Disclaimer
The Canadian Cardiovascular Society (CCS) welcomes reuse of our
educational slide deck for medical institution internal education or training (i.e.
grand rounds, medical college/classroom education, etc.). However, if the
material is being used in an industry sponsored CME program, permission
must be sought through our publisher Elsevier (www.onlinecjc.com).
If your reuse request qualifies as medical institution internal education, you
may reuse the material under the following conditions:
•
•
•
•
You must cite the Canadian Journal of Cardiology and the Canadian
Cardiovascular Society as references.
You may not use any Canadian Cardiovascular Society logos or
trademarks on any slides or anywhere in your presentation or
publications.
Do not modify the slide content.
If repeating recommendations from the published guideline, do not
modify the recommendation wording.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
1
Canadian Cardiovascular Society Guidelines
2012 UPDATE
Diagnosis and Treatment of Dyslipidemia
for the Prevention of
Cardiovascular Disease in the Adult
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
2
2012 CCS Dyslipidemia Guidelines Update
Revision/Correction History
Date
Revision
April 25, 2013
Adjusted ranges in slide 24 and 27 to be inclusive (IE ≥,
≤) to match publication
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
3
2012 CCS Dyslipidemia Guidelines Update
Primary Panel
Todd J Anderson MD, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta
Jean Grégoire MD, Institut de Cardiologie de Montréal, Université de Montréal, Québec
Robert A. Hegele MD, Robarts Research Institute, London, Ontario
Patrick Couture MD, Centre Hospitalier Universitaire de Québec, Québec City, Québec
G. B. John Mancini MD, University of British Columbia, Vancouver, British Columbia
Ruth McPherson MD, PhD, University of Ottawa Heart Institute, Ottawa, Ontario
Gordon A. Francis MD, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
Paul Poirier MD, PhD, Institut Universitaire de cardiologie et de Pneumologie de Québec, Quebec City, Québec
David C. Lau MD, PhD, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta
Steven Grover MD, McGill University Health Center, Montreal, Quebec
Jacques Genest Jr., MD, McGill University Health Center, Montreal, Quebec
André C. Carpentier MD, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec
Robert Dufour MD, Institut de Recherches Cliniques de Montréal, Montréal, Québec
Milan Gupta MD, Department of Medicine, McMaster University, Hamilton, Ontario
Richard Ward MD, University of Calgary, Alberta
Lawrence A. Leiter MD, St Michael’s Hospital, University of Toronto, Ontario
Eva Lonn MD, Population Health Research Institute, McMaster University, Hamilton, Ontario
Dominic S. Ng MD, PhD, St Michael’s Hospital, University of Toronto, Ontario
Glen J. Pearson Pharm D, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta
Gillian M. Yates MN, NP, QE II Health Sciences Centre, Halifax, Nova Scotia
James A. Stone MD, PhD, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta
Ehud Ur MB, University of British Columbia, Vancouver, British Columbia
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
4
2012 CCS Dyslipidemia Guidelines Update
Introduction
Todd J Anderson, MD
Who to screen & risk assessment
Robert Dufour, MD
Levels of Risk
Milan Gupta, MD
Secondary testing
Todd Anderson, MD
Health Behaviours
Gillian M. Yates, MN NP
Statin intolerance
Glen J. Pearson, Pharm D
Cases
Jean Grégoire MD
Open questions
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
5
2012 CCS Dyslipidemia Guidelines Update
Changes since 2009
•
•
•
•
•
•
GRADE recommendations
Addition of CKD definitions and treatment
Lower age for treatment in diabetes – CDA harmonization
Addition of non-HDL –C as alternative target
Recommendation for secondary testing in selected patients
More explicit recommendations for health behaviour
changes
• Statin intolerance approach
• Cardiovascular Age determination
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
6
2012 UPDATE
Diagnosis and Treatment of Dyslipidemia
for the Prevention of Cardiovascular Disease in the Adult
Who to Screen & Risk Assessment
Robert Dufour, MD
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
7
2012 CCS Dyslipidemia Guidelines Update
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
8
2012 CCS Dyslipidemia Guidelines Update
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
9
2012 CCS Dyslipidemia Guidelines Update
Risk assessment
1. We recommend that a cardiovascular risk assessment using the “10 Year Risk”
provided by the Framingham model be completed every 3 to 5 years for men
age 40 to 75, and women age 50 to 75. This should be modified (percent risk
doubled) when family history of premature CVD is positive (i.e. 10 relative <55
years for men; <65 years for women). A risk assessment may also be completed
whenever a patient’s expected risk status changes. Younger individuals with >1
risk factor for premature CVD may also benefit from a risk assessment to
motivate them to improve their lifestyle.
