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
Treatment of dyslipidemia should not be considered as
an isolated process, but rather within the context of
integrated prevention of cardiovascular disease in each
patient →the SCORE system
Anguita M, et al. Rev Esp Cardiol. 2011 Dec;64(12):1090-5.
SCORE Scale
 The preference for the
SCORE system over other risk
scales is based on the fact
that it was designed and
evaluated using representative
European cohorts.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
SCORE Scale
 The SCORE scale allows for
estimating the 10-year risk of
the first fatal atherosclerotic
complication based on the
following risk factors:
 Age
 Gender
 Smoking
 Systolic blood pressure
 Total cholesterol
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
SCORE Scale
 Charts for high and low risk
regions in Europe.
 The low risk charts→in
Belgium, Germany, Finland,
France, Greece, Italy, Spain,
Denmark, The Netherlands,
United Kingdom, Sweden,
Norway, Iceland, Ireland,
Austria, Malta, Portugal,
Slovenia, Monaco, San Marino.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
SCORE Scale
 The high risk charts→in
Bulgaria, Macedonia, Russia,
Moldova, Ukraine, Belarus,
Latvia.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
SCORE Scale
 SCORE database has shown
that HDL-C modifies risk at
all levels of risk as estimated
from the SCORE cholesterol
charts.
 Risk will be higher than
indicated in the charts in
individuals with low HDL-C.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
SCORE Scale
Risk will also be higher than indicated in the charts in;
*Socially deprived individuals
*Sedentary subjects and those with central obesity
*Individuals with diabetes
*Individuals with low apo A1, increased triglyceride, fibrinogen,
homocysteine, apo B, and lipoprotein(a) levels, familial
hypercholesterolaemia, or increased hs-CRP
*Asymptomatic individuals with preclinical evidence of
atherosclerosis
*Those with impaired renal function
*Those with a family history of premature CVD
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
SCORE Scale
 A particular problem relates to
young people with high levels
of risk factors.
 Although the absolute SCORE
risk can be low in young
patients, if several risk
factors are present, the
relative risk will be high.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Risk Levels
 Very High Risk:
 A calculated SCORE ≥10%
 Documented CVD by invasive or non-invasive testing
 Type 2 diabetes, type 1 diabetes with target organ damage
 Moderate to severe CKD
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Risk Levels
 High Risk:
 A calculated SCORE ≥5 to <10%
 Markedly elevated single risk factors
 Moderate Risk:
 A calculated SCORE ≥1 to <5%
 Low Risk:
 A calculated SCORE <1%
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Intervention Strategies
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Novel/Important Aspects-2
Recommendations for lipid analysis as treatment targets
in the prevention of CVD and strengthening of strict
LDL cholesterol targets for patients with very high,
high, and intermediate risk levels
Anguita M, et al. Rev Esp Cardiol. 2011 Dec;64(12):1090-5.
Treatment Targets
•
LDL-C→recommended as target for tx (class I A)
•
TC→considered as tx target if other analyses are
not available (class IIa A)
•
TG→analysed during the tx of dyslipidaemias with
high TG levels (class IIa B)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Treatment Targets
•
Non-HDL-C→considered as a secondary tx target
(class IIa B)
•
Apo B→considered as a secondary tx target
(class IIa B)
•
HDL-C or the ratios→not recommended as
targets for tx (class III C)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Treatment Targets for 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 Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Treatment Targets Other Than 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 Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
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.
Pharmacological
Treatment of Hypercholesterolaemia
•
Statin→prescribe up to the highest recommended dose or highest
tolerable dose to reach the target level (class I A)
•
Statin intolerance→bile acid sequestrants or nicotinic acid (class
IIa B)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Pharmacological
Treatment 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 Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Pharmacological
Treatment of Hypertriglyceridaemia
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Drugs Affecting HDL-C
 Nicotinic acid→the most efficient drug to raise HDL-C and should
be considered (class IIa A)
 Statins and fibrates→raise HDL-C with similar magnitude and may
be considered (class IIb B)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Drug Combinations for the Management of
Mixed Dyslipidaemias
•
↑ 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→n3 fatty acids to decrease TG further
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
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.
