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NEW LIPID GUIDELINES:WHAT HAS CHANGED?

NEW LIPID GUIDELINES:WHAT HAS CHANGED?. ASSOC.PROF.DR. OKAN GULEL ONDOKUZ MAYIS UNIVERSITY FACULTY OF MEDICINE CARDIOLOGY DEPARTMENT SAMSUN, TURKEY. Novel / Important Aspects-1.

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NEW LIPID GUIDELINES:WHAT HAS CHANGED?

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  1. NEW LIPID GUIDELINES:WHAT HAS CHANGED? ASSOC.PROF.DR. OKAN GULELONDOKUZ MAYIS UNIVERSITYFACULTY OF MEDICINECARDIOLOGY DEPARTMENTSAMSUN, TURKEY

  2. Novel/Important Aspects-1 Treatment of dyslipidemiashould not be considered as an isolatedprocess, but ratherwithinthecontext of integratedprevention of cardiovasculardisease in eachpatient→the SCORE system Anguita M, et al. Rev Esp Cardiol. 2011 Dec;64(12):1090-5.

  3. SCORE Scale • Thepreferenceforthe SCORE systemoverother risk scales is based on thefactthat it wasdesignedandevaluatedusingrepresentativeEuropeancohorts. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  4. SCORE Scale • The SCORE scaleallowsforestimatingthe 10-year risk of thefirstfatalatheroscleroticcomplicationbased on thefollowing risk factors: • Age • Gender • Smoking • Systolicbloodpressure • Total cholesterol ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  5. SCORE Scale • Chartsforhighandlow risk regions in Europe. • Thelow risk charts→inBelgium, Germany, Finland, France, Greece, Italy, Spain, Denmark, TheNetherlands, United Kingdom, Sweden, Norway, Iceland, Ireland, Austria, Malta, Portugal, Slovenia, Monaco, San Marino. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  6. SCORE Scale • Thehigh risk charts→inBulgaria, Macedonia, Russia, Moldova, Ukraine, Belarus, Latvia. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  7. SCORE Scale • SCORE database has shownthat HDL-C modifies risk at alllevels of risk as estimatedfromthe SCORE cholesterolcharts. • Risk will be higherthanindicated in thecharts in individualswithlow HDL-C. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  8. SCORE Scale Risk willalso be higherthanindicated in thecharts in; *Sociallydeprivedindividuals *Sedentarysubjectsandthosewithcentralobesity *Individualswithdiabetes *Individualswithlowapo A1, increasedtriglyceride, fibrinogen, homocysteine, apo B, andlipoprotein(a) levels, familialhypercholesterolaemia, orincreasedhs-CRP *Asymptomaticindividualswithpreclinicalevidence of atherosclerosis *Thosewithimpairedrenalfunction *Thosewith a familyhistory of premature CVD ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  9. SCORE Scale • A particular problem relatestoyoungpeoplewithhighlevels of risk factors. • Althoughtheabsolute SCORE risk can be low in youngpatients, ifseveral risk factorsarepresent, therelative risk will be high. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  10. Risk Levels • Very High Risk: • A calculated SCORE ≥10% • Documented CVD byinvasiveornon-invasivetesting • Type 2 diabetes, type 1 diabeteswithtarget organ damage • Moderateto severe CKD ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  11. Risk Levels • High Risk: • A calculated SCORE ≥5 to <10% • Markedlyelevatedsingle risk factors • Moderate Risk: • A calculated SCORE ≥1 to <5% • Low Risk: • A calculated SCORE <1% ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  12. InterventionStrategies ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  13. Novel/Important Aspects-2 Recommendationsforlipidanalysis as treatmenttargets in theprevention of CVD andstrengthening of strict LDL cholesteroltargetsforpatientswithveryhigh, high, andintermediate risk levels Anguita M, et al. Rev Esp Cardiol. 2011 Dec;64(12):1090-5.

