1) This document provides guidelines for screening, assessing cardiovascular risk, and managing dyslipidemia from the 2016 Canadian Cardiovascular Society guidelines.
2) It recommends screening all adults aged 40-75 for lipids and assessing risk every 5 years using the Framingham Risk Score or Cardiovascular Life Expectancy Model.
3) For primary prevention, it recommends considering statin therapy for those at intermediate risk with LDL-C ≥3.5 mmol/L or other risk factors. For high risk it recommends statin therapy.
What’s new in Lipidology, Lessons from “recent guidelines“Arindam Pande
1. The 2018 ACC/AHA cholesterol guidelines provide 10 key take-home messages focusing on lifestyle management, statin therapy for various risk groups, and risk assessment approaches.
2. The guidelines emphasize lifestyle therapy and statins for secondary prevention, with an LDL-C goal of 70 mg/dL for very high risk patients to consider adding nonstatins.
3. They provide guidance on statin use for various primary prevention groups based on risk levels and discussion, including an expanded definition of intermediate risk factors.
This document discusses several clinical studies that compare the effects of different statin drugs on cardiovascular outcomes and the progression of atherosclerosis. The STELLAR study showed that rosuvastatin more effectively lowered LDL-C and raised HDL-C than other statins. Two real-world studies found that rosuvastatin use was associated with a 28-40% lower risk of cardiovascular events compared to other statins. The METEOR study found that rosuvastatin slowed the progression of atherosclerosis whereas the ENHANCE study found that ezetimibe added to simvastatin provided no benefit.
This document summarizes clinical guidelines for cholesterol management and cardiovascular risk reduction. It compares the 2013 ACC/AHA guidelines to previous NCEP ATP III guidelines. The new guidelines have a focus on reducing atherosclerotic cardiovascular disease risk rather than just coronary heart disease risk. They recommend high-intensity statin therapy for more patient groups based on revised risk assessment categories and calculators. Key changes include expanding statin benefit to those with diabetes or a 7.5% or higher 10-year risk without cardiovascular disease. Management of high triglycerides is also discussed.
This document provides guidelines for the management of dyslipidemia from the European Society of Cardiology in 2016. It discusses lipid profiling, total cardiovascular risk assessment, treatment strategies, lifestyle modifications, treatment targets, and choice of treatment. Lipid profiling is recommended for those with cardiovascular disease, at increased risk, or for risk stratification. LDL-C is the primary treatment target, while non-HDL-C and apoB are secondary targets. Lifestyle changes and statin therapy are first-line treatment, with fibrates, nicotinic acid or PCSK9 inhibitors as options for additional lowering of lipids. Guidelines for treatment targets and special populations are also covered.
Empagliflozin and Cardiovascular OutcomesUyen Nguyen
1) The EMPA-REG OUTCOME trial evaluated the cardiovascular outcomes of empagliflozin compared to placebo in over 7000 patients with type 2 diabetes at high risk of cardiovascular events.
2) Empagliflozin was found to significantly reduce the risk of the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to placebo.
3) Additional benefits observed with empagliflozin included a significant reduction in all-cause mortality, cardiovascular mortality, and hospitalization for heart failure.
The SUSTAIN-6 trial evaluated the cardiovascular safety of the GLP-1 receptor agonist semaglutide compared to placebo in patients with type 2 diabetes at high risk of cardiovascular events. Over 3,000 patients were followed for a median of 2.1 years. The trial found that semaglutide was noninferior to placebo with respect to cardiovascular safety and reduced the primary composite outcome of death from cardiovascular causes, nonfatal myocardial infarction or nonfatal stroke by 26% compared to placebo. Semaglutide also significantly reduced HbA1c, body weight, and systolic blood pressure.
What’s new in Lipidology, Lessons from “recent guidelines“Arindam Pande
1. The 2018 ACC/AHA cholesterol guidelines provide 10 key take-home messages focusing on lifestyle management, statin therapy for various risk groups, and risk assessment approaches.
2. The guidelines emphasize lifestyle therapy and statins for secondary prevention, with an LDL-C goal of 70 mg/dL for very high risk patients to consider adding nonstatins.
3. They provide guidance on statin use for various primary prevention groups based on risk levels and discussion, including an expanded definition of intermediate risk factors.
This document discusses several clinical studies that compare the effects of different statin drugs on cardiovascular outcomes and the progression of atherosclerosis. The STELLAR study showed that rosuvastatin more effectively lowered LDL-C and raised HDL-C than other statins. Two real-world studies found that rosuvastatin use was associated with a 28-40% lower risk of cardiovascular events compared to other statins. The METEOR study found that rosuvastatin slowed the progression of atherosclerosis whereas the ENHANCE study found that ezetimibe added to simvastatin provided no benefit.
This document summarizes clinical guidelines for cholesterol management and cardiovascular risk reduction. It compares the 2013 ACC/AHA guidelines to previous NCEP ATP III guidelines. The new guidelines have a focus on reducing atherosclerotic cardiovascular disease risk rather than just coronary heart disease risk. They recommend high-intensity statin therapy for more patient groups based on revised risk assessment categories and calculators. Key changes include expanding statin benefit to those with diabetes or a 7.5% or higher 10-year risk without cardiovascular disease. Management of high triglycerides is also discussed.
This document provides guidelines for the management of dyslipidemia from the European Society of Cardiology in 2016. It discusses lipid profiling, total cardiovascular risk assessment, treatment strategies, lifestyle modifications, treatment targets, and choice of treatment. Lipid profiling is recommended for those with cardiovascular disease, at increased risk, or for risk stratification. LDL-C is the primary treatment target, while non-HDL-C and apoB are secondary targets. Lifestyle changes and statin therapy are first-line treatment, with fibrates, nicotinic acid or PCSK9 inhibitors as options for additional lowering of lipids. Guidelines for treatment targets and special populations are also covered.
Empagliflozin and Cardiovascular OutcomesUyen Nguyen
1) The EMPA-REG OUTCOME trial evaluated the cardiovascular outcomes of empagliflozin compared to placebo in over 7000 patients with type 2 diabetes at high risk of cardiovascular events.
2) Empagliflozin was found to significantly reduce the risk of the primary composite outcome of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to placebo.
3) Additional benefits observed with empagliflozin included a significant reduction in all-cause mortality, cardiovascular mortality, and hospitalization for heart failure.
The SUSTAIN-6 trial evaluated the cardiovascular safety of the GLP-1 receptor agonist semaglutide compared to placebo in patients with type 2 diabetes at high risk of cardiovascular events. Over 3,000 patients were followed for a median of 2.1 years. The trial found that semaglutide was noninferior to placebo with respect to cardiovascular safety and reduced the primary composite outcome of death from cardiovascular causes, nonfatal myocardial infarction or nonfatal stroke by 26% compared to placebo. Semaglutide also significantly reduced HbA1c, body weight, and systolic blood pressure.
This document is the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. It was written by a committee of experts and provides recommendations to reduce the risk of atherosclerotic cardiovascular disease through cholesterol management. The guideline covers topics such as measurements of LDL-C and other lipids, therapeutic lifestyle changes, lipid-lowering drugs including statins, and recommendations for different patient groups including those with secondary prevention of ASCVD or severe hypercholesterolemia.
The document discusses statin therapy and its potential side effects. It notes that while statins are effective for lowering LDL cholesterol and reducing cardiovascular risk, they have been associated with small increased risks of new-onset diabetes, muscle symptoms, and mild liver enzyme elevations in some patients. However, it finds no clear evidence of increased risks of cognitive impairment, renal or hepatic dysfunction, or hemorrhagic stroke with statin use. Overall, the benefits of statins in reducing cardiovascular events far outweigh these potential risks.
The document provides the top 10 take-home messages from the 2023 AHA/ACC Guideline for the Management of Patients with Chronic Coronary Disease. The messages emphasize team-based and patient-centered care, nonpharmacologic therapies like exercise for all patients, and updated recommendations for medications and testing. Risk stratification should incorporate all available information to classify patients' risk levels. A multidisciplinary team approach is recommended to improve outcomes and modify risk factors.
1. There is a vicious cycle between diabetes and liver disease, as diabetes can cause liver damage and liver disease increases the risk of diabetes.
2. Hepatogenous diabetes differs from type 2 diabetes in that it has a lower risk of cardiovascular complications and less often a family history of diabetes.
