Dyslipidemia
Disorder of Lipid & Lipoprotein Metabolism
A common form of Dyslipidemia is characterized
by three lipid abnormalities:
Elevated triglycerides,
Elevated LDL and
Reduced HDL cholesterol.
Important Modifiable Risk Factor for CAD
Cardiovascular disease - more common in diabetic patients than in the general population
Dyslipidemia – common in patients with both types of diabetes.
Aggressive lipid treatment goals have been recommended for patients with type 2 diabetes
Diabetic Dyslipidemia is highly prevalent in the Indian diabetic population
Dyslipidemia in diabetes differs significantly with hypertriglyceridemia and small dense LDL-C
Dyslipidemia management an evidence based approachDr Vivek Baliga
In this presentation by Dr Vivek Baliga, he discusses the different available statins and how you can choose the right one in different clinical situations. See articles from Dr Baliga on http://drvivekbaliga.net
Dyslipidemia
Disorder of Lipid & Lipoprotein Metabolism
A common form of Dyslipidemia is characterized
by three lipid abnormalities:
Elevated triglycerides,
Elevated LDL and
Reduced HDL cholesterol.
Important Modifiable Risk Factor for CAD
Cardiovascular disease - more common in diabetic patients than in the general population
Dyslipidemia – common in patients with both types of diabetes.
Aggressive lipid treatment goals have been recommended for patients with type 2 diabetes
Diabetic Dyslipidemia is highly prevalent in the Indian diabetic population
Dyslipidemia in diabetes differs significantly with hypertriglyceridemia and small dense LDL-C
Dyslipidemia management an evidence based approachDr Vivek Baliga
In this presentation by Dr Vivek Baliga, he discusses the different available statins and how you can choose the right one in different clinical situations. See articles from Dr Baliga on http://drvivekbaliga.net
Cardiovascular safety of anti-diabetic drugs.Cardiovascular Outcome Trials ...magdy elmasry
Cardiologists and diabetes.Target organs and action mechanism of antidiabetic drugs.Cardiovascular Outcome Trials
( CVOTs ) in Diabetes.Completed and ongoing CVOTs in type 2 diabetes.Diabetes Medications
and
Cardiovascular Impact.Recommendations for management of diabetes
Cardiovascular safety of anti-diabetic drugs.
India has a large pool of diabetic patients
ICMR-INDIAB study – extrapolated estimations suggest 62.4 million people with diabetes and 77.2 million are prediabetic
Estimates show ~ 85.5% men and 97.8% women who are diabetic in India have concomitant dyslipidemia
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
Cardiovascular safety of anti-diabetic drugs.Cardiovascular Outcome Trials ...magdy elmasry
Cardiologists and diabetes.Target organs and action mechanism of antidiabetic drugs.Cardiovascular Outcome Trials
( CVOTs ) in Diabetes.Completed and ongoing CVOTs in type 2 diabetes.Diabetes Medications
and
Cardiovascular Impact.Recommendations for management of diabetes
Cardiovascular safety of anti-diabetic drugs.
India has a large pool of diabetic patients
ICMR-INDIAB study – extrapolated estimations suggest 62.4 million people with diabetes and 77.2 million are prediabetic
Estimates show ~ 85.5% men and 97.8% women who are diabetic in India have concomitant dyslipidemia
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
Diabetes tends to lower good cholesterol levels and raise triglyceride and bad cholesterol levels, which increases the risk for heart disease and stroke. This common condition is called ”Diabetic Dyslipidemia.”
ABSTRACT- Diabetes mellitus is associated with hyperglycemia and patients are at an increased risk of cardiovascular disease. The present study
was carried out to evaluate the diagnostic value of Glycated hemoglobin (HbA1c) in predicting risk of development of diabetic dyslipidemia. 70 clinically
diagnosed cases of type 2 diabetes mellitus with the age range 30-75 years were included in the study group. Out of which 35 diabetic patients
with good glycemic control were included under Group A and 35 diabetic patients with poor glycemic control were included under Group B. 70 age
and sex matched healthy individuals served as controls. HbA1c demonstrated positive and significant correlation with total cholesterol (TC), low
density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and LDL/HDL-C, non-HDL-C and TC/HDL-C ratio. Patients
with HbA1c value > 7.0% had significantly higher value of TC, Triacylglycerol (TAG), LDL-C, LDL-C/HDL-C ratio, non-HDL-C and TC/HDL-C
ratio as compared to the patients with HbA1c ≤ 7.0%. However, there was no significant difference in value of HDL-C between two groups. Thus
HbA1c can be used as a potential dual marker of glycemic control and dyslipidemia in type 2 diabetes mellitus.
