Guidelines for management of dyslipidemia and prevention of cardiovascular disease (ATP III, ATP IV, AACE 2017, AHA/ACC 2018) por Dr. Ricardo Mora Moreno R3C; IMSS UMAET1 León, Guanajuato, México; 15 de Enero del 2019
Artifacts in Nuclear Medicine with Identifying and resolving artifacts.
Guias para manejo de dislipidemia y prevencion de enfermedad cardiovascular
1. Instituto Mexicano del Seguro Social
Centro Médico Nacional del Bajío
Unidad Médica de Alta Especialidad
>> Departamento de Cardiología <<
Tema:
“Guidelines for management of dyslipidemia and prevention
of cardiovascular disease”
[ATP-III, ATP-IV, AACE 2017, ACC/AHA 2018]
Dr. Ricardo Mora Moreno
Médico Residente 3er Año de Cardiología (R3C)
León, Guanajuato
15 / Enero / 2019
3. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). Third Report of the National Cholesterol Education Program
(NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation
2002;106:3143-421.
4. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
5. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
6. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
7. 1.- Determinar niveles de lipoproteínas
después de ayuno 9-12 horas
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
8. 2.- Identificar la presencia de enfermedad ateroesclerótica clínica
que confiere alto riesgo de enfermedad coronaria (EC)
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
Clínica enfermedad coronaria
Enfermedad arteria carótida
sintomática
Aneurisma de aorta abdominal
Enfermedad arterial periférica
9. 3.- Determinar presencia de factores de riesgo mayores
(otros diferentes a LDL)
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
10. 4.- Si existen +2 factores de riesgo (otros diferentes a LDL) sin EC o
equivalente de riesgo para EC, determinar riesgo de EC a 10-años
• >20% o equivalente riesgo EC
• 10-20%
• <10%
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
11. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
12. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
13. 5.- Determinar categoría de riesgo
• Establecer meta de tratamiento de LDL
• Determinar necesidad terapéutica
cambios estilo de vida (CEV)
• Determinar nivel para consideración
farmacológica (TF)
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
14. 6.- Iniciar cambios estilo de vida (CEV) si los niveles de LDL están
por arriba de la meta
Cambios estilo de vida (CEV)
Dieta:
• Grasas saturadas <7% de calorías, colesterol <200mg/día
• Considerar incrementar consumo de fibra soluble (10-25gr/día)
y proteínas de origen vegetal (estanoles/esteroles)
Manejo de peso
Incrementar actividad física
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
15. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
16. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
17. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
18. 7.- Considerar agregar terapia
farmacológica si los niveles de LDL
exceden a las metas
• Considerar terapia farmacológica
simultáneamente con cambios en
estilo de vida (CEV) para EC y
equivalentes de EC
• Considerar agregar terapia
farmacológica a los cambios en estilo
de vida (CEV) después de 3 meses
para otras categorías de riesgo
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
19. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
20. NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
21. 8.- Identificar Síndrome Metabólico y
tratar, si esta presente, después de 3
meses de cambios en estilo de vida
(CEV)
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
22. Tratamiento Síndrome Metabólico
Tratar causas subyacentes (Sobrepeso/Obesidad y
Sedentarismo)
Intensificar manejo de peso
Incrementar actividad física
Tratar factores de riesgo lipídicos y no-lipídicos si
estos persisten a pesar de terapias en cambios de
estilo de vida
Tratar hipertensión
Usar Aspirina para pacientes con EC para reducir estado
protrombotico
Tratar hipertrigliceridemia y/o HDL bajo
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
23. 9.- Tratar Hipertrigliceridemia
• Objetivo primario de la terapia es
alcanzar meta de LDL
• Intensificar manejo de peso
• Incrementar actividad física
• Si los triglicéridos son ≥200mg/dl
después de que la meta de LDL es
alcanzada, alcanzar meta secundaria
para colesterol no-HDL (total-HDL)
30mg/dl arriba de la meta de LDL
Clasificación ATP III para
triglicéridos séricos (mg/dl)
<150 Normal
150-199 Límite Alto
200-499 Alto
≥500 Muy Alto
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
24. Triglicéridos 200-499 mg/dl, después de
alcanzar meta de LDL, considerar agregar
terapia farmacológica si es necesaria para
alcanzar meta de no-HDL
Intensificar terapia con fármacos reductores-LDL
Agregar ácido nicotínico o fibratos para
incrementar disminución VLDL
Triglicéridos ≥500 mg/dl, primero disminuir
triglicéridos para prevenir pancreatitis
Dieta muy baja en grasas (≤15% de calorías por
grasas)
Manejo de peso y actividad física
Fibrato o acido nicotínico
Cuando se alcancen triglicéridos <500 mg/dl, cambiar
a terapia para reducir-LDL
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
25. Tratamiento de Colesterol HDL bajo (<40 mg/dl)
• Primero alcanzar meta de LDL,
después…..