  14. TreatmentTargets LDL-C→recommended as targetfortx(class I A) TC→considered as txtargetifotheranalysesare not available (classIIa A) TG→analysedduringthetx of dyslipidaemiaswithhigh TG levels (classIIa B) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  15. TreatmentTargets Non-HDL-C→considered as a secondarytxtarget (classIIa B) ApoB→considered as a secondarytxtarget (classIIa B) HDL-C ortheratios→notrecommended as targetsfortx (class III C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  16. TreatmentTargetsfor LDL-C In patients at VERY HIGH CV risk→the LDL-C goal is <1.8 mmol/L (<~70 mg/dL) and/or ≥50% LDL-C reduction when target level can not be reached (class I A) In patients at HIGH CV risk→the LDL-C goal <2.5 mmol/L (<~100 mg/dL) should be considered (class IIa A) In patients at MODERATE CV risk→the LDL-C goal <3.0 mmol/L (<~115 mg/dL) should be considered (class IIa C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  17. TreatmentTargetsOtherThan LDL-C If non-HDL-C is used, the targets should be; <2.6 mmol/L (<~100 mg/dL) in those at VERY HIGH CV risk and <3.3 mmol/L (<~130 mg/dL) in those at HIGH CV risk (class IIa B) If apo B is available, the targets are; <80 mg/dL in those at VERY HIGH CV risk and <100 mg/dL in those at HIGH CV risk (class IIa B) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  18. Novel/Important Aspects-3 Choice of lipid-lowering drugs in the management of dyslipidaemias Anguita M, et al. Rev Esp Cardiol. 2011 Dec;64(12):1090-5.

  19. PharmacologicalTreatment of Hypercholesterolaemia Statin→prescribeuptothehighestrecommendeddoseorhighesttolerabledosetoreachthetargetlevel (class I A) Statinintolerance→bileacidsequestrantsornicotinicacid (classIIa B) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  20. PharmacologicalTreatment of Hypercholesterolaemia Statin intolerance→a cholesterol absorption inhibitor, alone or in combination with bile acid sequestrants or nicotinic acid (class IIb C) Target level is not reached→statin combination with a cholesterol absorption inhibitor or bile acid sequestrants or nicotinic acid (class IIb C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  21. PharmacologicalTreatment of Hypertriglyceridaemia ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  22. DrugsAffecting HDL-C • Nicotinicacid→themostefficientdrugtoraise HDL-C andshould be considered (classIIa A) • Statinsandfibrates→raise HDL-C withsimilarmagnitudeandmay be considered (classIIb B) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  23. Drug Combinations for the Management of MixedDyslipidaemias ↑ in HDL-C and ↓ in TG on top of ↓ in LDL-C can be achieved by statins. Statin+nicotinic acid→the adverse effect of flushing may affect compliance Statin+fibrate→monitor for myopathy; combination with gemfibrozil should be avoided TG are not controlled by statins or fibrates→n-3 fatty acids to decrease TG further ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  24. Novel/Important Aspects-4 Detailed description of treatment targets and prescriptions in special clinical situations Anguita M, et al. Rev Esp Cardiol. 2011 Dec;64(12):1090-5.