3. Metformin is the preferred agent for managing diabetes in patients with nonalcoholic fatty liver disease (NAFLD) or advanced liver disease, while insulin is recommended for decompensated cirrhosis.
This particular presentation of mine covers salient features of recent drug developed for treatment of dyslipidaemia particularly familial hypercholesterolemia. This presentation also covers recent modifications in treatment guidelines.
The Role of SGLT 2 Inhibitors and GLP 1 Receptor Agonists and DPP 4 InhibitorsPHAM HUU THAI
This document discusses the role of SGLT-2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors in managing type 2 diabetes. It provides background on the pathophysiology and progression of type 2 diabetes and limitations of older drug classes. It then describes the mechanisms and roles of the newer drug classes like SGLT-2 inhibitors in promoting urinary glucose excretion and GLP-1 agonists and DPP-4 inhibitors in augmenting the body's own incretin response. It also discusses ongoing cardiovascular outcome trials and FDA approvals of these newer agents.
Glimepiride +Metformin an integral part in achieving goals (1).pptxHarshit Gupta
This document discusses the role of the fixed-dose combination of Glimepiride and Metformin in achieving glycemic control goals for patients with type 2 diabetes. It notes that 90% of patients with diabetes should be detected, 90% of those detected should be treated, and 90% of those treated should achieve glycemic control. The combination of Glimepiride and Metformin is presented as an effective, safe, and tolerable treatment that provides durable glycemic control, especially when initiated early in the course of the disease. It also discusses the benefits of this combination in patients with comorbidities and its superior glycemic control compared to DPP-4 inhibitors.
This document discusses guidelines for lowering LDL cholesterol levels to reduce cardiovascular risk. It notes that while normal LDL levels are considered low risk, even normal levels still carry some risk. Current guidelines recommend lowering LDL as much as possible, by at least 50%, with a target under 70 mg/dL or lower for high-risk patients. Clinical trials have shown lower LDL levels are associated with greater risk reduction, down to levels under 40 mg/dL, though very low levels below 25 mg/dL require more evidence. Potential safety risks of extremely low levels are also examined. The conclusion emphasizes the importance of early detection and management of dyslipidemia to prevent cardiovascular disease.
Treatment Options For The Chronic Stable AnginaRodolfo Rafael
This document discusses treatment options for chronic stable angina, including the metabolic agent trimetazidine. It provides an overview of angina and its epidemiology. Trimetazidine improves energy metabolism in ischemic heart tissue by inhibiting fatty acid oxidation and stimulating glucose utilization. Clinical trials show trimetazidine reduces angina symptoms and improves exercise tolerance. It may benefit patients with heart failure or diabetes by optimizing energy production and preserving heart cell function.
Diabetic nephropathy is a leading cause of end-stage renal disease worldwide. Strict control of blood glucose, blood pressure, angiotensin system inhibitors, and other risk factors can help prevent or slow the progression of kidney damage. The stages include early hyperfiltration, development of microalbuminuria, progression to macroalbuminuria and renal failure. Management focuses on glycemic control, blood pressure reduction, angiotensin blockade, cholesterol control, and management of anemia and cardiovascular risk factors to preserve kidney function for as long as possible.
John B. Buse, MD, PhD, discusses type 2 diabetes in this CME activity titled "Exploring the Science and Practice of GLP-1 Receptor Agonists: An Update on Current and Emerging Evidence." For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2oL19BK. CME credit will be available until October 21, 2020.
1) Several early trials evaluated lipid lowering drugs such as mevastatin and lovastatin, which were isolated from fungi and shown to inhibit HMG CoA reductase. However, mevastatin was not marketed due to toxicity in dogs. Lovastatin was first marketed as Mevacor in 1987.
2) Large primary prevention trials such as WOSCOPS, AFCAPS/TexCAPS, CARDS and JUPITER demonstrated significant reductions in cardiovascular events with statin therapy compared to placebo in various populations with and without known heart disease.
3) Secondary prevention trials in patients with stable CAD such as 4S, CARE, LIPID and TNT showed that statin therapy reduces
This document provides guidelines and recommendations for lipid management:
1. It summarizes the 2013 ACC/AHA guidelines and 2016 ACC expert consensus, focusing on proven therapy rather than arbitrary lipid targets. Lifestyle changes like diet and exercise are encouraged for all.
2. Statins are recommended for four major groups to reduce ASCVD risk. High, moderate, and low intensity statin therapies are defined based on average LDL-C reduction.
3. For patients who are truly statin intolerant or require additional lowering, the document provides guidance on use of non-statin therapies like ezetimibe, basing selection on risk level and comorbidities.
- The patient is a 50-year-old male smoker with hypertension for 6 years. His lipid profile shows a total cholesterol of 210 mg/dL, triglycerides of 180 mg/dL, LDL of 119 mg/dL, and HDL of 30 mg/dL.
- According to guidelines, he is at high cardiovascular risk due to smoking, hypertension, and lipid levels. Egypt is also considered a very high risk country.
- The appropriate measures for this high risk patient include lifestyle modifications plus high-intensity statin therapy, with an LDL cholesterol goal of less than 70 mg/dL. Monitoring is also needed.
Diabetic Dyslipidemia
By Dr. Usama Ragab Youssif
ISMA CME Activity 2021
In Tolip EL Galala Hotel
-----------
Introduction
Physiology of lipid metabolism
Pathophysiology of diabetic dyslipidemia
Statin therapy (+/- ezetimibe) evidence and translation of evidence
Residual CV risk: excess TG
EPA therapy evidence and translation of evidence
This document provides an overview of dyslipidemia including the physiology of lipid metabolism, the role of lipoproteins in atherosclerosis, screening and treatment approaches. It covers topics such as the exogenous and endogenous pathways of lipid metabolism, key enzymes involved, how lipids contribute to atherosclerosis, diagnostic evaluation, and management with an emphasis on statin therapy and other lipid-lowering drug classes and their mechanisms of action and side 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.
The document summarizes several misconceptions about new prevention guidelines for lifestyle, obesity, cholesterol, risk prediction, and hypertension. It clarifies that the lifestyle guidelines endorse Mediterranean and DASH diets but not low-fat diets; intensive behavioral therapy is recommended for more patients to help with weight loss; and the role of non-statin therapy is reduced but still exists for some high-risk patients. It also notes that the new risk calculator looks similar to prior scores but uses larger datasets and separate equations for different races.
1. The document summarizes 10 key points from expert panel recommendations for treating blood cholesterol to reduce cardiovascular risk.
2. It identifies four groups that benefit from statin therapy based on extensive evidence: those with clinical cardiovascular disease, very high LDL levels, diabetes with moderately high LDL, and those at high 10-year risk of cardiovascular disease.
3. The panel recommends using the new Pooled Cohort Equations risk calculator to estimate 10-year cardiovascular risk and determine who benefits most from statin therapy.
This document is the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. It was written by a committee of experts and provides recommendations to reduce the risk of atherosclerotic cardiovascular disease through cholesterol management. The guideline covers topics such as measurements of LDL-C and other lipids, therapeutic lifestyle changes, lipid-lowering drugs including statins, and recommendations for different patient groups including those with secondary prevention of ASCVD or severe hypercholesterolemia.
The document discusses statin therapy and its potential side effects. It notes that while statins are effective for lowering LDL cholesterol and reducing cardiovascular risk, they have been associated with small increased risks of new-onset diabetes, muscle symptoms, and mild liver enzyme elevations in some patients. However, it finds no clear evidence of increased risks of cognitive impairment, renal or hepatic dysfunction, or hemorrhagic stroke with statin use. Overall, the benefits of statins in reducing cardiovascular events far outweigh these potential risks.
The document provides the top 10 take-home messages from the 2023 AHA/ACC Guideline for the Management of Patients with Chronic Coronary Disease. The messages emphasize team-based and patient-centered care, nonpharmacologic therapies like exercise for all patients, and updated recommendations for medications and testing. Risk stratification should incorporate all available information to classify patients' risk levels. A multidisciplinary team approach is recommended to improve outcomes and modify risk factors.
1. There is a vicious cycle between diabetes and liver disease, as diabetes can cause liver damage and liver disease increases the risk of diabetes.
2. Hepatogenous diabetes differs from type 2 diabetes in that it has a lower risk of cardiovascular complications and less often a family history of diabetes.