Management of Dyslipidaemias
in Different Clinical Settings
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Familial dyslipidaemias
Children
Women
The elderly
Metabolic syndrome and diabetes mellitus
Patients with acute coronary syndrome and patients undergoing
percutaneous coronary intervention
Heart failure and valvular disease
Autoimmune diseases
Renal disease
Transplantation patients
Peripheral arterial disease
Stroke
Human immunodeficiency virus patients
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Diabetes Mellitus
Type 1 DM and in the presence of microalbuminuria and renal
disease
LDL-C lowering (at least 30%) with statins as the first choice
(eventually drug combination) irrespective of the basal LDL-C
concentration
(class I C)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Diabetes Mellitus
●Type 2 DM+CVD or CKD
●Type 2 DM without CVD+age>40 years+≥1 other CVD risk factors
or markers of target organ damage
●Primary goal for LDL-C is <1.8 mmol/L (<~70 mg/dL)
●Secondary goal for non-HDL-C is <2.6 mmol/L (~<100 mg/dL) and
for apo B is <80 mg/dL
(class I B)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Diabetes Mellitus
Type 2 DM
●LDL-C <2.5 mmol/L (<~100 mg/dL) is the primary target
●Non-HDL-C <3.3 mmol/L (<~130 mg/dL) and apo B <100 mg/dL are
the secondary targets
(class I B)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Moderate to Severe Chronic Kidney Disease
 Primary target of therapy→LDL-C
reduction
 LDL-C lowering ↓ CVD risk in CKD
patients
 Statins→slow the rate of kidney fx
loss modestly and thus protect against
the development of ESRD requiring
dialysis (class IIa C)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Moderate to Severe Chronic Kidney Disease
 Statins→beneficial effect on
pathological proteinuria (>300 mg/day);
considered in stage 2-4 CKD patients
(class IIa B)
 Statins (as monotherapy or in
combination with other
drugs)→considered to achieve LDL-C
<1.8 mmol/L (<~70 mg/dL)(class IIa C)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Familial Hypercholesterolaemia
 FH is suspected in subjects with
 CVD aged <50 years (♂) or <60 years (♀),
 relatives with premature CVD,
 known FH in the family.
 Confirm the diagnosis with clinical criteria or with DNA analysis.
 Family screening is indicated when a patient with HeFH is
diagnosed.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Familial Hypercholesterolaemia
 HeFH→high dose statin (whenever needed in combination with
cholesterol absorption inhibitors and/or a bile acid
sequestrant)(class I C)
 Treatment targets;
 For high risk subjects→LDL-C<2.5 mmol/L (<~100 mg/dL)
 For very high risk subjects→LDL-C<1.8 mmol/L (<~70 mg/dL)
 If targets can not be reached, max reduction of LDL-C by
drug combinations in tolerated doses
(class IIa C)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Heart Failure and Valvular Diseases
 n-3 PUFAs (1 g/day)→to be added to
optimal tx in patients with HF (class IIb
B)
 Cholesterol-lowering therapy by
statins→not indicated in patients with
moderate to severe HF (NYHA IIIIV)(class III A)
 Lipid-lowering tx→not indicated in
patients with valvular disease without
CAD (class III B)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Peripheral Arterial Disease
 PAD is a high risk condition and lipid-
lowering therapy (mostly statins) is
recommended (class I A)
 Statins→recommended to reduce the
progression of carotid atherosclerosis
(class I A)
 Statins→recommended to prevent the
progression of aortic aneurysm (class I C)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
The Elderly
 Tx with statins→recommended for elderly
patients with established CVD in the same way
as for younger patients (class I B)
 Elderly people often have comorbidities and
have altered pharmacokinetics
 Recommended to start lipid-lowering medication
at a low dose and then titrate with caution to
achieve target lipid levels which are the same as
in the younger subjects (class I C)
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Women
 Statin tx→recommended for primary
prevention of CAD in high risk women
 Statins→recommended for secondary
prevention in women with the same
indications and targets as in men
 Lipid-lowering drugs should not be given
when pregnancy is planned, during pregnancy
or during the breast-feeding period
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
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.
Lifestyle Changes
 The guidelines place a great
amount of emphasis on the
effects of lifestyle changes on
the different plasma lipids
associated with the
atherosclerotic process.
 The recommendations related to
lifestyle changes are presented
in detail, including which foods
are more or less advisable,
physical activity, and smoking
cessation.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Lifestyle Changes
 Consumption of fruits,
vegetables, legumes, nuts,
wholegrain cereals and bread,
fish (especially oily).
 Saturated fat should be
replaced with those foods and
with monounsaturated and
polyunsaturated fats from
vegetable sources.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Lifestyle Changes
 Energy intake should be adjusted to prevent
overweight and obesity.
 Reduce energy intake from:
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total fat to <35%
saturated fat to <7%
trans fats to <1%
dietary cholesterol to <300 mg/day
 The intake of beverages and foods with
added sugars, particularly soft drinks, should
be limited.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Lifestyle Changes
 Dietary supplements and functional foods:
 2 g/day of phytosterols→lower TC and LDL-C by 7–10% when
consumed with the main meal.
 Foods enriched with water-soluble fibres→recommended for
LDL-C lowering (5–15 g/day).
 2–3 g/day of fish oil (rich in long chain n-3 fatty acids)→reduce
TG levels by 25–30%.
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Lifestyle Changes
 Salt intake <5 g/day
 Alcohol consumption:
 <10-20 g/day for women
 <20-30 g/day for men
 Regular physical exercise for at least
30 minutes/day every day
 Use and exposure to tobacco products
should be avoided
ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J. 2011 Jul;32(14):1769-818.
Guidelines are Nothing without
Implementation
We should develop implementation strategies bearing always in mind
that the aim of the guidelines is to assist the physicians in selecting
the best management strategies for treating dyslipidaemia in an
individual patient and having a reliable guidance in this is definitely
better than having none.
Reiner Z. Eur J Cardiovasc Prev Rehabil. 2011; 18(5): 724-7.
THANK YOU
ONDOKUZ MAYIS UNIVERSITY, SAMSUN, TURKEY