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2019 ESC/EAS Guidelines on Dyslipidaemias

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La Dra. Begoña Benito Villabriga repasa los puntos clave del documento presentado en ESC Congress 2019.

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2019 ESC/EAS Guidelines on Dyslipidaemias

  1. 1. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias Begoña Benito VillabrigaGuidelines for the management of dyslipidaemiasGuidelines for the management of dyslipidaemias
  2. 2. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemiasGuidelines for the management of dyslipidaemias BACKGROUND: New evidence: • LDL-C (and ApoB-contaning LP) are key elements in atherogenesis. • Mendelian randomization studies have confirmed that LDL-C is causally related to ASCVD. • Raising HDL-C with available therapies do not reduce the ASCVD risk. • The addition of ezetimibe or PCSK9 monoclonal antibodies provides further benefit: • Further reduction in LDL-C  further reduction in ASCVD. • The lower LDL-C levels, the better: • No J-curve effect, apparent safety of low LDL-C values (<1.4 mmol/L - 55 mg/dL).
  3. 3. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias NEW CONCEPTS AND RECOMMENDATIONS: • RISK STRATIFICATION: • CV imaging for assessment of ASCVD risk: • Arterial (carotid/femoral) plaque burden (US) • CAC score assessment (CT) • SPECIAL POPULATIONS: • > 65 years, DM, FH, hypertriglyceridaemia, ACS, CHF, PCI, CKD, prior stroke. Risk modifiers in low/moderate risk patients
  4. 4. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias NEW CONCEPTS AND RECOMMENDATIONS: • Assessment of predicted benefit: Pre-treatment LDL-C levels Lipid-lowering strategy Relative reduction of LDL-C Baseline CV risk ABSOLUTE CARDIOVASCULAR RISK REDUCTION
  5. 5. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias NEW CONCEPTS AND RECOMMENDATIONS: • Assessment of predicted benefit: Pre-treatment LDL-C levels Lipid-lowering strategy Relative reduction of LDL-C Baseline CV risk ABSOLUTE CARDIOVASCULAR RISK REDUCTION
  6. 6. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias RISK CATEGORIES: Very high risk High risk Moderate risk Low risk Documented ASCVD Always - - - DM • Target organ damage, • > 20 years • No target organ damage • > 10 years • No other RF • < 10 years - FH + ASCVD Without RF - - CKD eGFR < 30 30-60 - - SCORE (10y-risk) ≥ 10 5-10 1-5 <1
  7. 7. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias NEW CONCEPTS AND RECOMMENDATIONS: • Assessment of predicted benefit: Pre-treatment LDL-C levels Lipid-lowering strategy Relative reduction of LDL-C Baseline CV risk ABSOLUTE CARDIOVASCULAR RISK REDUCTION
  8. 8. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias RECOMMENDED STRATEGIES: Pre-treatment LDL-C levels Baseline CV risk
  9. 9. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias NEW CONCEPTS AND RECOMMENDATIONS: • LDL-C goals: 2P: 1P: CTT meta-analysis (Lancet 2010) IMPROVE-IT (NEJM 2015) FOURIER (NEJM 2017) ODYSSEY (NEJM 2018)
  10. 10. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias ALGORYTHM OF PHARMACOLOGICAL LDL-C LOWERING (I): 1. High potency statin at highest recommended dose Reevaluation at 4-6 wks
  11. 11. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias ALGORYTHM OF PHARMACOLOGICAL LDL-C LOWERING (I): Reevaluation at 4-6 wks 2. + Ezetimibe 3. + PCSK9 inhibitor
  12. 12. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias CONCLUSIONES: • El manejo del perfil lipídico para mejorar el riesgo CV viene condicionado por: 1) Riesgo CV basal 2) Niveles de LDL-C basales • Además de hábitos de vida saludables, se recomienda inicio farmacológico para reducir los niveles de LDLD-C en: Considerar Iniciar Objetivo Prev. secundaria Cualquier LDL-C LDL-C ≥ 55  50% + < 55 Prev. primaria - VHR LDL-C ≥ 55 LDL-C ≥ 70  50% + < 55 Prev. primaria – HR LDL-C ≥ 70 LDL-C ≥ 100  50% + < 70 Prev. primaria - MR LDL-C ≥ 100 LDL-C ≥ 190 < 100 Prev. primaria – LR LDL-C ≥ 116 LDL-C ≥ 190 < 116
  13. 13. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias CONCLUSIONES: • El tratamiento hipolipemiante debe realizarse de forma escalonada: Estatinas de alta potencia: primera elección Aumentar estatinas a máxima dosis tolerada Añadir Ezetimibe Añadir inhibidores de PCSK9 (en prev. secundaria y prev. primaria + HF o prev. primaria – VHR)

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