3. Metformin is the preferred agent for managing diabetes in patients with nonalcoholic fatty liver disease (NAFLD) or advanced liver disease, while insulin is recommended for decompensated cirrhosis.
This particular presentation of mine covers salient features of recent drug developed for treatment of dyslipidaemia particularly familial hypercholesterolemia. This presentation also covers recent modifications in treatment guidelines.
The Role of SGLT 2 Inhibitors and GLP 1 Receptor Agonists and DPP 4 InhibitorsPHAM HUU THAI
This document discusses the role of SGLT-2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors in managing type 2 diabetes. It provides background on the pathophysiology and progression of type 2 diabetes and limitations of older drug classes. It then describes the mechanisms and roles of the newer drug classes like SGLT-2 inhibitors in promoting urinary glucose excretion and GLP-1 agonists and DPP-4 inhibitors in augmenting the body's own incretin response. It also discusses ongoing cardiovascular outcome trials and FDA approvals of these newer agents.
Glimepiride +Metformin an integral part in achieving goals (1).pptxHarshit Gupta
This document discusses the role of the fixed-dose combination of Glimepiride and Metformin in achieving glycemic control goals for patients with type 2 diabetes. It notes that 90% of patients with diabetes should be detected, 90% of those detected should be treated, and 90% of those treated should achieve glycemic control. The combination of Glimepiride and Metformin is presented as an effective, safe, and tolerable treatment that provides durable glycemic control, especially when initiated early in the course of the disease. It also discusses the benefits of this combination in patients with comorbidities and its superior glycemic control compared to DPP-4 inhibitors.
This document discusses guidelines for lowering LDL cholesterol levels to reduce cardiovascular risk. It notes that while normal LDL levels are considered low risk, even normal levels still carry some risk. Current guidelines recommend lowering LDL as much as possible, by at least 50%, with a target under 70 mg/dL or lower for high-risk patients. Clinical trials have shown lower LDL levels are associated with greater risk reduction, down to levels under 40 mg/dL, though very low levels below 25 mg/dL require more evidence. Potential safety risks of extremely low levels are also examined. The conclusion emphasizes the importance of early detection and management of dyslipidemia to prevent cardiovascular disease.
Treatment Options For The Chronic Stable AnginaRodolfo Rafael
This document discusses treatment options for chronic stable angina, including the metabolic agent trimetazidine. It provides an overview of angina and its epidemiology. Trimetazidine improves energy metabolism in ischemic heart tissue by inhibiting fatty acid oxidation and stimulating glucose utilization. Clinical trials show trimetazidine reduces angina symptoms and improves exercise tolerance. It may benefit patients with heart failure or diabetes by optimizing energy production and preserving heart cell function.
Diabetic nephropathy is a leading cause of end-stage renal disease worldwide. Strict control of blood glucose, blood pressure, angiotensin system inhibitors, and other risk factors can help prevent or slow the progression of kidney damage. The stages include early hyperfiltration, development of microalbuminuria, progression to macroalbuminuria and renal failure. Management focuses on glycemic control, blood pressure reduction, angiotensin blockade, cholesterol control, and management of anemia and cardiovascular risk factors to preserve kidney function for as long as possible.
John B. Buse, MD, PhD, discusses type 2 diabetes in this CME activity titled "Exploring the Science and Practice of GLP-1 Receptor Agonists: An Update on Current and Emerging Evidence." For the full presentation, downloadable infographics, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2oL19BK. CME credit will be available until October 21, 2020.
1) Several early trials evaluated lipid lowering drugs such as mevastatin and lovastatin, which were isolated from fungi and shown to inhibit HMG CoA reductase. However, mevastatin was not marketed due to toxicity in dogs. Lovastatin was first marketed as Mevacor in 1987.
2) Large primary prevention trials such as WOSCOPS, AFCAPS/TexCAPS, CARDS and JUPITER demonstrated significant reductions in cardiovascular events with statin therapy compared to placebo in various populations with and without known heart disease.
3) Secondary prevention trials in patients with stable CAD such as 4S, CARE, LIPID and TNT showed that statin therapy reduces
This document provides guidelines and recommendations for lipid management:
1. It summarizes the 2013 ACC/AHA guidelines and 2016 ACC expert consensus, focusing on proven therapy rather than arbitrary lipid targets. Lifestyle changes like diet and exercise are encouraged for all.
2. Statins are recommended for four major groups to reduce ASCVD risk. High, moderate, and low intensity statin therapies are defined based on average LDL-C reduction.
3. For patients who are truly statin intolerant or require additional lowering, the document provides guidance on use of non-statin therapies like ezetimibe, basing selection on risk level and comorbidities.
- The patient is a 50-year-old male smoker with hypertension for 6 years. His lipid profile shows a total cholesterol of 210 mg/dL, triglycerides of 180 mg/dL, LDL of 119 mg/dL, and HDL of 30 mg/dL.
- According to guidelines, he is at high cardiovascular risk due to smoking, hypertension, and lipid levels. Egypt is also considered a very high risk country.
- The appropriate measures for this high risk patient include lifestyle modifications plus high-intensity statin therapy, with an LDL cholesterol goal of less than 70 mg/dL. Monitoring is also needed.
Diabetic Dyslipidemia
By Dr. Usama Ragab Youssif
ISMA CME Activity 2021
In Tolip EL Galala Hotel
-----------
Introduction
Physiology of lipid metabolism
Pathophysiology of diabetic dyslipidemia
Statin therapy (+/- ezetimibe) evidence and translation of evidence
Residual CV risk: excess TG
EPA therapy evidence and translation of evidence
This document provides an overview of dyslipidemia including the physiology of lipid metabolism, the role of lipoproteins in atherosclerosis, screening and treatment approaches. It covers topics such as the exogenous and endogenous pathways of lipid metabolism, key enzymes involved, how lipids contribute to atherosclerosis, diagnostic evaluation, and management with an emphasis on statin therapy and other lipid-lowering drug classes and their mechanisms of action and side 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.
The document summarizes several misconceptions about new prevention guidelines for lifestyle, obesity, cholesterol, risk prediction, and hypertension. It clarifies that the lifestyle guidelines endorse Mediterranean and DASH diets but not low-fat diets; intensive behavioral therapy is recommended for more patients to help with weight loss; and the role of non-statin therapy is reduced but still exists for some high-risk patients. It also notes that the new risk calculator looks similar to prior scores but uses larger datasets and separate equations for different races.
1. The document summarizes 10 key points from expert panel recommendations for treating blood cholesterol to reduce cardiovascular risk.
2. It identifies four groups that benefit from statin therapy based on extensive evidence: those with clinical cardiovascular disease, very high LDL levels, diabetes with moderately high LDL, and those at high 10-year risk of cardiovascular disease.
3. The panel recommends using the new Pooled Cohort Equations risk calculator to estimate 10-year cardiovascular risk and determine who benefits most from statin therapy.
The document provides guidelines from a committee for managing blood cholesterol to reduce atherosclerotic cardiovascular disease risk. It includes 10 key recommendations, such as emphasizing lifestyle changes for all ages, using high-intensity statin therapy for patients with clinical ASCVD, considering additional nonstatin drugs for very high risk patients, and assessing adherence to medication and lifestyle changes. The guidelines cover measuring cholesterol levels, risk assessment, and treatment approaches for different patient groups including those with diabetes or severe hypercholesterolemia.
ATP IV Guideline for Blood cholesterol levelkamalmodi481
The document summarizes new guidelines for treating blood cholesterol to reduce ASCVD risk. It classifies individuals into 4 statin benefit groups based on clinical risk factors like age and cholesterol/diabetes status. The guidelines focus on global ASCVD risk assessment for primary prevention and appropriate statin therapy intensity. Biomarkers and tests can help treatment decisions for those not in the main groups. Safety monitoring and limitations are discussed. Future updates may provide guidance for complex cases and refine risk assessment based on new data.