(Strong Recommendation, Moderate-quality Evidence)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
10
2012 CCS Dyslipidemia Guidelines Update
Risk assessment and Framingham Model
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
11
2012 CCS Dyslipidemia Guidelines Update
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
12
2012 CCS Dyslipidemia Guidelines Update
CVD − Cardiovascular risk for men
POINTS
RISK
POINTS
RISK
POINTS
RISK
-3 or less
<1%
5
3.9 %
13
15.6 %
-2
1.1 %
6
4.7 %
14
18.4 %
-1
1.4 %
7
5.6 %
15
21.6 %
0
1.6 %
8
6.7 %
16
25.3 %
1
1.9 %
9
7.9 %
17
29.4 %
2
2.3 %
10
9.4 %
18+
> 30 %
3
2.8 %
11
11.2 %
4
3.3 %
12
13.3 %
Multiplied by 2 when family history of premature CVD is positive
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
13
2012 CCS Dyslipidemia Guidelines Update
Limitations of 10 year risk estimates
•
•
•
•
•
•
Sensitive to the patient’s age
Majority of individuals identified as being at low risk
More accurate among younger individuals
Competing risk increases with age (i.e cancer)
Risk categories (low, inter.,high) chosen arbitrary by consensus
Sub-optimal understanding and use
Despite the limitations assessing total CVD risk improves
management of blood pressure and blood lipids
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
14
2012 CCS Dyslipidemia Guidelines Update
Adherence to Statins is Sub-Optimal Among
Canadians
Anderson
TJ, Gregoire
et al., Can
J Cardiol
2013
Feb;29(2):
151-167syndromes. JAMA. 2002;288(4):462-467
Jackevicius CA, Mamdani M, Tu JV. Adherence
with statin
therapy inJ elderly
patients
with and
without
acute coronary
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
15
2012 CCS Dyslipidemia Guidelines Update
Risk Assessment: Recommendation 2
1. We recommend calculating and discussing a patient’s
“Cardiovascular Age” to improve the likelihood that patients
will reach lipid targets and that poorly controlled
hypertension will be treated
(Strong Recommendation, High-Quality Evidence).
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
16
2012 CCS Dyslipidemia Guidelines Update
Risk Assessment: Values & preferences
• The primary evaluation of risk is the modified 10-year
Framingham Risk Score (FRS)
• Given the overlap in risk factors for diabetes, a simultaneous
evaluation of cardiometabolic risk for diabetes may be useful to
motivate lifestyle changes
• It is well known that a 10-year risk does not fully account for risk
in younger individuals
• In these individuals, the calculation of a Cardiovascular Age has
been shown to motivate subjects to achieve risk factor targets
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
17
2012 CCS Dyslipidemia Guidelines Update
Risk Assessment: Practical Tip
For patients older than 75 years of age, the Framingham
model is not well validated. Though clinical studies are
currently under way to address this group, at this point
clinical judgement is required in consultation with the patient
to determine the value of pharmacotherapy.