Keywords: - Type2 Diabetes Mellitus, Glycated hemoglobin, Dyslipidemia, Cardiovascular disease, Lipid Profile panel
Dyslipidemia management an evidence based approachDr Vivek Baliga
How is dyslipidemia managed in clinical practice? Here is a short review on how current guidelines are shaping clinical practice, and how saroglitazar is playing a role in it.
Diabetes is often accompanied by high triglyceride and high cholesterol levels. Saroglitazar (Lipaglyn) is a novel molecule that not only reduces elevated TG levels; it also reduces blood glucose levels. This presentation by Dr Vivek Baliga discusses this novel molecule.
the study was a pilot study done at National Institute of Ayurveda under the Phd Research Programme with an aim to find out new avenues in the managegement of Dyslipidemia - Medoroga and Coronary Heart Disease - Hridroga, thus initiating a new concept of Preventive Cardiology through Ayurveda & Panchakarma
Atorvastatin: Statins in CVD management. Is just lipid lowering enough Dr Vivek Baliga
When it comes to management of cardiovascular diseases, are achieving lipid lowering targets sufficient. Here Dr Vivek Baliga, Consultant Internal medicine discusses the additional benefits of statins in CVD in India.
Slide Presentation
Diabetes Melliuts Type 2 management basics are life style modifications followed by use of Metformin
What is the best and safest next pharmacologic choice
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. WHAT DO YOU THINK?
A 45 year old woman
She was diagnosed with DM2 one year ago
Also has HTN diagnosed 2 years ago
No history CHD, CKD or Atrial fibrillation
Non smoker No F.Hx of premature CHD
BP 128 /78 on ACE-I daily
Height 165 cm Weight 84 kg
Total -C 220 mg/dl (5.7 mmol/L)
HDL-C 45 (1.16 mmol/L) ,TAG 140 (1.6 mmol/L)
LDL-C 140 (3.65 mmol/L)
3. WHAT DO YOU THINK ?
Does this patient need pharmacologic Rx for lipids?
Will you apply primary vs secondary prevention?
What is your objective : Target vs Intensity of Rx?
What is your medication choice ? One vs combination
Which guidelines do you follow ?
5. CARDIOVASCULAR DISEASE (CVD)
(CVD) =
Disease of the heart and blood vessels caused by the
process of atherosclerosis;
Includes CHD; ACS/Angina,
TIA/Stroke and PAD
6.
7. CARDIOVASCULAR DISEASE (CVD)
(CVD) predominantly affects people older than 50 years
Risk factors
Non-modifiable
Age
Sex
Family history of CVD
Ethnic background
Modifiable
Smoking
HTN
Dyslipidemia
DM
Social : Low income and
social deprivation
8. Type 2 Diabetes Prevalence
MI, myocardial infarction.
1. IDF Diabetes Atlas 6th Edition 2014 http://www.idf.org/diabetesatlas; 2. The Emerging
Risk Factors Collaboration. JAMA. 2015;314(1):52-60.
8
This will rise to
592 million by
20351
Disease status
at baseline
Hazard
ratio
(95% Cl)a
Diabetes, stroke,
and MI
6.9 (5.7,
8.3)
Stroke and MI
3.5 (3.1,
4.0)
Diabetes and
stroke
3.8 (3.5,
4.2)
Diabetes and MI
3.7 (3.3,
4.1)
MI
2.0 (1.9,
2.2)
Stroke
2.1 (2.0,
2.2)
Diabetes
1.9 (1.8,
2.0)
None 1.0 (Ref)
Globally, 387 million
people are living with
diabetes1 All-cause mortality by disease
status of participants at
baseline2
Hazard ratio
(95% CI)
1.0 2.0 4.0 8.0 16.0
Type 2 Diabetes is a CVD
9. DM AND DYSLIPIDEMIA
WHAT MAKES PEOPLE WITH DIABETES
AT SUCH HIGH RISK?