Dyslipidemia and CVS by Mohit Soni and Chandan KumarOlgaGoryacheva4
My students Mohit Soni and Chandan Kumar had presented this topic in our 22nd Student Scientific Society Conference in the department of Propaedeutic of Internal Diseases No.2
The American Heart Association and American College of Cardiology, in partnership with the National Heart, Lung and Blood Institute, have released new joint guidelines on cardiovascular disease prevention focusing on hyperlipidemia, hypertension, cardiovascular risk assessment, lifestyle interventions, and obesity. The guidelines provide recommendations on screening and treating dyslipidemia and cardiovascular risk through lifestyle modifications like diet, exercise, weight loss and smoking cessation as well as pharmacological interventions including statin therapy. The guidelines stratify treatment approaches based on levels of cardiovascular risk and recommend high or moderate intensity statins for primary and secondary prevention.
The document provides the executive summary of the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. It lists the top 10 take-home messages from the guideline, including emphasizing a healthy lifestyle throughout life to prevent cardiovascular disease, using a team-based care approach, assessing 10-year cardiovascular risk in adults aged 40-75 before starting pharmacological therapy, and promoting a healthy diet and regular physical activity. It also provides recommendations on assessing cardiovascular risk factors, addressing social determinants of health, nutrition, exercise, weight management, and management of type 2 diabetes to reduce cardiovascular risk.
This document provides guidelines for the diagnosis and management of dyslipidemia for adults over 18 years old. It was developed by a multidisciplinary task force and has been reviewed and approved regularly since 1999. The guidelines establish screening recommendations and lipid treatment goals based on a patient's risk level. They provide a sequence of medication recommendations depending on a patient's lipid patterns. The guidelines are intended to help clinicians manage dyslipidemia and reduce patients' risk of coronary heart disease.
1. Dyslipidemia is an important risk factor for cardiovascular disease and is defined by disorders of lipoprotein metabolism that result in high cholesterol, LDL, and triglycerides or low HDL.
2. Lifestyle changes and medications like statins are recommended to lower LDL levels and reduce cardiovascular risk, with lower LDL targets for those at highest risk.
3. Statins are the first-line treatment for lowering LDL but can cause side effects like muscle pain; newer drugs like PCSK9 inhibitors can further lower LDL in those unable to tolerate statins.
2019 prevention-guideline-slides-gl-preventionPHAM HUU THAI
The document provides the top 10 take-home messages from the 2019 ACC/AHA guidelines on primary prevention of cardiovascular disease. The key recommendations are to promote a healthy lifestyle through diet, physical activity, not smoking, and controlling conditions like diabetes and high blood pressure. It also recommends calculating 10-year heart disease risk for adults aged 40-75 and discussing treatment such as statins based on that risk level. The guidelines emphasize a team-based approach and addressing social factors that influence health.
1. The document discusses managing comorbidities that can arise from inflammatory arthritis, including cardiovascular disease.
2. It notes that patients with inflammatory rheumatic diseases have an increased risk of cardiovascular issues compared to the general population. Several guidelines are mentioned for assessing and managing cardiovascular risk in these patients.
3. The challenges of accurately quantifying cardiovascular risk specific to inflammatory arthritis patients and determining appropriate lipid treatment targets for these patients are discussed. Modification of traditional risk prediction models to account for arthritis-related inflammation is an area lacking guidance.
This document discusses cardiovascular disease (CVD) prevention and treatment goals for dyslipidemia. It notes that CVD is a leading cause of death in Europe and prevention is important. The importance of lifestyle modifications and controlling risk factors like lipids and blood pressure is emphasized. Treatment goals for low-density lipoprotein cholesterol (LDL-C) are personalized based on a patient's risk level, ranging from less than 130 mg/dL for low risk to less than 55 mg/dL for extreme risk. Additional goals for high-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoproteins, and triglycerides are provided. Compliance with statin therapy is important for achieving benefits.
Diabetes and heart two sides of the same coinSunil Wadhwa
This ppt presented in a CME of doctors in March 2017 discusses-if all Diabetics should be treated aggressively for prevention of coronary artery disease & SHOULD IT BE PRESUMED AS IF THEY ARE ALREADY PATIENTS OF CAD?
This presentation is updated till March 2017
This document provides an overview of diabetic dyslipidemia and lipid management recommendations for patients with diabetes. It discusses that excess fat contributes to atherosclerosis and mortality in diabetes. It outlines traditional and non-traditional risk factors for cardiovascular disease. The spectrum of diabetic dyslipidemia includes quantitative changes like high triglycerides and qualitative changes in lipoprotein composition. Lifestyle modifications and statin therapy are recommended to improve lipid profiles and reduce cardiovascular risk according to guidelines. The appropriate screening, interpretation of results, and intensity of statin therapy depends on individual patient risk factors and characteristics.
1) LDL-C levels are a major risk factor for acute coronary syndrome (ACS) and lowering LDL-C through intensive statin therapy leads to significant reductions in recurrent events and mortality after ACS.
2) Guidelines recommend initiating high-dose statins early for ACS patients and achieving an LDL-C reduction of at least 50% from baseline and an LDL-C level below 55 mg/dL to reduce risk.
3) Studies show high-dose rosuvastatin preloading before percutaneous coronary intervention (PCI) significantly reduces major adverse cardiac events and peri-procedural myocardial injury compared to no preloading or lower statin doses.
This document discusses cardiovascular risk reduction strategies for a patient with type 2 diabetes and a strong family history of cardiovascular disease. It reviews the cardiovascular safety data of various anti-diabetic medications and recommends intensifying treatment to achieve an A1C less than 7%, blood pressure lower than 130/80 mmHg, high-intensity statin therapy, and aspirin. For this patient's secondary prevention, drugs like liraglutide, empagliflozin, canagliflozin, and pioglitazone that have demonstrated cardiovascular benefits in clinical trials are preferable additions to metformin over sulfonylureas. While these newer anti-diabetic drugs have robust evidence for secondary prevention, data for their use in
Comparacion entre las guias dislipidemias 2022 .pptxJuan Diego
This document summarizes and compares guidelines from the European Society of Cardiology (ESC), American Heart Association/American College of Cardiology/American Stroke Association (AHA/ACC/MS), and Canadian Cardiovascular Society (CCS) regarding cardiovascular disease (CVD) risk assessment and lipid management. The guidelines recommend calculating 10-year CVD risk using different tools. They provide risk categories and recommend treatment based on risk level, with the ESC guidelines targeting lower LDL-C levels than the other two. All emphasize lifestyle changes and statin treatment, with intensification options including ezetimibe, PCSK9 inhibitors, or apheresis for very high risk patients.
This document provides guidelines from the 2019 ACC/AHA on primary prevention of cardiovascular disease. It discusses assessing cardiovascular risk in adults aged 40-75 using pooled cohort equations to calculate 10-year risk. For those at borderline or intermediate risk, additional risk-enhancing factors can guide treatment decisions such as statin therapy. Lifestyle modifications like diet, exercise, weight management and treating conditions like diabetes and high blood pressure are emphasized. Nutrition recommendations include eating vegetables, fruits, whole grains and fish; limiting sodium, processed meats and sugar-sweetened drinks. Adults should aim for 150 minutes of moderate exercise weekly.
2013 prevention guidelines cholesterol slide set 4Sara Sirna
This document summarizes the 2013 ACC/AHA guidelines for treating blood cholesterol to reduce cardiovascular risk. It provides an overview of the guideline development process, which included a systematic review of randomized controlled trials and development of recommendations based on evidence. The guidelines emphasize adherence to lifestyle changes and identify four statin benefit groups. They also discuss assessing risk and initiating appropriate intensity statin therapy, while noting a lack of evidence for specific cholesterol treatment targets.
This document provides guidelines for the assessment and management of dyslipidemia from several major organizations. It discusses risk assessment tools for cardiovascular disease from ATP III, ADA, ACC/AHA, and QRISK2. It also compares statin intensity categories between NICE and ACC/AHA guidelines. The document recommends lifestyle modification as first-line treatment and the use of high-intensity statins for primary and secondary prevention of CVD according to the guidelines of NICE, ADA, and ACC/AHA.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- 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
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
3. About this Pocket Guide
This pocket guide is a quick-reference tool that features diagnostic and treatment recommendations based on the CCS
Dyslipidemia Guidelines (2006, 2009, 2012 and 2016).
These recommendations are intended to provide a reasonable and practical approach to care for specialists, physicians
and allied health professionals. They are subject to change as scientific knowledge and technology advance and
practice patterns evolve, and are not intended to be a substitute for clinical judgement. Adherence to these
recommendations will not necessarily produce successful outcomes in every case.
