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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
I use other Canadian
or international lipid
guidelines
These guidelines are
not relevant to my
practice
I am bound to adhere
to current
institutional
guidelines for lipid-
lowering medications
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
These guidelines are
not relevant to my
practice
I am bound to adhere
to current
institutional
guidelines for lipid-
lowering m edications
I use other Canadian
or international lipid
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
I am bound to adhere
to current
institutional
guidelines for lipid-
lowering medications
These guidelines are
not relevant to my
practice
I use other Canadian
or international lipid
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
Men 90 cm; women 80 cm
Men 90 cm; women 80 cm
Men 90 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
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