• Intensificar manejo de peso e
incremento actividad física
• Si triglicéridos 200-499 mg/dl,
alcanzar meta de colesterol No-HDL
• Si triglicéridos <200mg/dl (HDL bajo
aislado) en EC o equivalente de EC,
considerar acido nicotínico o fibrato
NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third
Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)
final report. Circulation 2002;106:3143-421.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
26. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the
Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in
Adults: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
27. Los principales cambios en las nuevas guías se pueden
resumir en los siguientes puntos:
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
• Todas las recomendaciones se basan en estudios clínicos randomizados basados en la evidencia científica.
Queda a criterio del médico tratante el uso de terapias alternativas en el manejo de las dislipidemias.
• Da prioridad al uso de estatinas de alta y moderada intensidad en el manejo del colesterol.
• Define cuatro grupos de sujetos que se benefician de la terapia con estatinas.
• Desecha el uso de objetivos de niveles de colesterol LDL o colesterol no-HDL en el tratamiento de la
hipercolesterolemia.
• Se incluye el accidente vascular encefálico y la crisis de isquemia transitoria como eventos ateroscleróticos,
además de los tradicionales eventos ateroscleróticos coronarios. Al conjunto se los nombra como "enfermedad
cardiovascular aterosclerótica".
• Desaconseja terapias con otros fármacos "no-estatinas" en el manejo del colesterol, salvo que exista intolerancia
demostrada a las estatinas.
• Excluye de la terapia con estatinas a los pacientes con insuficiencia cardíaca clase funcional III a IV de la
NYHA y a pacientes en hemodiálisis.
• Enfatiza el diálogo del médico con el paciente en relación a la indicación farmacológica, basada en riesgo
versus beneficio, y en la decisión consensuada de terapia con estatinas.
• Incorpora una nueva calculadora de riesgo de enfermedad cardiovascular aterosclerótica a diez años.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
28. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
29. Recomendaciones para el uso de estatinas en pacientes
con diferente riesgo cardiovascular
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
30. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
31. Terapia con estatinas:
Indicaciones e intensidades
Grupos
GRUPO 1: Pacientes con enfermedad aterosclerótica
definida
GRUPO 2: Todos los sujetos >21 años con un colesterol
LDL mayor o igual a 190 mg/dL
GRUPO 3: Diabéticos de 40-75 años, sin enfermedad
aterosclerótica, y LDL 70-189 mg/dL
GRUPO 4: Sujetos sin enfermedad cardiovascular
ateroesclerótica y sin dibetes, entre 40 y 75 años, con
colesterol LDL entre 70-189 mg/dL y un riesgo
cardiovascular aterosclerótico a 10 años > 7.5%
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
32. http://static.heart.org/riskcalc/app/index.html#!/baseline-risk
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
33. A. Tratar por metas: Es la estrategia más
utilizada en los últimos 15 años, pero con 3
problemas:
• Datos de RCT actuales no especifican cuál es
la mejor meta.
• Se desconoce la magnitud de la reducción
adicional del RCV que se obtiene con una
meta de colesterol más baja que otra.
• No se tiene en cuenta posibles efectos
adversos de polimedicación que puede ser
necesaria para lograr un objetivo específico.
Estrategias de tratamiento:
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
34. B. “Más bajo es mejor”: Este enfoque no tiene en cuenta
los posibles efectos adversos de la polimedicación con una
magnitud desconocida en la reducción del RCV.
Estrategias de tratamiento:
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
35. C. Tratar según el nivel de RCV: Considera tanto los
beneficios en la reducción del RCV y los efectos adversos
del tratamiento con estatinas. De aquí salen los 4 grupos
que se benefician, ya mencionados previamente, con La
excepción de uso en individuos en hemodiálisis o falla
cardíaca con clase funcional NYHA III-IV.
Estrategias de tratamiento:
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
36. D. Riesgo a lo largo de la vida: Aún faltan datos acerca de
seguimiento por > 15 años, seguridad, reducción del RCV
cuando se utiliza estatinas por períodos > 10 años y
tratamiento en individuos <40 años.
Estrategias de tratamiento:
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
37. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
38. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
39. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
40. Resumen:
Tome perfil lipídico antes del inicio de estatinas.