Atherogenic Profile
Insulin resistance /Metabolic syndrome
Low HDL-C
High triglycerides
Higher number of Small dense LDL particles
High non-HDL-C
13. DM AND DYSLIPIDEMIA
HEART PROTECTION STUDY (HPS)
>20,000 Patients ; average follow-up of 5.5 years
Simvastatin (40 mg/day) Vs Placebo
33% with baseline LDL-C <116 mg/dL (<3 mmol/L),
25% with a level of 116 to 135 mg/dL (3 to 3.5 mmol/L)
42% with levels >135 mg/dL (>3.5 mmol/L)
History of CVD (CAD ,CVA or PAD), DM, or HTN on Rx)
Most patients were treated for secondary prevention.
15. DM AND DYSLIPIDEMIA
(HPS)- RESULTS : PRIMARY PREVENTION
Significant benefits with Simvastatin
3982 DM patients without prior CVD
28 %
(14 versus 18.7 percent)
Reduction in the incidence of
MI and stroke
16.
17.
18. DM AND DYSLIPIDEMIA
CARDS TRIAL
2838 Type 2 DM without known CVD
LDL –C concentration ≤160 mg/dL (4.14 mmol/L), a
Fasting TAG ≤ 600 (6.78 mmol/L) + at least one of the
following: retinopathy, albuminuria, current smoking,
or hypertension
Randomly assigned
Atorvastatin 10 mg Vs Placebo
19. DM AND DYSLIPIDEMIA
CARDS TRIAL- RESULTS
●Terminated two years earlier than expected
●CV events was reduced by 37 % (95% CI -52 to -17)
(Treat 1000 pts for 4 yrs =Prevent 37 major vascular events)
●The absolute reduction in events with Atorvastatin
was similar Regardless of baseline LDL level
(LDL-C above or below 120 mg/dL (3.1 mmol/L)
(reduction from 9.5 to 6.1 % Vs from 8.5 to 3.6 %)
21. LDL : 77 vs 101 mg/dl
Using 80 mg/day of atorvastatin with baseline LDL-C levels of 150 mg/dL,
Total CHD events were reduced 45% to 50%.
22.
23. 18,000 patients with ACS within the preceding 10 days
Baseline LDL 50-125 mg/dl
Or 50-100 mg/dl on prior cholesterol drug
(Average baseline LDL-C was 93.8 mg/dL in each group)
Patients with DM represented 27% of each group
7-Years follow up
25. EZETIMIBE + STATIN VS PBO + STATIN
IMPROVE-IT TRIAL
-Composite primary endpoint
(CV death, major coronary events, or nonfatal stroke)
-33 % vs 35 % (a 2% lower)
-6.4% risk reduction of total CV events
(Modest impact)
Morbidity … Yes
Less risk by… MI 13 %
Stroke 14% Ischemic Stroke 21%
Mortality :No differences
26. DM AND DYSLIPIDEMIA
LDL RECEPTORS AND CV RISK?
The key target is the LDL-C receptor in the liver
If LDL receptors are not present in sufficient numbers,
>> Hyper-Cholesterolemia
>> High CV Risk.
1-Can be upregulated / increased by Statins
2-New class PCSK9 monoclonal antibodies,
increases the expression of the LDL-C receptors by
enhancing receptor recycling
PCSK9 = Proprotein Convertase Subtilisin/ Kexin type 9 (PCSK9) serine protease
31. DYSLIPIDEMIA AND (CVD)
PCSK9 INHIBITION- ODYSSEY COMBO
ALIROCUMAB VS EZETIMIBE
Efficacy and safety of Alirocumab as add-on to stable,
maximally tolerated, daily statin therapy (Patients with
hypercholesterolemia at high CV risk)
35% of patients have T2DM
An LDL-C of <1.8 mmol/L(<70 mg/dL) was achieved in:
77% with Alirocumab vs
45.6% with Ezetimibe
(P =.0001),
32. DYSLIPIDEMIA AND (CVD)
PCSK9 INHIBITION- ODYSSEY COMBO
ALIROCUMAB VS EZETIMIBE
Comparable reduction rate of the LDL-C level was
comparable in the diabetic and nondiabetic
The LDL-C level :
Reduced from 130 mg/dL to 50 mg/dL; i.e
average decline of 50% ( 60% for non DM )
33. DM AND DYSLIPIDEMIA
FIELD TRIAL / ACCORD-LLA
FIELD trial
9795 patients ages 50 to 75 with type 2 DM (2131 with prior CVD
; 2nd Prevention)
Median follow-up of 5 years
Micronized Fenofibrate 200 mg daily Vs Placebo
ACCOR-LLA
5518 patients with type 2 DM
Fenofibrate 160 mg Vs Placebo;
All patients were treated with Simvastatin
Mean follow-up of 4.7 years
35. DM AND DYSLIPIDEMIA
GUIDELINES?