One approach is extrapolation of the modified FRS, and this
approach identifies most subjects as having intermediate- to
high-risk based on age.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
18
2012 CCS Dyslipidemia Guidelines Update
Cardiovascular Age Tables / Diabetes: NO
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
19
2012 CCS Dyslipidemia Guidelines Update
Cardiovascular Age Tables / Diabetes: YES
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
20
2012 CCS Dyslipidemia Guidelines Update
Cardiovascular Age Tables / Diabetes: NO
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
21
2012 CCS Dyslipidemia Guidelines Update
Cardiovascular Age Tables / Diabetes: YES
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
22
2012 UPDATE
Diagnosis and Treatment of Dyslipidemia
for the Prevention of Cardiovascular Disease in the Adult
Levels of Risk
Milan Gupta, MD
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
23
2012 CCS Dyslipidemia Guidelines Update
Low risk recommendations
1. Pharmacotherapy with LDL-C ≥ 5.0 mmol/L, or evidence of
genetic dyslipidemia (e.g. familial hypercholesterolemia)
(Strong Recommendation, Moderate-Quality Evidence).
2. ≥ 50 % reduction of LDL-C after treatment is initiated
(Strong Recommendation, Moderate-Quality Evidence)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
24
2012 CCS Dyslipidemia Guidelines Update
Low risk recommendations
Values and preferences: Unchanged. Less clinical trial evidence,
so practice will vary and depend on patient wishes and
clinical evaluation.
For subjects with 5-9% risk:
- more frequent monitoring of risk
- discuss risks/benefits of statin therapy
- judicious use of secondary testing.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
25
2012 CCS Dyslipidemia Guidelines Update
Intermediate Risk Recommendations
1.
IR category: adjusted FRS > 10% and <20%
(Strong Recommendation, Moderate-Quality Evidence)
2.
Treat IR individuals with LDL-C > 3.5 mmol/L
(Strong Recommendation, Moderate-Quality Evidence)
3.
In IR individuals with LDL-C < 3.5 mmol/L, apo B ≥ 1.2 g/L or
non-HDL-C ≥ 4.3 mmol/L can help identify patients to benefit from
pharmacotherapy
(Strong Recommendation, Moderate-Quality Evidence)
4.
Target LDL-C ≤ 2.0 mmol/L or ≥ 50% reduction once treatment is initiated
(Strong Recommendation, Moderate-Quality Evidence).
Alternative targets: apo B ≤ 0.8 g/L or non-HDL cholesterol ≤ 2.6 mmol/L
(Strong Recommendation, Moderate-Quality Evidence).
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
26
2012 CCS Dyslipidemia Guidelines Update
Non-HDL-C as an alternate target to LDL-C
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
27
2012 CCS Dyslipidemia Guidelines Update
Intermediate risk and non-HDL: values and
preferences
• Adding non-HDL-C would seem to contradict the philosophy
of simplifying the guidelines.
• However, apo B is not available in some jurisdictions, while
non-HDL-C is available without any additional cost or testing.
• Also, increasing data demonstrate its potential advantages
over LDL-C: superior risk predictor, fasting not required.
• Therefore, it was decided to increase its profile in the
guidelines. Non-HDL-C would be particularly useful where
apo B is unavailable and where TG ≥ 1.5 mmol/L.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
28
2012 CCS Dyslipidemia Guidelines Update
High risk recommendations
1.
High risk is defined in those subjects who have clinical atherosclerosis, diabetes >15
years duration and age >30 years, or age >40 years with diabetes, or adjusted
Framingham Risk Score of ≥20%.
(Strong Recommendation, High-Quality Evidence).
We now include abdominal aortic aneurysm, high risk kidney disease (eGFR < 45)
and high risk hypertension in this category
(Strong Recommendation, Moderate-Quality Evidence).
2.
Treatment target for LDL-C ≤ 2.0 mmol/L or ≥ 50% reduction for optimal risk
reduction.
(Strong Recommendation, Moderate-Quality Evidence).
3.
Apo B (≤ 0.80 g/L) or non-HDL-C (≤ 2.6 mmol/L) be considered as alternative
(Strong Recommendation, High-Quality Evidence).
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
29
2012 CCS Dyslipidemia Guidelines Update
High risk: values and preferences
• Our decision to add chronic kidney disease (eGFR <
45) to the high risk category was based on significant
emerging epidemiology data and the recently
published Study of Heart and Renal Protection
(SHARP).