For information about the GRADE approach for rating the strength of recommendations and quality of evidence, visit
www.ccs.ca.
Please visit www.ccs.ca for more information and additional resources.
Co-Chairs
Todd J. Anderson MD, Jean Grégoire MD and Glen J. Pearson PharmD
CCS Dyslipidemia Guidelines Primary Panel
Arden Barry PharmD, Patrick Couture MD, Martin Dawes MD, Gordon A. Francis MD, Jacques Genest Jr MD, Steven
Grover MD, Milan Gupta MD, Robert A. Hegele MD, David C. Lau MD, PhD, Lawrence A. Leiter MD, Eva Lonn MD, G.B
John Mancini MD, Ruth McPherson MD, PhD, Daniel Ngui MD, Paul Poirier MD, PhD, John Sievenpiper MD, PhD,
James A. Stone MD, PhD, George Thanassoulis MD, Richard Ward MD for the CCS Dyslipidemia Guidelines
Committee.
4. Table of Contents
Summary of 2016 Guideline Changes and Highlights ........................................................................................ 2
Screening
Who to screen and How to Screen ........................................................................................................ 3
Secondary Testing ................................................................................................................................ 5
Risk Assessment
Risk Assessment for Primary Prevention ................................................................................................ 6
Risk Stratification ........................................................................................................................................ 7
Primary and Secondary Lipoprotein Determinants ................................................................................ 8
Management
When to Consider Pharmacological Treatment ........................................................................................ 9
Targets of Therapy ................................................................................................................................12
Potential Adverse Effects of Statins ........................................................................................................14
Non-Statin therapy ................................................................................................................................15
Health Behaviour Interventions ................................................................................................................17
Approach to Risk Management (Algorithm) ................................................................................................21
Follow-up and Referral to Specialist Clinics ................................................................................................23
5. Summary of 2016 Guideline Changes and Highlights
2
• Lipid screening for both men and women ≥ 40 years of age, and screening for women with a history of HDP (page 3)
• Non-fasting lipid determination recommendation (page 4)
• Risk assessment using FRS and CLEM (page 6)
• Broader treatment recommendations for those in intermediate risk category (includes statin indicated conditions) (page 9)
• Expanded definition of CKD as high-risk phenotype (page 9)
• New targets: LDL-C <2.0 mmol/L for individuals for whom treatment is initiated, or consider more aggressive targets of
LDL-C <1.8 mmol/L for recent ACS patients (page 13)
• New recommendations for non-statin drugs (page 15)
• Nutritional guidelines that focus on dietary patterns – Mediterranean, DASH or Portfolio diet (page 17)
• Detailed review of the impact of nutritional components on lipids and CV events (page 19)
What’s new?
LDL-C – low density lipoprotein cholesterol; CKD – chronic kidney disease; DASH – Dietary Approaches to Stop Hypertension; HDP - Hypertensive disease of pregnancy
Key Messages
• LDL-cholesterol levels are directly linked to the development of atherosclerosis and its reduction is directly linked to
the reduction in cardiovascular disease events
• Health behaviour modification remains a cornerstone of risk reduction
6. Who to Screen 3
5
*Men <55 and women <65 yrs of age in first degree relative
**CKD: eGFR <60 ml/min/1.73 m2 or ACR >3 mg/mmol for at least 3 months duration
Diabetes mellitus
arcus cornealis
**
Screening
7. Screening
How to Screen
4
RECOMMENDATION
• We recommend non-fasting lipid and lipoprotein testing can be performed in adults in whom screening is indicated as part of a
comprehensive risk assessment to reduce CVD events (Strong Recommendation, High Quality Evidence).
• We suggest that for individuals with a history of triglyceride levels >4.5 mmol/L that lipid and lipoprotein levels be measured
fasting (Conditional Recommendation, Low Quality Evidence).
Pratical Tip - Compared to fasting lipid values, there will be minimal change with non-HDL-C, a slight decrease in LDL-C and
small increase in triglyceride concentrations when most individuals do not fast.
LIPID TESTING CAN GENERALLY BE DONE NON-FASTING
8. Screening
Secondary Testing 5
• We suggest that CAC screening using computed tomography imaging might be appropriate for asymptomatic, middle-aged adults (FRS 10-20%)
for whom treatment decisions are uncertain (Conditional Recommendation, Moderate Quality Evidence).
• We suggest that CAC screening using computed tomography imaging might not be undertaken for a) high risk individuals b) patients receving statin
treatment or c) most asymptomatic, low-risk adults (Strong Recommendation, Moderate Quality Evidence).
• We suggest that CAC screening might be considered for a subset of low-risk middle-aged individuals with a family history of premature CHD (men
<55 years; women <65 years) (Conditional Recommendation, Low Quality Evidence).
• We suggest that in patients who warrant risk factor management on the basis of usual criteria, CAC scoring not be undertaken. Moreover, CAC
scoring (seeking a result with a value of zero) should not be used as a rationale for withholding otherwise indicated, preventive therapies (Strong
recommendation, Low Quality Evidence).
Values and preferences - Lp(a) is a marker of CVD risk. Particular attention should be given to individuals with Lp(a) levels above 30mg/dL for
whom CVD risk is increased by approximately twofold. Although no randomized clinical trials are available to support basing treatment decisions
solely on an elevated LP(a) level, identification of high levels of Lp(a) might be particularly useful for mutual decision-making in intermediate-risk
subjects. Moreover, in younger patients who have a very strong family history of premature CVD suspected to be related to atherogenic dyslipidemia
but who by virtue of young age, do not meet usual risk criteria for treatment, detection of high Lp(a) might help inform mutual decision making
regarding treatment. Lp(a) is not considered a treatment target and repeat measures are not indicated.
Coronary Artery Calcium (CAC) Measurement - Recommendations
• We suggest that Lp(a) might aid risk assessment in subjects at intermediate Framingham risk or with a family history of premature coronary artery
disease (Conditional Recommendation, Moderate Quality Evidence).
Lipoprotein (a) Measurement - Recommendation
9. Risk Assessment for Primary Prevention
6
RECOMMENDATIONS
• We recommend that a cardiovascular risk assessment be completed every 5 years for men and women age 40 to 75 using the
modified FRS or CLEM to guide therapy to reduce major cv events. A risk assessment may also be completed whenever a
patient’s expected risk status changes (Strong Recommendation, High Quality Evidence).
• We recommend sharing the results of the risk assessment with the patient to support shared decision making and improve the
likelihood that patients will reach lipid targets (Strong Recommendation, High Quality Evidence).
Pratical Tip - While there is good evidence to support the use of statins in secondary prevention in patients over the age of 75
years for some outcomes, a mortality benefit has not been demonstrated. In addition, the evidence for statin use in primary
prevention is lacking in this population, mainly because they have not been extensively studied. For robust elderly patients
believed to be at higher risk, a discussion about the importance of statin therapy in overall management should be undertaken
as these patients are often at high risk because a CVD event has important consequences for morbidity.
✝
Can calculate Cardiovascular Age with the Cardiovascular Life Expectancy Model at: www.chiprehab.com
For mobile device applications from the CCS, please visit: www.ccs.ca
FRS calculator: myhealthcheckup.com
Calculate risk (unless statin-indicated condition) using the Framingham Risk Score (FRS)✝
or Cardiovasular Life Expectancy Model (CLEM)✝
Repeat screening every 5 years for FRS <5% or every year for FRS ≥5%
RIsk Assessment
10. Statins are first line therapy but add-on or alternative therapy may be required as per the algorithm
RIsk Assessment
Risk Stratification 7
11. RECOMMENDATION
• We recommend that non-HDL-C and apo B should continue to be considered alternate targets to LDL-C to evaluate risk in
adults (Strong Recommendation, High Quality Evidence).
Values and preferences - As clinicians are most familiar with LDL-C we continue to recommend its use as the primary target,
but recognize the advantages of non-HDL-C or apo B.
