Dyslipidemia Guidelines Presentation v2

8/22/2019 Dyslipidemia Guidelines Presentation v2

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2009 Guidelines for the

Diagnosis and Treatment of

Dyslipidemia and Prevention ofCardiovascular Disease


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INTRODUCTION AND RATIONALE2009 Dyslipidemia Guidelines


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Burden of Disease: Cardiovascular Disease in Canada

*Causes of death are coded to the 10th revision of the World Health Organization'sInternational Statistical Classification of Diseases and Related Health Problems (ICD-10).


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A Look at Canada

In the last decade 40% in mortality from CVD

Improvements in control of CVD risk factors and medical

management of patients with CVD

New clinical data available may enhance prevention andmanagement of CVD

Despite these improvements, CVD remains a major societal

burden

Need for harmonization of CVD

prevention practices across Canada

CVD=Cardiovascular disease


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22%

78%

Nurses (n=123)

No Yes

6%

94%

Physicians (n=344)

No Yes

5%

95%

Nurse Practioners (n=125)

No Yes

23%

77%

Pharmacists (n=545)

No Yes

Use of the

2009 CCS Dyslipidemia Guidelines

2011 Survey of Canadian Health Care Professionals asked if

they were aware of the 2009 CCS Dyslipidemia Guidelines


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Use of the

2009 CCS Dyslipidemia Guidelines

2011 Survey of Canadian Health Care Professionals asked if they use

the 2009 CCS Dyslipdemia Guidelines in their practice

216 (63%)

95 (28%)

13 (4%) 10 (3%) 9 (3%)2 (1%)

0

50

100

150

200

250

Yes I use these

recommendations in

my practice

I have adopted some

but not all of the

guideline

recommendations

No, I do not use these

guidelines

I am bound to adhere

to current

institutional

guidelines for lipid-

lowering medications

I use other Canadian

or international lipid

guidelines

These guidelines are

not relevant to my

practice

Physicians (n=345) 89 (71%)

27 (22%)

4 (3%) 4 (3%)2 (2%)

0

10

20

30

40

50

60

70

80

90

100

Yes I use these

recommendations in

my practice

I have adopted some

but not all of the

guideline

recommendations



guidelines


not relevant to my

practice


to current

institutional



No, I do not use

these guidelines

226 (49%)

125 (27%)

49 (11%)

30 (7%)

17 (4%)10 (2%)

0

50

100

150

200

250

Yes I use these

recommendations in

my practice

I have adopted some

but not all of the

guideline

recommendations

No, I do not use

these guidelines


not relevant to my

practice


to current

institutional


lowering m edications



guidelines

Pharmacists (n=457)

0

10

20

30

40

50

60

70

Yes I use these

recommendations in

my practice

I have adopted some

but not all of the

guideline

recommendations


to current

institutional




not relevant to my

practice



guidelines

No, I do not use

these guidelines

Nurses (n=100)


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THE SCREENING PROCESS2009 Dyslipidemia Guidelines


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No.Name

2

06

0

0

William D.

Dyslipidemia Screening

Male; bank manager; 38 years of age

Height: 180 cm (5 11)

Weight: 98.5 kg (217 lbs)

BMI: 30.3 kg/m2

Waist circumference: 97cm

Fasting glucose: 5.8 mmol/L

Blood pressure: 132/95 mmHg (not on any medication)

Smokes pack of cigarettes per day

Father suffered fatal MI at age 59

Mother has type 2 diabetes

Would you screen Williams plasma lipid profile?


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Target Patients

Men 40 years

Women 50 years or postmenopausal

Children with family history of hypercholesterolemia orchylomicronemia


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Target Patients Contd

Adults of any age with:

Hypertension

Diabetes

Current cigarette smoking

Overweight (BMI 27-30kg/m2) orobesity (BMI >30kg/m2)

Family history of premature CAD

(


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The Metabolic Syndrome (MetS)

The MetS is an association of several metabolicabnormalities including:

- Visceral adipose tissue mass (i.e. toxic waist)

- Dyslipidemia (elevated triglycerides and low HDL-C)

- Elevated blood pressure

- Elevated serum glucose

Individuals with the metabolic syndrome are

more likely to be at higher long-term cardiovascular

risk than estimated by the Framingham Risk Score

(FRS) alone.

HDL-C=high-density lipoprotein cholesterol


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International Diabetes Federation

Classification of the Metabolic Syndrome

Central Obesity (waist circumference criteria)*:

Europids

South Asians

Chinese

Japanese

Men 94 cm; women 80 cm




PLUS 2 of the following factors:

Plasma triglycerides

Blood pressure

HDL-C

Fasting plasma glucose

>1.7 mmol/L

>130/85 mmHg or treatmentfor hypertension

- Men


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CARDIOVASCULAR RISK ASSESSMENT2009 Dyslipidemia Guidelines


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No.Name

2

06

0

0

William D.

