Transcript FF Slide Template

Goals & Guidelines
A summary of international
guidelines for CHD
International guidelines: summary
• Guidelines developed for the prevention of CHD
• Based on major clinical trial evidence
• Help assess and assist in the management of
patients at risk of CHD
Risk Category
NCEP
LDL-C goal
European
LDL-C goal
CHD or CHD risk
equivalents
(10-year risk >20%)
100mg/dl
(2.6mmol/l)
115mg/dl
(3.0mmol/l)
2+ risk factors
(10-year risk 20%)
<130mg/dl
(3.4mmol/l)
115mg/dl
(3.0mmol/l)
Reference: National Cholesterol Education Program. JAMA 2001; 285: 2486-97; Wood D et al. EHJ
1998; 19: 1434-1503.
NCEP guidelines
LDL-C Goals and Cutpoints for Therapeutic
Lifestyle Changes (TLC) and Drug Therapy
Risk Category
LDL-C Goal
(mg/dL)
LDL-C Level at which
to Initiate Therapeutic
Lifestyle Changes
(TLC) (mg/dL)
LDL-C Level at which
to Consider
Drug Therapy
(mg/dL)
CHD or CHD Risk
Equivalents
(10-year risk >20%)
<100
100
130
(100–129: drug
optional)
2+ Risk Factors
(10-year risk 20%)
<130
130
10-year risk 10–
20%: 130
10-year risk <10%:
160
0–1 Risk Factor
<160
160
190
(160–189: LDL-C
lowering drug
optional)
NCEP guidelines
LDL-C Lowering Therapy in Patients with CHD
and CHD Risk Equivalents
• Baseline LDL-C 130 mg/dL
–
Intensive lifestyle therapies
–
Maximal control of other risk factors
–
Consider starting LDL-C lowering drugs simultaneously with lifestyle
therapies
• Baseline (or On-Treatment) LDL-C 100–129 mg/dL
–
–
–
LDL-C lowering therapy
• Initiate or intensify lifestyle therapies and/or LDL-C lowering
drugs
Treatment of metabolic syndrome
• Emphasise weight reduction and increased physical activity
Drug therapy for other lipid risk factors
• Baseline LDL-C: <100 mg/dL
–
–
–
Further LDL-C lowering not required
Therapeutic Lifestyle Changes (TLC) recommended
Consider treatment of other lipid risk factors (raised TG, low HDL-C)
NCEP guidelines
LDL-C Lowering Therapy in Patients With 2+ Risk
Factors and 10-Year Risk £20%
• 10-Year Risk 10–20%
–
–
–
–
LDL-C goal <130 mg/dL
Aim: reduce both short-term and long-term risk
Immediate initiation of Therapeutic Lifestyle Changes
(TLC) if LDL-C is 130 mg/dL
Consider drug therapy if LDL-C is 130 mg/dL after 3
months of lifestyle therapies
• 10-Year Risk <10%
–
LDL-C goal: <130 mg/dL
–
Therapeutic aim: reduce long-term risk
–
Initiate therapeutic lifestyle changes if LDL-C is 130
mg/dL
–
Consider drug therapy if LDL-C is 160 mg/dL after 3
months of lifestyle therapies
NCEP guidelines
LDL-Lowering Therapy in Patients With 0–1 Risk Factor
•
•
•
•
Most persons have 10-year risk <10%
Therapeutic goal: reduce long-term risk
LDL-C goal: <160 mg/dL
Initiate therapeutic lifestyle changes if LDL-C is 160
mg/dL
• If LDL-C is 190 mg/dL after 3 months of lifestyle
therapies, consider drug therapy
• If LDL-C is 160–189 mg/dL after 3 months of lifestyle
therapies, drug therapy is optional
Canadian guidelines
Target lipid values by level of risk
Level of risk
(definition)
Very high*
LDL-C level
mmol/L
TC:HDL-C
ratio
Triglyceride level
mmol/L
<2.5
<4
<2.0
<3.0
<5
<2.0
<4.0
<6
<2.0
<5.0
<7
<3.0
(10-year risk of CAD
> 30%, or history of CVD
or diabetes)
High*
(10-year risk 20%-30%)
Moderate†
(10-year risk 10%-20%)
Low‡
(10-year risk<10%)
*Start medication and lifestyle changes concomitantly if values are above target values
†Start medication if target values are not achieved after 3 months of lifestyle modification
‡Start medication if target values are not achieved after 6 months of lifestyle modification
Recommendations for the management and treatment of dyslipidemias
CMAJ 2000; 162 (10):1441-7
European guidelines
• Prioritisation
– Absolute risk
– 10 year risk
• Age
– 30-74 years
• Goals for primary and secondary prevention of CHD:
– Lifestyle
• Stop smoking
• Make healthy food choices
• Be physically active
– Other risk factors
•
•
•
•
Blood pressure <140/90mmHg
TC <5.0mmol/L (190mg/dL)
LDL-C <3.0mmol/L (115mg/dL)
