Transcript 2009 Dyslipidemia Guidelines - Canadian Cardiovascular Society

2009 Guidelines for the
Diagnosis and Treatment of
Dyslipidemia and Prevention of
Cardiovascular Disease
2009 Dyslipidemia Guidelines
INTRODUCTION AND RATIONALE
Burden of Disease: Cardiovascular Disease in Canada
*Causes of death are coded to the 10th revision of the World Health Organization's
International Statistical Classification of Diseases and Related Health Problems (ICD-10).
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 and
management of CVD
• Despite these improvements, CVD remains a major societal
burden
Need for harmonization of CVD
prevention practices across Canada
CVD=Cardiovascular disease
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
Physicians (n=344)
Nurse Practioners (n=125)
6%
5%
94%
95%
No
Yes
No
Pharmacists (n=545)
Yes
Nurses (n=123)
22%
23%
77%
78%
No
Yes
No
Yes
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
100
250
Physicians (n=345)
216 (63%)
90
89 (71%)
80
200
70
60
150
50
95 (28%)
100
40
30
50
27 (22%)
20
13 (4%)
10 (3%)
9 (3%)
10
2 (1%)
0
4 (3%)
4 (3%)
2 (2%)
0
Yes I use these
I have adopted some No, I do not use these I am bound to adhere I use other Canadian These guidelines are
recommendations in but not all of the
guidelines
to current
or international lipid not relevant to my
my practice
guideline
institutional
guidelines
practice
recommendations
guidelines for lipidlowering medications
Yes I use these
I have adopted some I use other Canadian These guidelines are I am bound to adhere
recommendations in but not all of the or international lipid not relevant to my
to current
my practice
guideline
guidelines
practice
institutional
recommendations
guidelines for lipidlowering medications
No, I do not use
these guidelines
Nurses (n=100)
Pharmacists (n=457)
70
250
226 (49%)
60
200
50
150
40
125 (27%)
30
100
20
49 (11%)
50
30 (7%)
17 (4%)
10 (2%)
10
0
Yes I use these
I have adopted some
recommendations in but not all of the
my practice
guideline
recommendations
No, I do not use
these guidelines
These guidelines are I am bound to adhere I use other Canadian
not relevant to my
to current
or international lipid
practice
institutional
guidelines
guidelines for lipidlowering medications
0
Yes I use these
I have adopted some I am bound to adhere These guidelines are I use other Canadian
recommendations in but not all of the
to current
not relevant to my or international lipid
my practice
guideline
institutional
practice
guidelines
recommendations guidelines for lipidlowering medications
No, I do not use
these guidelines
2009 Dyslipidemia Guidelines
THE SCREENING PROCESS
Name
William D.
No.
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 ½ pack of cigarettes per day
•
Father suffered fatal MI at age 59
•
Mother has type 2 diabetes
2
0
6
0
0
Would you screen William’s plasma lipid profile?
Target Patients
• Men ≥40 years
• Women ≥50 years or postmenopausal
• Children with family history of hypercholesterolemia or
chylomicronemia
Target Patients Cont’d…
• Adults of any age with:
–
–
–
–
Hypertension
Diabetes
Current cigarette smoking
Overweight (BMI 27-30kg/m2) or
obesity (BMI >30kg/m2)
– Family history of premature CAD
(<60 years in first-degree
relatives)
– Inflammatory diseases*
(systemic lupus erythematosis,
rheumatoid arthritis, psoriasis)
– Evidence of atherosclerosis
– Chronic renal disease
(eGFR <60 mL/min/1.73m2)
– HIV infection treated with highly
active antiretroviral therapy
– Clinical manifestations of
hyperlipidemia (xanthomas,
xanthelasmas,
premature arcus cornealis)
– Erectile dysfunction
– Smoking
* Data on inflammatory bowel diseases are lacking.