CV Risk Assessment

Williams lipid profile:

HDL-C: 1.0 mmol/L

LDL-C: 3.8 mmol/L

Total cholesterol: 5.3 mmol/L

Triglycerides: 2.2 mmol/L

TC/HDL-C: 5.3

FRS: 18.8%

How would you categorize Williams CV Risk?


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Risk Assessment

Risk assessment options Framingham Risk Score [FRS]

- Commonly preferred measures CVD (validated in

Canada*)

- May underestimate risk in some patients Reynolds Risk Score [RRS]

- Measures CVD optional risk engine (includes family

history and hsCRP)

Cardiovascular (CV) risk assessment remains imperfect

Total Cardiovascular Disease (CVD) Risk assessment

recommended

hsCRP=high-sensitivity C-reactive protein; CVD=cardiovascular disease*Validated with Cardiovascular Life Expectancy Model


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Special Considerations

If CVD present in

1stdegree relative

before 60 years

CVD Risk (by FRS) x 2

If male 50 or

female 60 years,

intermediate risk,LDL-C does not

suggest treatment

hs-CRP can be used forrisk stratification

CVD=Cardiovascular disease; hs-CRP=High-sensitivity C-reactive protein; LDL-C=Low density lipoprotein cholesterol


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Screening for High-Sensitivity C-reactive Protein (hsCRP)

Baseline criteria Men 50 years and women 60 years

Moderate risk for CVD (by FRS)

LDL-C is


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Testing for Atherosclerosis

Noninvasive assessment of atherosclerosis Ankle-brachial index

Exercise stress test

Carotid B mode ultrasonography

Coronary calcium score

Cardiac computed tomography (Electron beam computed

tomography [EBCT]); Multi-detector computed tomography

coronary angiography (MDCT-CA)

Atherosclerosis places the patient at HIGH RISK


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Short-term versus Long-term Risk

FRS estimates 10-year risk

Family history increases risk:

1.7-fold in women

2-fold in men Elevated hs-CRP may also modulate risk

Risk levels change over time

Reassess CVD risk every 3 years

FRS=Framingham risk score, hsCRP=high-sensitivity C-reactive protein; CVD=Cardiovascular disease


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High Risk Level

Target Demographic Diabetic adults >45 (men), >50 (women)

Documented evidence of atherosclerosis

Risk Score

FRS or RRS 20%

Overview of Treatment Recommendations

Provide intensive lifestyle modification advice

Pharmacological lowering of LDL-C

FRS= Framingham risk score; RRS=Reynolds Risk Score; LDL-C=low-density lipoprotein cholesterol


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Moderate Risk Level

Target Demographic Middle-aged Canadians

Risk Score

FRS 10-19% Family history and high hsCRP modulate risk RRS may be

useful

Overview of Treatment Recommendations Provide lifestyle modification advice

May require pharmacological lowering of LDL-C

FRS= Framingham risk score; RRS=Reynolds Risk Score; hsCRP= high-sensitivity C-reactive protein; LDL-C=low-densitylipoprotein cholesterol


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Low Risk Level

Risk Score FRS


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RECOMMENDED APPROACH TO

TREATMENT

2009 Dyslipidemia Guidelines


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No.Name

2

06

0

0

William D.

Approach to Treatment

According to the guidelines William's CVrisk is moderate

Would you treat William for dyslipidemia?

If yes, how?

Health behaviour/lifestyle?Pharmacotherapy?

What are your treatment targets for William?


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Targets of Therapy

Risk Level Initiate Treatment if: Primary Target (LDL-C)

HighFRS, RRS 20%

Most patients with diabetes

CAD, PVD, atherosclerosis*

Consider treatment in all

patients

2 mmo/L or

50% LDL-C

Alternate

apoB 3.5mmol/L

TC/HDL-C >5.0

hs-CRP >2mg/L

in men >50 years,

women >60 years

Family history and

hs-CRP modulates risk(RRS)

2 mmo/L or

50% LDL-C

Alternate

apoB


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Secondary Targets of Therapy (once LDL-C is at goal)


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Residual Risk

Clinical data suggests patients achieving secondary targetshave better outcomes

Therapeutic options may include:

- Fibrates lower triglycerides,

- Niacin increase HDL-C,- Increase statins and/or,

- Add cholesterol absorption inhibitors (i.e. ezetimibe*) to

further lower LDL-C, apo B and hsCRP

Must be clinically tested with CV outcome data

HDL-C=High-density lipoprotein cholesterol ; LDL-C=low-density lipoprotein cholesterol ; apoB=apolipoprotein B;

hsCRP= high-sensitivity C-reactive protein; CV=Cardiovascular*No outcome data available


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Health Behaviour and Lifestyle Changes

SmokingCessation

Referral tosmokingcessation

program Behaviouralcounseling

Nicotinereplacementtherapy

Diet

Low sodium andsimple sugars

Substitute

unsaturated fatsfor saturatedtrans fats

Increase intakeof fruits,vegetables andfiber

Moderatealcohol intake 1 drink/day forwomen, 2drinks/day formen

Exercise andWeight

Management

Caloricrestriction

Daily exercise

BMI


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What Works

Smoking Cessation

Address the issue clearly

Provide counseling, repetition

Offer medical options

Review aids and programs

Be supportive and non-

judgmental (respect patients

choice)

Consider what motivates

patient (family, reasons,

concerns)

Alcohol Intake

Men: 2 drinks per day, not more

than 14/week

Women : 1 drink a day, not more

than 9 drinks/week Should not be saved up to be

had all at once!