ATP III-2004
American College of Cardiology (ACC)/American Heart
Association (AHA) guideline- 2013
European Society of Cardiology (ESC)/European
Atherosclerosis Society (EAS) guideline 2014
NICE guideline 2014
36. DM AND DYSLIPIDEMIA
ACC/AHA
Statin Lowering Intensity ;
Lower LDL-C
with an anticipated percentage from base line
Example
High intensity level :
≥ 50% LDL-C in high-risk patients and
Moderate intensity level :
> 30% to <50% in low-risk patients with diabetes.
37. DM AND DYSLIPIDEMIA
NICE
Statin Lowering Intensity
Lower non -HDL-C
with an anticipated percentage from base line
Example
High intensity level :
>40% in high-risk patients and
Moderate intensity level :
31-40% in low-risk patients with diabetes.
38. DM AND DYSLIPIDEMIA
ESC/EAS
Europeans still favor, very much, the target-treated
lower LDL-C approach (like ATP III )
Target LDL-C <70 mg/dL
in almost all patients with T2D
Still evaluate for non-HDL
40. 1.Diabetes Mellitus
2.Symptomatic Carotid Artery Disease
3.Peripheral Arterial Disease
4.Abdominal Aortic Aneurysm
5.CRF with Cr > 1.5 or GFR< 60
6.Multiple risk factors with a 10 year risk of CHD> 20%
ATP III –NCEP
CHD RISK EQUIVALENTS
41.
42. LIPIDS ADA 2014… WAS
To get specified LDL target
Statin therapy should be added, regardless of baseline
lipid levels, for DM patients:
- With overt CVD
-Without CVD who is > 40 years old and
have ≥ 1 other CVD risk factors. (A)
An alternative therapeutic goal :
Reduction in LDL cholesterol by 30–40% from baseline
(A)
43. LIPIDS ADA 2014… WAS
If targets are not reached;
Use combination therapy
No outcome studies; CVD outcomes or safety.
(E)
44. Statins use is based on desired
LDL-C Intensity lowering rather than LDL target number
Adjustment of intensity of statin therapy
may be needed based on individual patient response to medication
(e.g., side effects, tolerability, LDL cholesterol levels). E
LIPIDS ADA 2015 … 2013 ACC/AHA
45. Combination therapy
(statin/ fibrate and statin/niacin)
has not been shown to provide additional
cardiovascular benefit above statin therapy alone
and is Not generally recommended
A
LIPIDS ADA 2015 … 2013 ACC/AHA
46.
47.
48. NICE CLINICAL GUIDELINE 181
GUIDANCE.NICE.ORG.UK/CG181
NICE 2014
An update of existing National Institute for Health and
Care Excellence (NICE) guidance (published in 2008)
49. NICE GUIDELINES-2014
DYSLIPIDEMIA AND (CVD)
No Risk Assessment tool use for people
1-With pre-existing CVD
2-Familial hyper-cholesterolemia
3- With type 1 DM
4-With CKD ; e GFR < 60 ml/min/1.73 m2 and/or
albuminuria
50. STATINS INTENSITY CATEGORIES
NICE VS ACC/AHA
NICE
low intensity
20% to 30%
medium intensity
31% to 40%
high intensity > 40%
ACC/AHA
low intensity
<30%
medium intensity
30% to <50%
high intensity ≥ 50%
Targeting LDLTargeting non-HDL
52. NICE
COMBINATION RX
Do not routinely offer Fibrates
(Field trial & ACCORD –Lipid)
and
Do not offer Nicotinic acid (niacin) or Bile acid sequestrants (anion
exchange resins) or omega-3 fatty acid compounds for the
prevention of CVD to any of the following group of patients :
-Treated for primary prevention
-Treated for secondary prevention
-With CKD
-With type 1 DM
-With type 2 DM
[new 2014]
53. NICE
COMBINATION THERAPY FOR PREVENTING CVD
Ezetimibe treatment in addition to Statins
should be considered (IMPROVE IT)
For people with primary hyper- cholesterolemia
(heterozygous familial and non-familial hyper- cholesterolemia )
55. ESC/EAS 2014
DYSLIPIDEMIA
VERY HIGH or HIGH TOTAL CARDIOVASCULAR RISK
Known CVD
Type 2 DM or type 1 DM with micro-albuminuria
Chronic kidney disease (CKD)
Very high levels of individual risk factors
All other people
Use of a risk estimation system such as SCORE to estimate total
CV risk
57. NICE
ADVICE AND MONITORING FOR STATINS AE
.