Chylomicron
Remnants
VLDL
Very low-density
lipoprotein
IDL
Intermediate-density
lipoprotein
Lp(a)
Lipoprotein
LDL
Low-density
lipoprotein
HDL
High-density
lipoprotein
Non-HDL-C = Total Cholesterol-HDL-C
Atherogenic
Apo B-containing
Lipoproteins
LDL-C: Calculated from standard Lipid Profile
Apo B: Measured separately
Primary and Secondary Lipoprotein Determinants
8
RIsk Assessment
12. Management
When to Consider Pharmacological Treatment in Risk Management 9
Statin-indicated Conditions
RECOMMENDATION
Statin-indicated conditions:
• We recommend management that includes statin therapy in high risk conditions including clinical atherosclerosis, abdominal aortic
aneurysm, most diabetes mellitus, chronic kidney disease (age >50 years) and those with LDL-C ≥5.0 mmol/L to decrease the risk
of CVD events and mortality (Strong Recommendation, High Quality Evidence).
CLINICAL
ATHEROSCLEROSIS
Myocardial infarction, acute
coronary syndromes
Stable angina, documented
coronary disease by angiography
Stroke, TIA, documented
carotid disease
Peripheral artery disease,
claudication and/or ABI <0.9
Abdominal aorta >3.0 cm
or Previous aneurysm
surgery
≥40 years of age or
>15 years duration and
age ≥30 years of age or
Microvascular complications
>3 months duration and
ACR >3.0 mg/mmol or
eGFR <60 ml/min/1.73m2
≥ 50 years of age
LDL-C ≥5.0 mmol/L or
Document familial
hypercholesterolemia
Excluded 2nd causes
ABDOMINAL AORTIC
ANEURYSM
DIABETES
MELLITUS
CHRONIC KIDNEY
DISEASE
LDL-C ≥5.0 MMOL/L
13. When to Consider Pharmacological Treatment in Risk Management
10
Management
RECOMMENDATION
Primary prevention:
a) We recommend management that does not include statin therapy for individuals at low risk (modified FRS <10 %) to decrease the risk of CVD events (Strong
Recommendation, High Quality Evidence).
b) We recommend management that includes statin therapy for individuals at high risk (modified FRS ≥20%) to decrease the risk of CVD events (Strong Recommen-
dation, High Quality Evidence).
c) We recommend management that includes statin therapy for individuals at intermediate risk (modified FRS 10-19%) with LDL-C ≥3.5 mmol/L to decrease the risk
of CVD events. Statin therapy should also be considered for intermediate risk persons with LDL-C <3.5 mmol/L but with apo B ≥1.2 g/L or non-HDL-C ≥4.3 mmol/L
or in men ≥50 and women ≥60 years of age with ≥1 CV risk factor (Strong Recommendation, High Quality Evidence).
Values and preferences - This recommendation applies to individuals with an LDL-C ≥1.8 mmol/L. Any decision regarding pharmacological therapy for CV risk
reduction in IR persons needs to include a thorough discussion of risks, benefits, and cost of treatment, alternative nonpharmacological methods for CV risk
reduction and each individual’s preference. The proportional risk reduction associated with statin therapy in RCTs in (IR) persons is of similar magnitude to that
attained in high-risk persons. Moreover, irreversible severe side effects are very rare and availability of generic statins results in low cost of therapy. However, the
absolute risk reduction is lower. Statin therapy may be considered in persons with FRS of 5%-9% with LDL-C ≥3.5 mmol/L or other CV risk factors as the proportional
benefit from statin therapy will be similar in this group as well.
Primary Prevention Conditions
or
FRS 10-19% and LDL-C ≥3.5 mmol/L or
Non-HDL-C ≥4.3 mmol/L or
Apo B ≥1.2 g/L or
Men ≥50 and women ≥60 with one additional risk
factor: low HDL-C, impaired fasting glucose,
high waist circumference, smoker, hypertension
14. Management
Chronic Kidney Disease 11
• We recommend treatment with a statin or statin/ezetimibe combination to reduce CVD events in adults ≥50 years with chronic kidney disease not
treated with dialysis or a kidney transplant (Strong Recommendation, High Quality Evidence).
RECOMMENDATIONS
Values and preferences - If the preference is to engage in early prevention and long-term risk reduction, in subjects <50 years the absolute risk of
events is lower but studies suggest that statins will result in a relative risk reduction similar to those ≥50 years. The statin/ezetimibe combination
recommendation is based on the SHARP study which utilized 20 mg of simvastatin and 10 mg of ezetimibe.
• We suggest that lipid-lowering therapy not be initiated in adults with dialysis-dependent CKD (Conditional Recommendation, Moderate Quality
Evidence).
Values and preferences - In younger individuals who may become eligible for kidney transplantation or with a longer life expectancy, statin or statin/eze-
temibe combination therapy may be desirable although high-quality studies have not been done in this population.
• We suggest that lipid-lowering therapy be continued in adults already receiving it at the time of dialysis initiation (Conditional Recommendation, Low
Quality Evidence).
• We suggest the use of statin therapy in adults with kidney transplantation (Conditional Recommendation, Moderate Quality Evidence).
Values and preferences - This recommendation reflects that fact that a substantial number of patients in SHARP transitioned to dialysis during the
study and there was no heterogeneity of results for the population as a whole. The evidence is of low quality overall and there is substantial debate about
best practice in this situation.
15. Management
Pharmacological Treatment Indications and Targets
12
Primary Prevention
Statin Indicated
Conditions**
High
(FRS ≥20%)
Intermediate
(FRS 10-19%)
LDL-C ≥3.5 mmol/L
or Non-HDL-C ≥4.3 mmol/L
or Apo B ≥1.2 g/L
or Men ≥50 and women ≥60 yrs
and one additional CVD RF
Clinical atherosclerosis*
Abdominal aortic aneurysm
Diabetes mellitus ≥40 yrs 15 yrs
duration for age ≥30 yrs (DM1)
Microvascular disease
Chronic kidney disease (age ≥50 y)
eGFR <60 mL/min/1.73
m2 or ACR > 3 mg/mmol
LDL-C ≥5.0 mmol/L
NNT: number needed to treat to prevent one CVD event for 5 years of treatment per 1 mmol/L reduction in LDL-C. NNT of <50 are generally regarded
as desirable by physicians with some patients wishing to see NNT<30 to deem an intervention as acceptable.
FRS – modified Framingham Risk Score; ACR – albumin:creatinine ratio;
* consider LDL-C <1.8 mmol/L for subjects with ACS within last 3 months
** statins indicated as initial therapy
LDL-C <2.0 mmol/L or >50%
Or
Or
Apo B <0.8 g/L
>50% in LDL-C
non-HDL-C <2.6 mmol/L
35
40
20
Category Target NNTConsider Initiating
pharmaco-therapy if:
16. Management
Monitoring, Surveillance and Targets 13
• We recommend a treat-to-target approach in the management of dyslipidemia to mitigate CVD risk (Strong Recommendation, High Quality
Evidence).
RECOMMENDATIONS
Statin Indicated Conditions:
a) We recommend a target LDL-C consistently <2.0 mmol/L or >50% reduction of LDL-C for individuals for whom treatment is initiated to decrease the
risk of CVD events and mortality (Strong Recommendation, Moderate-Quality Evidence). Alternative target variables are apo B <0.8 g/L or
non-HDL-C <2.6 mmol/L (Strong Recommendation, Moderate Quality Evidence).
b) We recommend a >50% reduction of LDL-C for patients with LDL-C >5.0 mmol/L in individuals for whom treatment is initiated to decrease the risk of
CVD events and mortality (Strong Recommendation, Moderate Quality Evidence).
Values and preferences - Based on the IMPROVE-IT trial, for those with a recent acute coronary syndrome and established coronary disease consider-
ation should be given to more aggressive targets (LDL-C <1.8 mmol/L or >50% reduction). This might require the combination of ezetimibe (or other
non-statin medications) with maximally tolerated statin. This would value more aggressive treatment in higher risk individuals.
Primary prevention conditions warranting therapy (All risk groups):
• We recommend a target LDL-C consistently <2.0 mmol/L or >50% reduction of LDL-C in individuals for whom treatment is initiated to decrease the
risk of CVD events (Strong Recommendation, Moderate Quality Evidence). Alternative target variables are apo B <0.8 g/L or non-HDL-C <2.6 mmol/L
(Strong Recommendation, Moderate Quality Evidence).
Values and preferences - According to evidence from randomized trials in primary prevention, achieving these levels will reduce CVD events. The
mortality reduction is statistically significant but modest (NNT =250). Treatment in primary prevention values morbidity reduction preferentially.
