2009 guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular...

2009 Guidelines for the Diagnosis and Treatment of Dyslipidemia and

Prevention of Cardiovascular Disease

INTRODUCTION AND RATIONALE2009 Dyslipidemia Guidelines

*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).

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

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

2011 Survey of Canadian Health Care Professionals asked if they were aware of the 2009 CCS Dyslipidemia Guidelines

2011 Survey of Canadian Health Care Professionals asked if they usethe 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


my practice




guidelines


practice





226 (49%)

125 (27%)

49 (11%)

30 (7%)17 (4%)

10 (2%)

0

50

100

150

200

250


my practice





practice





guidelines

Pharmacists (n=457)

0

10

20

30

40

50

60

70


my practice







practice


guidelines


Nurses (n=100)

THE SCREENING PROCESS2009 Dyslipidemia Guidelines

No.Name

20600

William D.

Dyslipidemia ScreeningDyslipidemia 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

Would you screen William’s plasma lipid profile?Would you screen William’s plasma lipid profile?

• Men ≥40 years

• Women ≥50 years or postmenopausal

• Children with family history of hypercholesterolemia or chylomicronemia

• 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 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

Central Obesity (waist circumference criteria)*:

• Europids • South Asians• Chinese • Japanese

Men ≥94 cm; women ≥80 cm Men ≥90 cm; women ≥80 cmMen ≥90 cm; women ≥80 cmMen ≥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 treatment for hypertension-Men <1.03 mmol/L-Women <1.3 mmol/L>5.6 mmol/L

HDL-C=high-density lipoprotein cholesterol

CARDIOVASCULAR RISK ASSESSMENT 2009 Dyslipidemia Guidelines

No.Name

20600

William D.

CV Risk AssessmentCV 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?How would you categorize William’s CV Risk?

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

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

• 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

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

• 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

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

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

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

RECOMMENDED APPROACH TO TREATMENT

2009 Dyslipidemia Guidelines

No.Name

20600

William D.

Approach to TreatmentApproach to Treatment

• According to the guidelines William's CV risk is moderate

Would you treat William for dyslipidemia?Would you treat William for dyslipidemia?

If yes, how?If yes, how?

Health behaviour/lifestyle?Health behaviour/lifestyle?

Pharmacotherapy?Pharmacotherapy?

What are your treatment targets for William?What are your treatment targets for William?

* 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

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

• 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

BMI=Body mass index

Smoking Cessation• Address the issue clearly• Provide counseling, repetition• Offer medical options• Review aids and programs• Be supportive and non-

judgmental (respect patient’s choice)

• Consider what motivates patient (family, reasons, concerns)

Smoking Cessation• Address the issue clearly• Provide counseling, repetition• Offer medical options• Review aids and programs• Be supportive and non-

judgmental (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!

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 Lifestyle intervention is cornerstone therapy

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

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

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 Lifestyle intervention is cornerstone therapy

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

• 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

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

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

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 levels• Semi-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)

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

No.Name

20600

• Patient has moderate 10-year risk for CVD

• Patient was started on a statin therapy, and provided with lifestyle recommendationsincluding smoking cessation

• After one month of treatment, his lipids were within target and he had stopped smoking

Treatment OutcomesTreatment Outcomes

William D.

Risk Factor Risk Points Points

Men Women

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

<0.9 2 2

Total Cholesterol

<4.1 0 0

4.1-5.2 1 1

5.2-6.2 2 3

6.2-7.2 3 4

>7.2 4 5

Systolic BloodPressure (mmHg)

NotTreated

TreatedNot

TreatedTreated

<120 -2 0 -3 -1

120-129 0 2 0 2

130-139 1 3 1 3

140-149 2 4 2 5

150-159 2 4 4 6

160+ 3 5 5 7

Diabetes

Yes 3 4

No 0 0

Smoker

Yes 4 3

No 0 0

Total Points

Total Points 10-Year CVD Risk (%)

Men Women

-3 or less <1 <1

-2 1.1 <1

-1 1.4 1.0

0 1.6 1.2

1 1.9 1.5

2 2.3 1.7

3 2.8 2.0

4 3.3 2.4

5 3.9 2.8

6 4.7 3.3

7 5.6 3.9

8 6.7 4.5

9 7.9 5.3

10 9.4 6.3

11 11.2 7.3

12 13.3 8.6

13 15.6 10.0

14 18.4 11.7

15 21.6 13.7

16 25.3 15.9

17 29.4 18.51

18 >30 21.5

19 >30 24.8

20 >30 27.5

21+ >30 >30

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

Relativerisk

Low

Moderate

Very High

2009 guidelines for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular...

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