BMI=body mass index; CAD=coronary artery disease; eGFR=estimated glomerular filtration rate
The Metabolic Syndrome (MetS)
• The MetS is an association of several metabolic
abnormalities 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
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
HDL-C=high-density lipoprotein cholesterol
>1.7 mmol/L
>130/85 mmHg or treatment
for hypertension
- Men <1.03 mmol/L
- Women <1.3 mmol/L
>5.6 mmol/L
2009 Dyslipidemia Guidelines
CARDIOVASCULAR RISK ASSESSMENT
Name
William D.
No.
CV Risk Assessment
• William’s 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 William’s CV Risk?
2
0
6
0
0
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
Special Considerations
If CVD present in
1st degree 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 for
risk stratification
CVD=Cardiovascular disease; hs-CRP=High-sensitivity C-reactive protein; LDL-C=Low density lipoprotein cholesterol
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 <3.5mmol/L
– Free of acute illness
• Baseline value
– Lower of two hs-CRP values, taken at two weeks apart
Not required for all patients
FRS=Framingham risk score; LDL-C=low density lipoprotein cholesterol; hsCRP=high-sensitivity C-reactive protein;
CVD=cardiovascular disease
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
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
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
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-density
lipoprotein cholesterol
Low Risk Level
Risk Score
• FRS <10%
• Careful family history may add risk factors → RRS may
re-classify low-risk patients
Overview of Treatment Recommendations
• Use clinical judgment and proper timing for initiation of
pharmacological lipid-lowering therapy
FRS=Framinham risk score; RRS= Reynolds risk score
2009 Dyslipidemia Guidelines
RECOMMENDED APPROACH TO
TREATMENT
Name
William D.
No.
Approach to Treatment
• According to the guidelines William's CV
risk is moderate
Would you treat William for dyslipidemia?
If yes, how?
Health behaviour/lifestyle?
Pharmacotherapy?
What are your treatment targets for William?
2
0
6
0
0
Targets of Therapy
Risk Level
Initiate Treatment if:
High
FRS, RRS ≥20%
Most patients with diabetes
CAD, PVD, atherosclerosis*
• Consider treatment in all
patients
Moderate
FRS 10-19%
• LDL-C >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)
Alternate
apoB <0.80 g/L
• LDL-C ≥5 mmol/L
≥50% ↓ LDL-C
Low
FRS <10%
Primary Target (LDL-C)
2 mmo/L or
≥50% ↓ LDL-C
Alternate
apoB <0.80 g/L
2 mmo/L or
≥50% ↓ LDL-C
* Atherosclerosis in any vascular bed, including carotid arteries.
apoB=apolipoprotein B level; CAD=coronary artery disease; FRS=Framingham risk score; HDL-C=high-density
lipoprotein cholesterol; hs-CRP=high-sensitivity C-reactive protein; PVD=peripheral vascular disease; RRS=Reynolds
Risk Score; TC=total cholesterol
Secondary Targets of Therapy (once LDL-C is at goal)
TC to HDL-C ratio
• <4.0
Non-HDL C*
• <3.5 mmol/L
Triglycerides
• <1.7 mmol/L
apoB to apoAI ratio
• <0.80
hs-CRP
• 2 mg/L
TC=Total cholesterol; HDL-C=High-density lipoprotein cholesterol ; LDL-C=low-density lipoprotein cholesterol ;
apoAI/B=apolipoprotein AI/B;evel; hsCRP= high-sensitivity C-reactive protein
Residual Risk
• Clinical data suggests patients achieving secondary targets
have 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
Health Behaviour and Lifestyle Changes
Smoking
Cessation
• Referral to
smoking
cessation
program
• Behavioural
counseling
• Nicotine
replacement
therapy
BMI=Body mass index
Diet
• Low sodium and
simple sugars
• Substitute
unsaturated fats
for saturated
trans fats
• Increase intake
of fruits,
vegetables and
fiber
• Moderate
alcohol intake →