17. Management
Potential Adverse Effects of Statins
14
• We recommend that despite concerns about a variety of possible adverse effects, all purported statin-associated symptoms should be evaluated
systematically, incorporating observation during cessation, re-initiation (same or different statin, same or lower potency, same or decreased frequency
of dosing) to identify a tolerated, statin-based therapy for chronic use (Strong Recommendation, Low Quality Evidence).
• We recommend that vitamins, minerals, or supplements for symptoms of myalgia perceived to be statin-associated not be used (Strong
Recommendation, Low Quality Evidence).
RECOMMENDATIONS
Values and preferences - Always confirm that there is an indication for statin use which, if present, would suggest that benefits, clearly communicated
to the patient, far outweigh the potential occurrence of any of the many side effects purported to be associated with statin use. Assess patient features
that might limit dosage or preclude use of statins (e.g. potential drug-drug interactions) and always emphasize dietary, weight and exercise interventions
to facilitate achievement of lipid goals and other benefits of comprehensive, CV prevention.
18. Management
Non-Statin Therapy 15
Values and preferences - It remains unclear whether niacin offers CV benefits in other patient groups, such as those with LDL-C above target or those
with low HDL-C or high triglyceride levels.
RECOMMENDATIONS
• We recommend ezetimibe as second-line therapy to lower LDL-C levels in patients with clinical CVD if targets are not reached with maximally tolerated
statin therapy (Strong Recommendation, High Quality Evidence).
• We recommend that niacin not be added to statin therapy for CVD prevention in patients who have achieved LDL-C targets (Strong Recommendation,
High Quality Evidence).
Values and preferences - In sub-group analysis, patients with elevated triglycerides and low HDL-C may benefit from fibrate therapy.
• We recommend that fibrates not be combined with statin therapy for CVD event prevention in patients who have achieved LDL-C targets (Strong
recommendation, High Quality Evidence).
19. Management
Non-Statin Therapy
16
Values and preferences - Definitive outcome trials with PCSK9 inhibitors are underway but have not yet been completed. However, phase 3 efficacy
trials show consistent reduction in LDL-C and reassuring trends towards reduced CV events, even though they were not powered for such. Given the
very high lifetime risk faced by patients with familial hypercholesterolemia or ASCVD, clinicians should balance the anticipated benefits of robust LDL-C
lowering with PCSK9 inhibitors against the lack of definitive outcomes data.
• We suggest that bile acid sequestrants be considered for LDL-C lowering in high risk patients whose levels remain above target despite statin
treatment +/- ezetimibe therapy (Conditional Recommendation, Low Quality Evidence).
• We suggest the use of PCSK9 inhibitors (evolocumab, alirocumab) to lower LDL-C for patients with heterozygous familial hypercholesterolemia whose
LDL-C level remains above target despite maximally tolerated statin therapy (Conditional Recommendation, Moderate Quality Evidence). We suggest
that evolocumab be combined with background therapy in patients with homozygous familial hypercholesterolemia and continued if LDL-C lowering is
documented (Conditional Recommendation, Moderate Quality Evidence).
• We suggest that PCSK9 inhibitors be considered to lower LDL-C for patients with atherosclerotic cardiovascular disease in those not at LDL-C goal
despite maximally tolerated statin doses +/- ezetimibe therapy (Conditional Recommendation, Moderate Quality Evidence).
• We suggest lomitapide and mipomersen* may be considered exclusively in patients with homozygous familial hypercholesterolemia (Conditional
Recommendation, Moderate Quality Evidence).
*not approved in Canada
RECOMMENDATIONS
20. Management
Treatment: Health Behaviour Interventions 17
Values and preferences - Adherence is one of the most important determinants for attaining the benefits of any diet. Individuals should choose the
dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long term.
• We suggest that individuals avoid the intake of trans fats and decrease the intake of saturated fats for CVD disease risk reduction (Conditional
Recommendation, Moderate Quality Evidence).
• We suggest that to increase the probability of achieving a cardiovascular benefit, individuals should replace saturated fats with polyunsaturated fats
(Conditional Recommendation, Moderate Quality Evidence), emphasizing those from mixed omega-3/omega-6 PUFAs sources (e.g. canola and
soybean oils) (Conditional Recommendation, Moderate Quality Evidence), and target an intake of saturated fats of <9% of total energy (Conditional
Recommendation, Low Quality Evidence). If saturated fats are replaced with mono-unsaturated fatty acids (MUFAs) and carbohydrates, then people
should choose plant sources of MUFAs (e.g. olive oil, canola oil, nuts, and seeds) and high-quality sources of carbohydrates (e.g. whole grains and low
glycemic index carbohydrates) (Conditional Recommendation, Low Quality Evidence).
Healthy Eating
• We recommend that all individuals are offered advice about healthy eating and activity and adopt the Mediterranean dietary pattern to decrease their
CVD risk (Strong Recommendation, High Quality Evidence).
Values and preferences - Although there is no apparent cardiovascular benefit, patients may choose to use these supplements for other indications
including the management of high triglycerides. Individuals should be aware that there are different preparations of long chain omega-3 PUFAs high in
docosahexaenoic acid (DHA) and eicosapentaenoic (EPA) acid from marine, algal, and yeast sources and that high doses are required (2-4 g/day).
• We recommend that omega-3 polyunsaturated fatty acids (PUFAs) supplements not be used to reduce CVD events (Strong Recommendation,
High Quality Evidence).
CVD: cardiovascular disease.
21. Management
Treatment: Health Behaviour Interventions
18
• We suggest that all individuals be encouraged to moderate energy (caloric) intake to achieve and maintain a healthy body weight (Conditional Recommendation,
Moderate-Quality Evidence) and adopt a healthy dietary pattern to lower their CVD risk:
(a) Mediterranean dietary pattern (Strong Recommendation, High Quality Evidence)
(b) Portfolio dietary pattern (Conditional Recommendation, Moderate Quality Evidence)
(c) DASH dietary pattern (Conditional Recommendation, Moderate Quality Evidence)
(d) Dietary patterns high in nuts (≥30 g/day) (Conditional Recommendation, Moderate Quality Evidence)
(e) Dietary patterns high in legumes (≥4 servings/week) (Conditional Recommendation, Moderate Quality Evidence)
(f) Dietary patterns high in olive oil (≥60 mL/day) (Conditional Recommendation, Moderate Quality Evidence)
(g) Dietary patterns rich in fruits and vegetables (≥5 servings/day) (Conditional Recommendation, Moderate Quality Evidence)
(h) Dietary patterns high in total fibre (≥30 g/day) (Conditional Recommendation, Moderate Quality Evidence) and whole grains (≥3 servings/day) (Conditional Recommenda-
tion, Low-Quality Evidence)
(i) Low-glycemic load (GL) (Conditional Recommendation, Moderate Quality Evidence) or low-glycemic index (GI) (Conditional Recommendation, Low Quality Evidence) dietary
patterns
(j) Vegetarian dietary patterns (Conditional Recommendation, Very Low Quality Evidence)
Healthy Eating - Continued
Values and preferences - Industrial trans fats are no longer generally regarded as safe (GRAS) in the United States and there are monitoring efforts aimed at reducing them to
the lowest level possible in Canada. These conditions make it increasingly difficult for individuals to consume trans fats in any appreciable amount. Individuals may choose to
reduce or replace different food sources of saturated fats in the diet, recognizing that some food sources of saturated fats, such as milk and dairy products and plant-based
sources of saturated fats, have not been reliably associated with harm.
Values and preferences - Adherence is one of the most important determinants for attaining the benefits of any diet. High food costs (e.g. fresh fruits and vegetables), allergies
(e.g. peanut and tree nut allergies), intolerances (e.g. lactose intolerance), and gastrointestinal (GI) side effects (e.g. flatulence and bloating from fibre) may present as important
barriers to adherence. Other barriers may include culinary (e.g. ability and time to prepare foods), cultural (e.g. culturally specific foods), and ecological/environmental (e.g.
sustainability of diets) considerations. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest
adherence over the long term.
CVD: cardiovascular disease.