• The treatment of dyslipidemia in subjects on
hemodialysis remains controversial and individual
judgment is required.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
30
2012 CCS Dyslipidemia Guidelines Update
Risk stratification by Framingham Risk Score (FRS) and phenotype
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
31
2012 CCS Dyslipidemia Guidelines Update
Risk stratification for intermediate risk subjects
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
32
2012 CCS Dyslipidemia Guidelines Update
Levels of risk - Practical tips:
• LDL-C remains the primary target in the guidelines. Clinicians would
be encouraged to be familiar with the use of LDL-C and one of the
two alternate targets.
• We do not advocate using all 3 indices regularly or testing for LDL-C,
non-HDL-C and apo B concurrently in subjects.
• For those who have apo B available and are comfortable with using
it, there are advantages that were previously addressed.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
33
2012 CCS Dyslipidemia Guidelines Update
Summary of treatment thresholds and targets
based on Framingham Risk Score (FRS), modified
by family history
Risk level
Initiate therapy if:
Primary target (LDL-C)
Alternate target
High
FRS ≥20%
•
Consider treatment in all
(Strong, High)
•
≤2 mmol/L or ≥50%
decrease in LDL-C
(Strong, Moderate)
•
•
Apo B ≤0.8 g/L or
Non-HDL-C ≤2.6 mmol/L
(Strong, High)
Intermediate
FRS 10-19%
•
LDL-C ≥3.5 mmol/L
(Strong, Moderate)
For LDL-C <3.5 mmol/L consider
if:
• Apo B ≥1.2 g/L
• OR Non-HDL-C ≥4.3
mmol/L
(Strong, Moderate)
•
≤2 mmol/L or ≥50%
decrease in LDL-C
(Strong, Moderate)
•
•
Apo B ≤0.8 g/L or
Non-HDL-C ≤2.6 mmol/L
(Strong, Moderate)
LDL-C ≥5.0 mmol/L
Familial hypercholesterolemia
(Strong, Moderate)
•
≥50% decrease in LDL-C
(Strong, Moderate)
N/A
•
Low
FRS <10%
•
•
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
34
2012 UPDATE
Diagnosis and Treatment of Dyslipidemia
for the Prevention of Cardiovascular Disease in the Adult
Secondary Testing
Todd J Anderson MD
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
35
2012 CCS Dyslipidemia Guidelines Update
Secondary Testing
1.
We recommend secondary testing for further risk
assessment in “intermediate risk” (10-19% FRS after
adjustment for family history) subjects who are not
candidates for lipid treatment based on conventional
risk factors or for whom treatment decisions are
uncertain.
(Strong Recommendation, moderate quality evidence)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
36
2012 CCS Dyslipidemia Guidelines Update
Secondary Testing
2. We suggest that secondary testing may be
considered for a selected subset of “low to
intermediate risk” (5-9% FRS after adjustment for
family history) subjects for whom further risk
assessment is indicated, e.g. strong family history of
premature CAD, abdominal obesity, South Asian
ancestry or impaired glucose tolerance.