Tome un control 4-12 semanas después de su inicio, para
determinar adherencia del paciente. Si se inició terapia del alta
intensidad, se espera una reducción del 50% del LDL basal. Si se inició
terapia de moderada intensidad, se espera reducción del 30-49% del
LDL basal.
Si no se consiguen éstas metas: evalúe adherencia a la terapia y
síntomas de intolerancia (que lleven a menor consumo de estatina) y
considere causas secundarias de hipercolesterolemia. Re-evalué en
4-12 semanas.
Si luego del paso anterior, el paciente sigue sin la respuesta esperada:
incremente la dosis de estatina (si es posible) o considere la
adición de un medicamento no derivado de estatina (ésta última
consideración es muy controvertida, según la guía). Ésta última
conducta, podría ser más aconsejada, en pacientes con alto riesgo
cardiovascular que no toleren ninguna estatina o cuando no toleren
tratamiento de alta intensidad.
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
41. Recomendaciones para evitar efectos adversos con el uso de estatinas:
Seleccione la dosis y el tipo de estatina, de acuerdo al tipo de paciente, su riesgo
cardiovascular y el potencial de efectos adversos (IA)
Usar terapia de moderada intensidad si el paciente
tiene:
• Disfunción renal
• Disfunción hepática
• Antecedentes de trastornos musculares o de
intolerancia a uso de estatinas
• Elevaciones de ALT>3 veces el límite superior
• Uso concurrente de medicación con conocidas
interacciones con estatina
• Edad mayor a 75 años
• Antecedentes de evento cerebrovascular
hemorrágico
• Ancestros asiáticos
La vigilancia de CK al inicio del tratamiento
en pacientes con (IIa) o sin antecedentes de
miopatía (III), no tienen una sólida
evidencia. Sólo podría ser recomendable, si
el paciente tiene síntomas musculares,
debilidad o fatiga (IIa).
El único examen que está plenamente
justificado, previo al inicio de estatina es la
medición de ALT (I).
El perfil hepático debe medirse si el paciente
tiene sospecha de hepatotoxicidad al uso de
estatina. Con el mismo nivel de evidencia,
está la vigilancia periódica de la glucemia,
por la aparición de DM asociada al
tratamiento (I)
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
42. ¿Qué se recomienda, si el paciente con el uso de estatina, presenta dolor, rigidez
muscular, debilidad o fatiga muscular?
Si los síntomas musculares son leves o moderados (IIa)
Suspender estatina hasta re evaluar los síntomas
Evaluar si el paciente tiene condiciones que incrementen riesgo de síntomas
musculares (hipotiroidismo, disfunción renal o hepática, polimialgia
reumática, miopatía por esteroides, deficiencia de vitamina D o miopatías
primarias)
Si se resuelven los síntomas y no hay contraindicaciones, reiniciar la misma
estatina a una dosis más baja. Si los síntomas reinciden: iniciar otra estatina a
dosis más baja e incrementar lentamente.
Si luego de 2 meses, los síntomas no mejoran o los niveles de CK no
disminuyen, considerar etiologías alternativas.
Si los síntomas musculares persisten luego de suspender estatina o
corresponden a otra condición clínica, reiniciar la terapia
Esclarecer si los síntomas efectivamente se
desarrollaron o intensificaron con la terapia
Si hay una relación causal aparente, y los
síntomas musculares son intolerables, suspender
la medicación.
Si se sospecha rabdomiolisis, medir CK-
creatinina y uroanálisis (buscando
mioglobinuria).
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of
the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
43. American association of clinical endocrinologists and American college of
endocrinology Guidelines for Management of Dyslipidemia and Prevention of
Cardiovascular Disease [AACE 2017 Guidelines]; Endocrine Practice Vol 23
(Suppl 2) April 2017
44. American association of clinical endocrinologists and American college of endocrinology Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease
[AACE 2017 Guidelines]; Endocrine Practice Vol 23 (Suppl 2) April 2017
“Guidelines for management of dyslipidemia
and prevention of cardiovascular disease”
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Determinación
lipídica
Ayuno o sin ayuno
En presencia de
alteraciones, repetir
determinación en
ayuno
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97. GRACIAS!!!
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• Grundy SM, et al; 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA, Guideline on management of blood
cholesterol; A report of the American College of Cardiology / American Heart Association Task Force on clinical practice guidelines; Circulation.
2018;000:e000–e000. DOI: 10.1161/CIR.0000000000000625
• American association of clinical endocrinologists and American college of endocrinology Guidelines for Management of Dyslipidemia and Prevention of
Cardiovascular Disease [AACE 2017 Guidelines]; Endocrine Practice Vol 23 (Suppl 2) April 2017
• Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular
Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013.
• NCEP. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
(Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.