  25. Management of Dyslipidaemiasin DifferentClinicalSettings • Familialdyslipidaemias • Children • Women • Theelderly • Metabolicsyndromeanddiabetesmellitus • Patientswithacutecoronarysyndromeandpatientsundergoingpercutaneouscoronaryintervention • Heartfailureandvalvulardisease • Autoimmunediseases • Renaldisease • Transplantationpatients • Peripheralarterialdisease • Stroke • Human immunodeficiencyviruspatients ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  26. DiabetesMellitus Type 1 DM and in the presence of microalbuminuriaandrenaldisease LDL-C lowering (at least 30%) withstatins as thefirstchoice (eventuallydrugcombination) irrespective of thebasal LDL-C concentration (class I C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  27. DiabetesMellitus ●Type 2 DM+CVD or CKD ●Type 2 DM withoutCVD+age>40 years+≥1 other CVD risk factorsormarkers of target organ damage ●Primarygoalfor LDL-C is <1.8 mmol/L (<~70 mg/dL) ●Secondarygoalfornon-HDL-C is <2.6 mmol/L (~<100 mg/dL) andforapo B is <80 mg/dL (class I B) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  28. DiabetesMellitus Type 2 DM ●LDL-C <2.5 mmol/L (<~100 mg/dL) is theprimarytarget ●Non-HDL-C <3.3 mmol/L (<~130 mg/dL) andapo B <100 mg/dLarethesecondarytargets (class I B) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  29. Moderateto Severe ChronicKidneyDisease • Primarytarget of therapy→LDL-Creduction • LDL-C lowering ↓ CVD risk in CKD patients • Statins→slowthe rate of kidneyfxlossmodestlyandthusprotectagainstthedevelopment of ESRD requiringdialysis (classIIa C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  30. Moderateto Severe ChronicKidneyDisease • Statins→beneficialeffect on pathologicalproteinuria (>300 mg/day); considered in stage 2-4 CKD patients (classIIa B) • Statins (as monotherapyor in combinationwithotherdrugs)→consideredtoachieve LDL-C <1.8 mmol/L (<~70 mg/dL)(classIIa C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  31. FamilialHypercholesterolaemia • FH is suspected in subjectswith • CVD aged <50 years (♂) or <60 years (♀), • relativeswithpremature CVD, • known FH in thefamily. • Confirmthediagnosiswithclinicalcriteriaorwith DNA analysis. • Familyscreening is indicatedwhen a patientwithHeFH is diagnosed. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  32. FamilialHypercholesterolaemia • HeFH→highdosestatin (wheneverneeded in combinationwith cholesterolabsorptioninhibitorsand/or a bile acid sequestrant)(class I C) • Treatmenttargets; • Forhigh risk subjects→LDL-C<2.5 mmol/L (<~100 mg/dL) • Forveryhigh risk subjects→LDL-C<1.8 mmol/L (<~70 mg/dL) • Iftargets can not be reached, maxreduction of LDL-C bydrugcombinations in tolerateddoses (classIIa C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  33. HeartFailureandValvularDiseases • n-3 PUFAs (1 g/day)→to be addedto optimal tx in patientswith HF (classIIb B) • Cholesterol-loweringtherapybystatins→notindicated in patientswithmoderateto severe HF (NYHA III-IV)(class III A) • Lipid-loweringtx→notindicated in patientswithvalvulardiseasewithout CAD (class III B) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  34. PeripheralArterialDisease • PAD is a high risk conditionandlipid-loweringtherapy (mostlystatins) is recommended (class I A) • Statins→recommendedtoreducetheprogression of carotidatherosclerosis (class I A) • Statins→recommendedtopreventtheprogression of aorticaneurysm (class I C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  35. TheElderly • Txwithstatins→recommendedforelderlypatientswithestablished CVD in thesameway as foryoungerpatients (class I B) • Elderlypeopleoftenhavecomorbiditiesandhavealteredpharmacokinetics • Recommendedto start lipid-loweringmedication at a lowdoseandthentitratewithcautiontoachievetargetlipidlevelswhicharethesame as in theyoungersubjects (class I C) ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  36. Statintx→recommendedforprimaryprevention of CAD in high risk women Statins→recommendedforsecondaryprevention in womenwiththesameindicationsandtargets as in men Lipid-loweringdrugsshould not be givenwhenpregnancy is planned, duringpregnancyorduringthebreast-feedingperiod Women ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  37. Novel/Important Aspects-5 Relevance of lifestyle changes not just in the reduction of total risk, but also in the specific treatment of dyslipidemias. Anguita M, et al. Rev Esp Cardiol. 2011 Dec;64(12):1090-5.

  38. LifestyleChanges • Theguidelinesplace a greatamount of emphasis on theeffects of lifestylechanges on thedifferentplasmalipidsassociatedwiththeatheroscleroticprocess. • Therecommendationsrelatedtolifestylechangesarepresented in detail, includingwhichfoodsaremoreorlessadvisable, physicalactivity, andsmokingcessation. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  39. LifestyleChanges • Consumption of fruits, vegetables, legumes, nuts, wholegraincerealsandbread, fish (especiallyoily). • Saturatedfatshould be replacedwiththosefoodsandwithmonounsaturatedandpolyunsaturatedfatsfromvegetablesources. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  40. Energyintakeshould be adjustedtopreventoverweightandobesity. Reduceenergyintakefrom: total fatto <35% saturatedfatto <7% trans fatsto <1% dietarycholesterolto <300 mg/day Theintake of beveragesandfoodswithaddedsugars, particularlysoftdrinks, should be limited. LifestyleChanges ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  41. LifestyleChanges • Dietarysupplementsandfunctionalfoods: • 2 g/day of phytosterols→lower TC and LDL-C by 7–10% whenconsumedwiththe main meal. • Foodsenrichedwithwater-solublefibres→recommendedfor LDL-C lowering (5–15 g/day). • 2–3 g/day of fishoil (rich in longchain n-3 fattyacids)→reduce TG levelsby 25–30%. ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  42. Salt intake <5 g/day Alcoholconsumption: <10-20 g/dayforwomen <20-30 g/dayfor men Regularphysicalexercisefor at least 30 minutes/dayeveryday Useandexposuretotobaccoproductsshould be avoided LifestyleChanges ESC/EAS Guidelinesforthemanagement of dyslipidaemias. EurHeart J. 2011 Jul;32(14):1769-818.

  43. GuidelinesareNothingwithoutImplementation We should develop implementation strategies bearing always inmind that the aim of the guidelines is to assist thephysicians in selecting the best management strategiesfor treating dyslipidaemia in an individual patient andhaving a reliable guidance in this is definitely better than having none. Reiner Z. Eur J CardiovascPrevRehabil. 2011; 18(5): 724-7.

  44. THANK YOU ONDOKUZ MAYIS UNIVERSITY, SAMSUN, TURKEY

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