Good glucose control in diabetes
• To be achieved with changes in lifestyle and, if needed, by
drug treatment
European guidelines
• Use coronary risk chart to estimate a
person’s absolute 10-year risk of a CHD
event
• High risk: 10 year risk exceeds 20% or will
exceed 20% if projected to age 60 years
• CHD risk is higher than the charts indicate
for those with:
– FH, diabetes, family history of premature CVD,
low HDL-C (<1.0mmol/L), raised triglycerides
(>2.0mmol/L) or approaching next age category
European guidelines
European guidelines
Primary prevention guide to lipid management
Estimate absolute CHD risk* using the Coronary Risk Chart
Use initial total cholesterol to estimate coronary risk
Absolute coronary risk <20%
TC > 5.0mmol/L (190mg/dL)
Lifestyle advice with the goal of
reducing
TC<5.0mmol/L (190mg/dL) and
LDL-C <3.0mmol/L (115mg/dL)
Follow-up at a minimum of 5year intervals
Absolute risk > 20%
Measure fasting lipids:
TC, HDL-C, triglycerides and calculate
LDL-C cholesterol
Lifestyle advice for at least 3 months with
repeat lipid measurements
TC <5.0mmol/L (190mg/dL)
and LDL-C <3.0mmol/L
(115mg/dL)
Maintain lifestyle advice with
annual follow-up
* High CHD risk >20% over 10 years or will
exceed 20% if projected age 60 years
TC >5.0mmol/L
(190mg/dL) and LDL-C
>3.0mmol/L (115mg/dL)
Maintain dietary advice with
drug therapy
Australian guidelines
Categorisation of Risk for Coronary Heart Disease (CHD)
Highest risk
High risk
Lower risk
• Existing coronary heart
disease and/or
• Existing extra coronary
vascular disease
At least one of the
following
• Diabetes
• Positive family history of
CHD
• Familial
hypercholesterolaemia
• Hypertension
• Smoking
• Others
(e.g.
overweight
physical
inactivity)
Australian guidelines
Assessment
Goal
Interview: Routinely ask about:
Dietary habits/familial
hyperlipidaemia
Lipid goals as per categorisation
of risk for coronary heart disease
Baseline fasting lipid profile for:
All adults > 18 yrs
Fasting lipid profile for CHD patients
EITHER
within 24 hours of the onset of MI
OR
6/52 post MI
For highest risk patients
TC
 < 4.5 mmol/l
LDL-C
 < 2.5 mmol/l
TG
 < 2.0 mmol/l
For high risk patients
TC
 < 5.0 mmol/l
LDL-C
 < 3.0 mmol/l
TG
 < 2.0 mmol/l
For lower risk population
TC
 < 6.0 mmol/l
LDL-C
 < 4.0 mmol/l
TG
 < 4.0 mmol/l
Australian guidelines
Intervention
Review
All hyperlipidaemic patients
Lifestyle: limit alcohol intake ±  physical activity ± weight
management].
Nutrition intervention: [as indicated below] ± referral to
dietitian ± referral to Heartline teleinfo service [see below].
For high risk  highest
risk patients:
Monitor diet fortnightly for
6/52, then retest at 68/52 until satisfactory and
stable response.
Ongoing follow-up for diet
and possible drug
intervention at 3-6/12.
Lipid lowering medication:
Be more aggressive in lowering lipids in those at highest
coronary risk. PBS regulations allow for drug therapy after
dietary mod. in:
• CHD patient, with total cholesterol (TC > 4.0 mmol/l;
• diabetes or familial hypercholesterolaemia or
hypertension or
family history CHD or PVD, with TC > 6.5 mmol/l; or
with HDL
< 1.0 mmol/l and TC > 5.5 mmol/l.
Statins: Consider as possible first line management.
General population:
Lipids at least every 5
years – including risk
factor assessment.
Issues with guidelines
• Goals are not reached resulting in the
undertreatment of patients
• Guidelines are not implemented
resulting in untreated patients
Goals not reached
• Evidence shows that patients are failing to
reach the goals set in guidelines
• 62% of patients failing to reach their goal*
• NHANES data show that 82% of CHD patients
are not meeting target LDL-C level*
• Only 49% of patients with CHD reach total
cholesterol targets (EUROASPIRE)
References: Pearson TA et al. Arch Intern Med 2000; 160: 458-67;
Hoerger TJ et al. Am J Cardiol; 82: 61-5; EUROASPIRE. EHJ 2001; 22: 54-72.
*relates to NCEP II ATP goals