Lifestyle intervention is cornerstone therapy


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What Works

Physical Activity

Recommend 30-60 min of

moderate activity every day of

the week slow start, gradual

increase in frequency, duration,

consistency

Consider exercise prescriptions

Weight Management

Provide realistic dietary options

Encourage physical activity

Establish multi-disciplinary team

Consider behavior modification(i.e. motivational enhancement)

Assess readiness and barriers to

change

Lifestyle intervention is cornerstone therapy


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Lipid-Lowering Pharmacotherapy

Rationale Meta-analysis of statin trials show:

1.0 mmol/L decrease in LDL-C 20% to 25% RR reduction

Intensive LDL-C lowering therapy is associated with

decreased CV risk

Clinicians must exercise expert judgment and cautionwhen implementing lipid-lowering therapy

CV=cardiovascular; LDL-C=low-density lipoprotein cholesterol


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Overview of Lipid-Lowering Medications

Statins: Lower LDL-C

Bile Acid and/or Cholesterol absorption inhibitors:

May lower LDL-C

Fibrates:

May lower triglycerides, prevent pancreatitis in patients with

extreme hypertriglyceridemia (>10 mmol/L)

Niacin:

May raise HDL-C, lower LDL-C

LDL-C=low-density lipoprotein cholesterol, HDL-C=High-density lipoprotein cholesterol


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Recommendations for Treatment

LDL-C Most patients will achieve target

LDL-C levels on statin

monotherapy

Ezetimibe, cholestyramine or

colestipol, niacin may be

required in a minority of cases

In high-risk individuals, treatment

should be started immediately

HDL-C Low HDL-C may pose no risk,

depending on genetic type

Medications may not increase

HDL-C to a clinically significant

extent

Health behaviour interventions

increase HDL-C

LDL-C=low-density lipoprotein cholesterol ; HDL-C=high-density lipoprotein cholesterol


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Recommendations for Treatment

Triglycerides No specific target level for

high-risk

Lower triglyceride levels are

associated with decreased CVD

risk

Health behaviour interventions

are first-line

Fibrates may prevent pancreatitis

in patients with extreme

hypertriglyceridemia (>10

mmol/L)

Combination Therapy Statin with niacin

- For combined dyslipidemia and

low HDL-C

Statin with a fibrate

- Close patient follow-up

required

Statin with omega-3 fatty acids

- May lower triglycerides andhelp achieve TC/HDL-C ratio

target in patients with

moderate hypertriglyceridemia

CVD=cardiocascular disease; HDL-C=high-density lipoprotein cholesterol; TC=total cholesterol


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Safety and Monitoring

Statins Niacin Fibrates

Well-tolerated

Most common side-

effects:

- Myopathy

- GI distress

Semi-annual liver enzyme

monitoring recommended

May elevate ALT and/or

blood glucose levels

Extended-release niacin is

better tolerated

ASA 325 mg 30-60 min

before niacin attenuates

flushing

Small risk of

hepatotoxicity

Monitor uric acid levelsSemi-annual follow-up

recommended

May cause reversible

increases in plasma

creatinine

Monitor renal function

and lipid parameters

avoid in renal insufficiency

or dose adjust

ALT=alanine aminotransferase; ASA=acetylsalicylic acid (aspirin)


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Referral and Advanced Testing

Referral may be warranted in the following cases: Drug intolerance or lack of response to therapy

Complex diagnostic cases

Lack of laboratory resources

Unexplained atherosclerosis

Extremes of lipoprotein disorders Genetic testing required


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No.Name

2

060

0

Patient has moderate 10-year risk for CVD

Patient was started on a statin therapy,and provided with lifestylerecommendationsincluding smoking cessation

After one month of treatment, his lipidswere within target and he had stoppedsmoking

Treatment Outcomes

William D.


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Framingham Risk ScoreRisk Factor Risk Points Points

M en Wo m en

Age

30-34 0 0

35-39 2 2

40-44 5 4

45-49 7 5

50-54 8 7

55-59 10 8

60-64 11 9

65-69 13 10

70-74 14 11

75+ 15 12

HDL-C (mmol/L)

>1.6 -2 -2

1.3-1.6 -1 -1

1.2-1.3 0 0

0.9-1.2 1 1

30

Double cardiovascular disease risk percentage ifanycardiovascular disease is present in a first-degree relative

before 60 years of age.

In men older than 50 years and women older than 60years of age, of interme diate risk whose LDL-C is

Dyslipidemia Guidelines Presentation v2

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