(Weak recommendation, low quality evidence)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
37
2012 CCS Dyslipidemia Guidelines Update
Optional Biomarkers for Further Risk Assessment
Biomarker
Indications for testing
Frequency of testing
Normal Range
Lp(a)
• Further risk assessment
particularly in individuals with a
family history of premature CVD
• Genetically determined risk
factor
• Repeat testing not required
< 30 mg/dl
(< 300 mg/L)
hsCRP
• Men > 50y and women > 60y who
are not candidates for statin Rx
based on conventional risk factors
• q 3 y from age 50 y (M) 60 y (F)
• If > 2.0 mg/L, repeat in 2-4 wk,
use lower value for risk
assessment
< 1.0 lowest risk
> 2.0 increased risk
> 3.0 high risk
A1C
• Further risk assessment in selected
subjects with FPG >5.6 mmol/L
• q1-5y
• more frequently if weight gain
or incr FBG
< 5.5% low risk
5.5-6.0 % mid risk
6.0-6.5 % high risk
> 6.5 % diabetes
Urinary Alb/Cr
• T2DM
• poorly controlled HTN
• Selected patients who are not
candidates for statin Rx based on
conventional risk factors
• q 1 y for patients with T2DM or
poorly controlled HTN
< 3 mg/mmol
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
38
2012 CCS Dyslipidemia Guidelines Update
Choose a test appropriate for the individual patient
(not multiple tests)
• Lp(a):30-70 mg/dl confers ~ 1.3X increased risk;
mg/dl ~ 1.5X increased CVD risk
> 80
• hsCRP > 2 mg/dl is associated with ~ 1.5 to 2.0 X increased
CVD risk
• HbA1c 6.0 – 6.5 % is associated with ~ 1.5 – 1.8 X increased
CVD risk
• Microalbuminuria is associated with ~ 1.5 X increased CVD
risk
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
39
2012 CCS Dyslipidemia Guidelines Update
Optional Noninvasive Tests for Further Risk Assessment
Noninvasive test
Indications for testing
Normal Range
Frequency of testing
Graded exercise
stress test
• Selected asymptomatic adults
with CVD risk factors especially
those who are embarking on a
vigorous exercise program
• Selected adults in the
intermediate risk category
Duke Scorea
Low risk
≥ +5
Moderate risk -10 to +4
High risk
≤ -11
q 3-10 y or if symptoms
develop
Carotid
imaging
Selected asymptomatic adults in
not candidates for statin Rx based
on conventional risk factors. Only in
centres with expertise
CIMT <1.0 mm
No visible plaqueb
q 5-10 y as indicated for
reassessment of risk
ABI
Selected asymptomatic adults, not
candidates for statin Rx based on
conventional risk factors
(particularly smokers, diabetes)
ABI 1.0-1.3c
q 5-10 y as indicated for
reassessment of risk or
if symptoms develop
CAC
Selected asymptomatic adults who
are not candidates for statin Rx
based on conventional risk factors
Low risk
Increased risk
High risk
Very high risk
CAC
0
0 – 100
100-300d
> 300e
CAC = 0 q 10y where
clinically indicated
CAC = 0 – 100
q 3-5y if Rx is deferred
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
40
2012 CCS Dyslipidemia Guidelines Update
Choice & Interpretation of Noninvasive Tests
GXT: May be indicated for sedentary patient wishing to start exercise program;
note that CAD risk is also increased in subjects with low exercise capacity (< 6
METS)
ABI: Consider for patient with suspected PAD. ABI < 0.90 is an indication for
intensive statin therapy
Carotid IMT: Each 0.1 mm increase in CIMT is associated with a 10% increased risk
for MI and a 13% increased risk for stroke. Visible arterial wall plaques defined as a
CIMT > 1.5 mm or CIMT values > 75% for age and sex are considered as evidence of
subclinical atherosclerosis and an indication for statin therapy
Coronary artery calcium: Highest incremental value but radiation exposure and not
yet generally available. CAC > 100 is generally an indication for statin Rx. CAC > 300
places patient in very high risk category (10 y risk of MI/CV death = 28%)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
41
2012 CCS Dyslipidemia Guidelines Update
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Eva Lonn
Copyright © 2013, Canadian Cardiovascular Society
42
2012 CCS Dyslipidemia Guidelines Update
Novel markers of atherosclerotic risk
Met-analysis of 37197 subjects
8 studies, 12 pubs of IMT
Anderson TJ, Gregoire
et Circ
al., Can
Cardiol 2013 Feb;29(2): 151-167
Lorenz etJal.