Statins and pregnancy/lactation
Potential teratogenicity
Stop Statins if pregnancy is a possibility
Stop Statins 3 months before any attempt to conceive and
to not restart them until breastfeeding is finished
58. NICE
ADVICE AND MONITORING FOR STATINS AE
Statins and creatine kinase (CK)
1- Do not measure CK levels in asymptomatic people who are being
treated with a statin
2- If patient has suggestive myopathy symptoms ( persistent
generalized unexplained muscle pain, associated or not with
previous lipid-lowering therapy) before or after start of a statin
If they have, measure creatine kinase (CK) levels
3- Review medications list ; Look for Drug-Drug interaction
(CYP450 / Gemfibrozil ; Macrolides; Cyclosporine, Ketoconazole…)
59. NICE
ADVICE AND MONITORING FOR STATINS AE
Statins and creatine kinase (CK)
4- If patient has suggestive myopathy symptoms measure (CK):
If CK levels are > 5 times the ULN, re-measure it after 7 days.
If CK levels are still 5 times ULN, do not start statin treatment
If CK levels are raised but < 5 times ULN, start statin treatment at a
lower dose
5- If statin therapy was tolerated for > 3 months ; R/O other causes
of muscle pain or weakness and raised CK
60. NICE
ADVICE AND MONITORING FOR STATINS AE
Statins and Liver Transaminases
1- Measure baseline liver transaminase enzymes (ALT or AST ) ,at
baseline , 3 and 12 months of starting a statin
-No more testing unless clinically indicated
2- Do not routinely exclude from statin therapy people who have
liver transaminase levels that are raised but are < 3 times ULN
61. NICE
INTOLERANCE OF STATINS
If a patient is un-able to tolerate a high-intensity statin
Treat with the maximum tolerated dose
If a certain statin is not tolerated
Try another statin
63. DYSLIPIDEMIA AND DIABETES MELLITUS
TAKE HOME MESSAGES
DM = Cardiovascular Disease
Risk assessment tools
High risk groups = No need to calculate Risk
Diabetics are a very high risk group
Treat Regardless of the baseline LDL-C
64. 1.ASCVD / CHD equivalent
2-Diabetes Mellitus
3-Severe Dyslipidemia –Familial
4-CKD
5- Risk calculator : High risk over next 10yrs
HIGH CVD RISK GROUPS - SUMMARY
65. DYSLIPIDEMIA GUIDELINES
HEADTO HEAD
NICE
low intensity
20% to 30%
medium intensity
31% to 40%
high intensity >
40%
ACC/AHA
low intensity
<30%
medium intensity
30% to <50%
high intensity
≥ 50%
Targeting LDLTargeting
non-HDL
ATP-III
Target Level
Reduction in LDL-C
30–40%
from base line
ESC/EAS
Target Level
Reduction in LDL-C
30–40%
from base line
66. DYSLIPIDEMIA GUIDELINES
HEADTO HEAD
NICE
The QRISK2
Risk Calculator
ACC-AHA
ASCVD
Risk Calculator
ATP III
Framingham
Scoring Calculator
All
≥ 30-40 % minimum decrease from baseline
(from ≥ 30 % to > 50%)
ESC/EAS
SCORE
Risk Calculator
67. DYSLIPIDEMIA AND (CVD)
TAKE HOME MESSAGES
Lipid-lowering drugs
-Statins for primary and secondary prevention
-Use the highest tolerated dose
-Residual risk reduction:
Add Ezetimibe / PCSK9
Use simultaneously guidelines on
other modifiable risk factors for CVD (like HTN , DM)
Editor's Notes
Statin eligibility and cardiovascular risk..