1 drink/day for
women, 2
drinks/day for
men
Exercise and
Weight
Management
• Caloric
restriction
• Daily exercise
• BMI <25 kg/m2
(<23 kg/m2 for
Asian, Chinese,
and Japanese)
Psychological
Factors
• Stress
management
What Works…
Smoking Cessation
•
•
•
•
•
Address the issue clearly
Provide counseling, repetition
Offer medical options
Review aids and programs
Be supportive and nonjudgmental (respect patient’s
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
What Works…
Weight Management
Physical Activity
Provide realistic dietary options
Encourage physical activity
Establish multi-disciplinary team
Consider behavior modification
(i.e. motivational enhancement)
• Assess readiness and barriers to
change
• Recommend 30-60 min of
moderate activity every day of
the week → slow start, gradual
increase in frequency, duration,
consistency
• Consider exercise prescriptions
•
•
•
•
Lifestyle intervention is cornerstone therapy
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 caution
when implementing lipid-lowering therapy
CV=cardiovascular; LDL-C=low-density lipoprotein cholesterol
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
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
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 and
help achieve TC/HDL-C ratio
target in patients with
moderate hypertriglyceridemia
CVD=cardiocascular disease; HDL-C=high-density lipoprotein cholesterol; TC=total cholesterol
Safety and Monitoring
Statins
Niacin
• Well-tolerated
• May elevate ALT and/or
• Most common sideblood glucose levels
effects:
• Extended-release niacin is
- Myopathy
better tolerated
- GI distress
• ASA 325 mg 30-60 min
• Semi-annual liver enzyme
before niacin attenuates
monitoring recommended flushing
• Small risk of
hepatotoxicity
• Monitor uric acid levels
• Semi-annual follow-up
recommended
ALT=alanine aminotransferase; ASA=acetylsalicylic acid (aspirin)
Fibrates
• May cause reversible
increases in plasma
creatinine
• Monitor renal function
and lipid parameters →
avoid in renal insufficiency
or dose adjust
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
Name
William D.
No.
Treatment Outcomes
• Patient has moderate 10-year risk for CVD
• Patient was started on a statin therapy,
and provided with lifestyle
recommendations
including smoking cessation
• After one month of treatment, his lipids
were within target and he had stopped
smoking
2
0
6
0
0
Framingham Risk Score
Risk Factor
Risk Points
Men
Points
Total Points
Age
10-Year CVD Risk (%)
Men
Women
-3 or less
<1
<1
Women
30-34
0
0
-2
1.1
<1
35-39
2
2
-1
1.4
1.0
40-44
5
4
0
1.6
1.2
45-49
7
5
1
1.9
1.5
50-54
8
7
2
2.3
1.7
55-59
10
8
3
2.8
2.0
60-64
11
9
4
3.3
2.4
65-69
13
10
5
3.9
2.8
70-74
14
11
6
4.7
3.3
75+
15
12
7
5.6
3.9
8
6.7
4.5
HDL-C (mmol/L)
>1.6
-2
-2
9
7.9
5.3
1.3-1.6
-1
-1
10
9.4
6.3
1.2-1.3
0
0
11
11.2
7.3
0.9-1.2
1
1
12
13.3
8.6
<0.9
2
2
13
15.6
10.0
14
18.4
11.7
<4.1
0
0
15
21.6
13.7
4.1-5.2
1
1
16
25.3
15.9
5.2-6.2
2
3
17
29.4
18.51
6.2-7.2
3
4
18
>30
21.5
>7.2
4
5
19
>30
24.8
20
>30
27.5
21+
>30
>30
Total Cholesterol
Not
Treated
Not
Treated
Treated
Treated
<120
-2
0
-3
-1
120-129
130-139
0
2
0
2
1
3
1
3
140-149
2
4
2
5
150-159
2
4
4
6
160+
3
5
5
7
Systolic Blood
Pressure (mmHg)
Diabetes
Yes
3
4
No
0
0
Yes
4
3
No
0
0
Smoker
Total Points
Double cardiovascular disease risk percentage if any
cardiovascular disease is present in a first-degree relative
before 60 years of age.
In men older than 50 years and women older than 60
years of age, of intermediate risk whose LDL-C is
<3.5mmol/L, hs-CRP can be used for risk stratification →
the lower of 2 values taken 2 weeks apart, when free of
acute illness, is the baseline value.
Legend
Relative
risk
Low
Moderate
Very High