22. Management
Treatment: Health Behaviour Interventions 19
• We suggest the following dietary patterns for LDL-C lowering:
(a) Dietary patterns high in dietary pulses (≥1 serving/day or ≥130 g/day) (beans, peas, chickpeas, and lentils) (Conditional Recommendation, Moderate
Quality Evidence)
(b) Low GI dietary patterns (Conditional Recommendation, Moderate Quality Evidence)
(c) DASH dietary pattern (Conditional Recommendation, Moderate Quality Evidence)
Healthy Eating - Continued
• We recommend the following dietary components for LDL-C lowering:
(a) Portfolio dietary pattern (Strong Recommendation, High Quality Evidence)
(b) Dietary patterns high in nuts (≥30 g/day) (Strong Recommendation, High Quality Evidence)
(c) Dietary patterns high in soy protein (≥30 g/day) (Strong Recommendation, High Quality Evidence)
(d) Dietary patterns with plant sterols/stanols (≥2 g/day) (Strong Recommendation, High Quality Evidence)
(e) Dietary patterns high in viscous soluble fibre from oats, barley, psyllium, pectin, or konjac mannan (≥10 g/day) (Strong Recommendation, High Quality
Evidence)
(f) US NCEP Step I and II dietary patterns (Strong Recommendation, High Quality Evidence)
Values and preferences - Individuals may choose to use an LDL-C lowering dietary pattern alone or as an add-on to lipid-lowering therapy to achieve
targets. Dietary patterns based on single-food interventions (high plant sterols/stanols, viscous soluble fibre, nuts, soy, dietary pulses) may be considered
additive (that is, the ~5-10% LDL-C lowering effect of each food can be summed) based on the evidence from the Portfolio dietary pattern.
23. Management
Treatment: Health Behaviour Interventions
20
Activity
• We recommend that adults should accumulate at least 150 minutes of moderate-to-vigorous intensity aerobic physical activity per week, in bouts of 10
minutes or more to reduce CVD risk (Strong Recommendation, High Quality Evidence).
Smoking Cessation
• We recommend that adults who smoke should receive clinician advice to stop smoking to reduce CVD risk (Strong Recommendation, High Quality
Evidence).
Facilitators for Change
• We recommend combining low-risk lifestyle behaviors that include achieving and maintaining a healthy body weight, healthy diet, regular physical
activity, moderate alcohol consumption, and moderate sleep duration to achieve maximal CVD risk reduction (Strong Recommendation, High Quality
Evidence).
Values and preferences - Low risk lifestyle behaviours are variably defined as follows: a healthy body weight (BMI 18.5-25 to <30kg/m2
or waist
circumference of <88 cm for women or <95 to <102 cm for men), healthy diet (higher fruits & vegetables to Mediterranean dietary pattern), regular physical
activity (≥1 time/week to 40 min/day plus 1 hour/week of intense exercise), smoking cessation (never smoked to smoking cessation >12 months),
moderate alcohol consumption (≥12-14g/month to 46 g/day), and moderate sleep duration (6 to 8hours/night). Individuals can achieve benefits in a
dose-dependent manner.
We recognize that lifestyle changes are not easy to achieve, but real effort should be exerted to realize the potential benefit of
these non-pharmacological interventions.
CVD: cardiovascular disease.
24. Approach to Risk Management 21
Statin-indicated Conditions‡
•Clinical atherosclerosis
•Abdominal aortic aneurysm
•Most diabetes including:
•Age ≥40y
•Age ≥30y & 15y duration
(type 1 DM)
•Microvascular disease
•Chronic kidney disease
LDL-C ≥5mmol/L
(genetic dyslipidemia)
Primary Prevention Conditions
High Risk
FRS ≥20%
or
alternative
method
Intermediate Risk
FRS 10-19%
and
LDL-C ≥3.5 mmol/L
or
Non-HDL-C ≥4.3 mmol/L
or
ApoB ≥1.2 g/L
or
Men ≥50 and women ≥60 with one additional
risk factor: low HDL-C, impaired fasting
glucose, high waist circumference, smoker,
hypertension
RISK ASSESSMENT, STRATIFICATION & TREATMENT CONSIDERATION
Calculate risk (unless statin-indicated condition) using the Framingham Risk Score (FRS)† or Cardiovascular Life Expectancy Model (CLEM)†
HOW TO SCREEN
Men ≥40 years of age;
women ≥40 years of age
(or postmenopausal)
Consider earlier in ethnic groups at
increased risk such as South Asian
or First Nations individuals
For all:
•History and physical examination
•Standard lipid panel (TC, LDL-C, HDL-C, TG)
•Non-HDL-C (will be calculated from profile)
•Glucose
•eGFR
Optional:
•ApoB
•Urine albumin:creatinine ratio
(if eGFR <60 mL/min/1.73m2
, hypertension or diabetes)
NON-FASTING LIPID TESTING IS ACCEPTABLE
WHO TO SCREEN
All patients with the following conditions
regardless of age:
•Clinical evidence of atherosclerosis
•Abdominal aortic aneurysm
•Diabetes
•Arterial hypertension
•Current cigarette smoking
•Stigmata of dyslipidemia (arcus cornea,
xanthelasma or xanthoma)
•Family history of premature CVD*
•Family history of dyslipidemia
•Chronic kidney disease
•Obesity (BMI ≥30 kg/m2
)
•Inflammatory disease
•HIV infection
•Erectile dysfuntion
•Chronic obstructive pulmonary disease
•Hypertensive diseases of pregnancy
No Pharmacotherapy
Low Risk
FRS <10%
Repeat screening every 5 years for FRS <5% or every year for FRS ≥5%
Discuss behavioural modifications
25. Management
22
Ezetimibe as 1st line
(BAS as alternative)
Ezetimibe 1st line
(BAS as alternative)
PCSK9 inhibitors as 2nd line
(add on to other drugs)**
Ezetimibe (or BAS)
or PCSK9 inhibitors
risk factor: low HDL-C, impaired fasting
glucose, high waist circumference, smoker,
hypertension
NO
ADD-ON
Initiate Statin Treatment: Treat to Target Approach
Confirm adherence and barriers to use
*Men <55 and women <65 yrs of age in first degree relative.
†http://ccs.ca
‡Statins are first line therapy but add-on or alternative therapy may be required as per the algorithm.
II
Anderson et al. 2016 Update of the Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular
disease in the adult (publication pending).
¶Consider more aggressive targets for recent ACS patients.
**PCSK9 inhibitors have not been adequately studied as add-on to statins for patients with diabetes and other co-morbidities.
apoB: apolipoprotein B; BAS: bile acid sequestrants; BMI: body mass index; CVD: cardiovascular disease; HDL-C: high-density lipoprotein cholesterol; HIV:
human immunodeficiency virus; LDL-C: low-density lipoprotein cholesterol; PCSK9: proprotein convertase subtilisin kexin 9; TC: total cholesterol; TG:
triglycerides; Rx: prescription.
Health Behavioural
Modifications
• Smoking cessation
• Diet:
It is recommended all
individuals adopt a
health dietary pattern.ll
• Exercise:
It is recommended
adults should
accumulate at least
150 minutes per week
of moderate-vigorous
intensity aerobic
physical activity
Monitor
• Response to statin Rx
• Health behaviours
LDL-C >50%
reduction
LDL-C <2.0 mmol/L or >50% reduction or
apoB <0.8 g/L or non-HDL-C <2.6 mmol/L
Target achieved on maximally tolerated dose?
Discuss add-on therapy with patient:¶
Evaluate reduction in CVD risk vs. additional cost & side effects
NO NO
YES
NO ADD-ON
ADD-ONADD-ON
Add-on Therapy
Discuss behavioural modifications
26. Management
Follow-up and Referral to Specialist Clinics 23
Follow-up
• Most lipid lowering medications are well-tolerated
• Serum transaminases should be checked within first 3 months
• Creatine kinase can be checked if myalgias develop
• Routine testing of ALT or CK is not required thereafter
ALT: alanine aminotransferase; CK: creatine kinase.
Referral May be Warranted in the Following Cases
• Unexplained atherosclerosis
• Severe dyslipidemias
• Genetic lipoprotein disorders
• Patients refractory to pharmacological treatment
27. Update your Lipids iCCS app
iCCS replaces our individual guideline apps
and contains the most up-to-date
guideline information
Download the
iCCS App today
For more information visit CCS.CA/apps
28. DYSLIPIDEMIA
DYSLIPIDEMIA
Please visit us at
Printing of this pocket guide made possible through grants provided by
Amgen, Pfizer and Sanofi.
www.ccs.ca
Pocket Guide Print / Version Number: Lipids-2016-12-P1