Cost-effectiveness of the medications in primary prevention given that statins are now available cheaply as generics.
Is the 7.5% is too low ; overestimating the eligible number to need statins
This guideline offers best practice advice on the care of people at risk of cardiovascular disease.
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
PROVE IT trial (7), more than 4000 very-high-risk patients with acute coronary syndrome and a total cholesterol level < 240 mg/dL untreated or < 200 mg/dL on lipid-lowering therapy
Randomized to receive intensive therapy with atorvastatin 80 mg or moderate therapy with pravastatin 40 mg. Intensive therapy decreased LDL cholesterol to 62 mg/dL versus 95 mg/dL
Reduced the composite primary endpoint (death, MI, unstable angina requiring rehospitalization, revascularization after 30 days, and stroke) by 16% compared with moderate therapy.
TNT study : 10,000 patients with stable CHD and LDL cholesterol < 130 mg/dL on
atorvastatin 10 mg randomly received either high-dose 80 mg or low-dose 10 mg atorvastatin.
After 4.9 years and mean LDL-C 77 mg/dL Vs 101 mg/dL for the 80- and 10-
mg doses, respectively
Nonfatal MI and CHD death were reduced by 20% and stroke by 23%.
Patients using 80 mg/day of atorvastatin with baseline LDL cholesterol levels of 150
mg/dL, total CHD events were reduced 45% to 50%.
Primary end points: CV death , MI ,hospitalization for unstable angina ,stroke or coronary revascularization after one month of randomizaion
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
For example, mortality from stroke is increased almost 3-fold when patients with diabetes are matched to those without diabetes.[1,2]
This guideline offers best practice advice on the care of people at risk of cardiovascular disease.
Lifestyle modification focusing on the reduction of saturated fat, trans fat,and cholesterol intake; increase of n-3
fatty acids, viscous fiber, and plant stanols/sterols; weight loss (if indicated);and increased physical activity should be recommended to improve
the lipid profile in patients with diabetes.
(A)
The evidence that combination therapy provides a significant increment in CVD risk reduction over statin therapy
alone is still elusive.
Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD
This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes
Slide 1 of 7 – Screening
In most adult patients, measure fasting lipid profile at least annually
In adults with low-risk lipid values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years (E)
Patients with type 2 diabetes have an increased prevalence of lipid abnormalities, contributing to their high risk of CVD
This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes
Slide 1 of 7 – Screening
In most adult patients, measure fasting lipid profile at least annually
In adults with low-risk lipid values (LDL cholesterol <100 mg/dl, HDL cholesterol >50 mg/dl, and triglycerides <150 mg/dl), lipid assessments may be repeated every 2 years (E)
This guideline offers best practice advice on the care of people at risk of cardiovascular disease.
LDL cholesterol is not directly measured but requires a calculation using a fasting sample and for triglyceride levels to be less than
4.5 mmol/litre, whereas the measurement of non-HDL cholesterol does not.
ASCVD ….AHA/ACA
Moderate 30% -<50%
High ≥ 50%)
LDL cholesterol is not directly measured but requires a calculation using a fasting sample and for triglyceride levels to be less than
4.5 mmol/litre, whereas the measurement of non-HDL cholesterol does not.
The SCORE system estimates the 10 year risk of a first only fatal atherosclerotic event, whether heart attack, stroke, or other occlusive arterial disease, including sudden cardiac death
The new nomenclature In the 2007 guideline5 is that everyone with a 10 year risk of CV death of ≥5% has an increased risk.
So that a SCORE risk of 5% translates into a CVD risk of 15% of total (fatal plus non-fatal) hard CVD endpoints; the multiplier is slightly higher in women
and lower in older persons.
LDL cholesterol is not directly measured but requires a calculation using a fasting sample and for triglyceride levels to be less than
4.5 mmol/litre, whereas the measurement of non-HDL cholesterol does not.
ASCVD ….AHA/ACA
Moderate 30% -<50%
High ≥ 50%)
LDL cholesterol is not directly measured but requires a calculation using a fasting sample and for triglyceride levels to be less than
4.5 mmol/litre, whereas the measurement of non-HDL cholesterol does not.
ASCVD ….AHA/ACA
Moderate 30% -<50%
High ≥ 50%)