2007J 115:459
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
43
2012 CCS Dyslipidemia Guidelines Update
IMT and Discrimination, Reclassification
• USE-IMT meta-analysis
– 15 large cohort studies
– 45,000 subjects
– 4007 first MI or stroke
– C-statistic 0.757 and not changed with IMT
– NRI significant but 0.8% given sample size
– NCRI for intermediate risk 3.6%
Den Ruijiter JAMA 2012; 308:796Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
44
2012 CCS Dyslipidemia Guidelines Update
Coronary Artery Calcium
Due to atherosclerosis
Related to age and risk factors
Not related to stenosis but is
related to plaque volume
Can be detected by EBCT or
MDCT
Radiation dose is moderate
(0.5-1.5 mSev and acquisition
very quick
Variance about 40% for
repeated measures
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
45
2012 CCS Dyslipidemia Guidelines Update
Coronary calcium score – Prevalence
aSx group 44,052
CAC related to all
cause mortality across
age range
Tota-Maharaj EHJ 2012;33:2955
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
46
2012 CCS Dyslipidemia Guidelines Update
Coronary calcium score - Prognosis
MESA – 6722 subjects
162 events
HR 7.08 for major
Coronary event
With CAC >100
Detrano NEJM 2008;356:1336
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
47
2012 CCS Dyslipidemia Guidelines Update
Comparison of novel risk markers
MESA
1330 IR subjects
CAC, IMT, CRP,
FH and ABI
123 CVD events
Carotid IMT not
associated with
events while
others were
CAC was best
Yeboah JAMA 2012;308:788
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
48
2012 UPDATE
Diagnosis and Treatment of Dyslipidemia
for the Prevention of Cardiovascular Disease in the Adult
Health Behaviours
Gillian M. Yates, MN NP
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
49
2012 CCS Dyslipidemia Guidelines Update
Search Strategy
• Update on international and US dietary guidelines for the treatment
of dyslipidemias and cardiovascular diseases since 2007
• Update on physical activity guidelines for the treatment of
dyslipidemias and cardiovascular diseases since 2007
• Three primary questions to be addressed:
1. Effect of diets and macronutrient composition in interventions
≥ 8 weeks in duration
2. Effect of physical activity in interventions ≥ 8 weeks
3. Effect of health behaviour changes (i.e., lifestyle modification
with combined dietary and exercise, with or without weight
loss) in interventions ≥ 8 weeks
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
50
2012 CCS Dyslipidemia Guidelines Update
Lifestyle Modification
• Health behaviour interventions are the cornerstone
of cardiovascular disease management and
prevention
–
–
–
–
–
Diet
Exercise
Alcohol intake
Cigarette smoking
Stress and mental health issues
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
51
2012 CCS Dyslipidemia Guidelines Update
Table 7. Expected Benefit of Health Behaviour Changes
Intervention (minimal dose for effect)
Dietary cholesterol intake98
< 300 mg/day (NCEP step I diet)
< 200 mg/day (NCEP step II diet)
Expected Outcome
↓ LDL-C
10-12%
12-16%
Saturated fats < 7% of daily caloric intake107
↓ LDL-C 5-10%; ↓ CVD mortality 14%
Phytosterols 1-2 g/day100
↓ LDL-C 5-8%
Soy proteins with isoflavones 25g/day101
↓ LDL-C 3-5%
Viscous fibre 10 g/day102
↓ LDL-C 3-5%
Nuts 30-67 g/day103
↓ LDL-C 5-7%, ↓ TG 5-10%
Portfolio type diet104
↓ LDL-C 8-14%
Mediterranean type diet105
↓ LDL-C 5-10%; ↓ CVD mortality
DASH (Dietary Approaches to Stop
Hypertension) diet106
↓ CVD mortality in those with hypertension
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
52
2012 CCS Dyslipidemia Guidelines Update
Table 7. Expected Benefit of Health Behaviour Changes
Intervention (minimal dose effect)
Expected Outcome
Moderated Alcohol intake 1-2 drinks/day
↑ HDL 5-10%, ↓ CVD events
Weight loss and reduction of abdominal obesity42
5-10% of body weight loss
↓ LDL-C, ↑ HDL, ↓ TG,
↓cardiometabolic risk
Omega -3 - 2-4 g of eicosapentaenoic acid (EPA) plus
docosahexaenoic acid (DHA)/day
↓ TG 25-30% in pts. with ↑ TG
Exercise109,110
30-60 min/day moderate to vigorous intensity
↑ HDL 5-10%, ↓ CVD events
Smoking cessation
↑ HDL, ↓ CVD events
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
53
2012 CCS Dyslipidemia Guidelines Update
Recommendations
We suggest that all individuals be encouraged to adopt healthy
