with the maximally
tolerated statin dose, combination with ezetimibe is recommended.
I B

Recommendations for drug treatments of
patients with hypertriglyceridaemia (1)
©ESC
Statin treatment is recommended as the first drug of choice for reducing
CVD risk in high-risk individuals with hypertriglyceridaemia (TG >2.3
mmol/L (>200 mg/dL)).
I B
In high-risk (or above) patients with TG between 1.5 and 5.6 mmol/L (135–
499 mg/dL) despite statin treatment, n-3 PUFAs (icosapent ethyl 2 x 2 g/day)
should be considered in combination with statin.
IIa B

what doses should we start with?
Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol
Guideline

Expected clinical benefit of low
-density lipoprotein cholesterol
lowering therapies
©ESC
Intensity of lipid lowering treatment
Average LDL-C reduction
Treatment
Moderate intensity statin
High intensity statin
≈ 30%
≈ 50%
High intensity statin plus ezetimibe
PCSK9 inhibitor
PCSK9 inhibitor plus high intensity statin
plus ezetimibe
≈ 65%
≈ 60%
≈ 75%
≈ 85%
% reduction LDL-C Baseline LDL-C
Absolute reduction LDL-C
Relative risk reduction Baseline risk
Absolute risk reduction
LDL-C = low-density lipoprotein cholesterol;
PCSK9 = proprotein convertase subtilisin/kexin type 9.

So we have set the goals
• LDL ≤ 55 mg/dl
• TG ≤ 200 mg/dl
• Follow up after 4 weeks
• Statin was changed to Rosuvastatin 20 mg OPD
• We also modified to Valsartan 160 mg for BP controle

Central Illustration Lower panel: Treatment
algorithm for pharmacological LDL-C lowering (2)
©ESC
Define treatment goal
Lifestyle advice /
Lifestyle intervention
High potency statin at highest
recommended /
tolerable dose to reach the goal
LDL-C goal reached?
Y N
Y N

After 4 weeks
• LDL → 70 mg/dl
• TG → 170 mg/dl
•What is the next step?
( follow up or modification of the treatment)

Central Illustration Lower panel: Treatment
algorithm for pharmacological LDL-C lowering (3)
©ESC
Add ezetimibe
LDL-C goal reached?
Y N
Follow-up annually,
or more frequently
if indicated
Follow-up annually,
or more frequently
if indicated
Add PCSK9 inhibitor
•Secondary prevention (very-
high-risk)
•Primary prevention:
patients with FH and
another major risk factor
(very-high-risk)
Consider adding
PCSK9 inhibitor
•Primary prevention: patients at
very-high risk but without FH
Y N

4 weeks later after adding 10 mg Esitimibe
•LDL 53 mg/dl
•TG 160 mg/dl
•The patient has no symptoms and
tolerating the drug combination

• Patient has a steady course for 5 months
•Then she had an attack of TIA !!!
• Carotid duplex showed bilateral non calcific plaques of 50%
•What else could we do to this patient?

•Should we change her statin combination therapy ?
•Could we seek a lower LDL target? and using what?
•Should we look for another risk target in lipid
profile?

What about other lipid parameters?

•Non-HDL-C : 75 mg/dl
•Apo B: 60mg/dl

Recommendations for treatment goals for
low-density lipoprotein cholesterol (2)
©ESC
For patients with ASCVD who experience a second vascular event within 2
years (not necessarily of the same type as the first event) while taking
maximally tolerated statin therapy, an LDL-C goal of <1.0 mmol/L (<40
mg/dL) may be considered.
IIb B
In patients at high-risk , an LDL-C reduction of at least 50% fromc
baselined and an LDL-C goal of <1.8 mmol/L (<70 mg/dL) are
recommended.
I A
c
For definitions see Table 1.
d
The term ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C lowering medication. In people who
are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based
on the average LDL-C-lowering efficacy of the given medication or combination of medications.

Goal now is ≤ 40 mg/dl LDL
Expected clinical benefit of low
-density lipoprotein cholesterol
lowering therapies
©ESC
Intensity of lipid lowering treatment
Average LDL-C reduction
Treatment
Moderate intensity statin
High intensity statin
≈ 30%
≈ 50%
High intensity statin plus ezetimibe
PCSK9 inhibitor
plus ezetimibe
≈ 65%
≈ 60%
≈ 75%
≈ 85%
% reduction LDL-C Baseline LDL-C
Absolute reduction LDL-C
Relative risk reduction Baseline risk
Absolute risk reduction
LDL-C = low-density lipoprotein cholesterol;
PCSK9 = proprotein convertase subtilisin/kexin type 9.

Recommendations for pharmacological
low-density lipoprotein cholesterol lowering (2)
©ESC
For secondary prevention, patients at very-high risk not achieving their
goal on a maximum tolerated dose of statin and ezetimibe, a combination
with a PCSK9 inhibitor is recommended.
c I A
For very-high-risk FH patients (that is, with ASCVD or with another major
risk factor) who do not achieve their goal on a maximum tolerated dose of
statin and ezetimibe, a combination with a PCSK9 inhibitor is
recommended.
I C
If a statin-based regimen is not tolerated at any dosage (even after re-
challenge), ezetimibe should be considered. IIa C

•LDL now is 35 mg/dl
•TG is 155 mg/dl
•BP is 130/80

Summary
• Risk stratification is extremely important to set goals for treatment
• Follow up period in ASCVD patients must not exceeds 6 weeks
• Combination therapy is a great tool for reaching the goal
• Risk factors ( other than lipid profile) must be modified
• In recurrent vascular events even lower LDL to 40 mg/dl could be
reached
• The Lowest LDL seems to be the best

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