eating habits to lower their cardiovascular (CVD) risk:
1.Moderate energy (caloric) intake to achieve and maintain a healthy body
weight
2.Emphasize a diet rich in vegetables, fruit, whole-grain cereals, and
polyunsaturated and monounsaturated oils, including omega-3 fatty acids
particularly from fish
3.Avoid trans fats, limit saturated and total fats to < 7% and < 30% of daily
total energy (caloric) intake, respectively
4.Increase daily fibre intake to > 30 g
5.Limit cholesterol intake to 200 mg daily for individuals with dyslipidemia or
at increased CVD risk
(Conditional Recommendation, Moderate-Quality Evidence)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
54
2012 CCS Dyslipidemia Guidelines Update
Recommendations
We recommend the Mediterranean, Portfolio or
DASH diets to improve lipid profiles or decrease CVD
risk
(Strong Recommendation, High-quality Evidence)
and for cholesterol lowering consider increasing
phytosterols, soluble fibre, soy and nut intake
(see Table 7)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
55
2012 CCS Dyslipidemia Guidelines Update
Recommendations
• We recommend that adults should accumulate at
least 150 min. of moderate-to-vigorous-intensity
aerobic physical activity per week, in bouts of 10 min
or more to reduce cardiovascular disease risk.
(Strong Recommendation, High-Quality Evidence)
• We recommend smoking cessation
(Strong Recommendation, Moderate-Quality Evidence)
• and limiting alcohol intake to 30 g or less per day (1-2
drinks)
(Conditional Recommendation, Moderate-Quality Evidence)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
56
2012 UPDATE
Diagnosis and Treatment of Dyslipidemia
for the Prevention of Cardiovascular Disease in the Adult
Statin Intolerance
Glen J. Pearson PharmD
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
57
2012 CCS Dyslipidemia Guidelines Update
Statin Intolerance Recommendations
1. Because overall risk/benefit favours therapy in patients
meeting criteria for lipid lowering therapy and
cardiovascular risk reduction, we recommend that:
i.
despite concerns about a variety of other possible
adverse effects, all purported statin-associated
symptoms should be evaluated systematically,
incorporating observation during cessation, reinitiation
(same or different statin, same or lower potency, same
or decreased frequency of dosing) to identify a
tolerated, statin-based therapy for chronic use; and
(Strong Recommendation, Very Low-Quality Evidence)
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
58
2012 CCS Dyslipidemia Guidelines Update
Statin Intolerance Recommendations
1. Because overall risk/benefit favours therapy in patients
meeting criteria for lipid lowering therapy and
cardiovascular risk reduction, we recommend that: (cont)
ii.
Statins not be withheld on the basis of a potential,
small risk of new-onset diabetes mellitus emerging
during long-term therapy
(Strong Recommendation, Very Low-Quality Evidence)
2. We do not recommend vitamins, minerals, or supplements
for symptoms of myalgia perceived to be statin-associated
(Strong Recommendation, Very Low-Quality Evidence).
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
59
2012 CCS Dyslipidemia Guidelines Update
Statin Intolerance Practical tip
• Patients should be advised to stop statin therapy and contact the
prescribing health care provider if worrisome symptoms develop.
• The amount of effort spent persevering with statin therapy in
subjects with adverse effects should be directly related to the
level of risk for an individual patient.
• In those at highest risk all options should be exercised before
changing to alternative lipid-lowering therapy or withdrawing all
lipid-lowering treatment. Lower dose combination therapy
remains an option for these subjects.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
60
2012 CCS Dyslipidemia Guidelines Update
Statin Intolerance Practical tip
• Strong emphasis should be put on a more aggressive
nonpharmacologic approach such as diet modulation and
exercise.
• For subjects at lower risk who do not tolerate statin therapy, a reevaluation of the need for lipid lowering therapy should precede a
change to alternative therapy because outcomes studies are not
as robust.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
61
2012 CCS Dyslipidemia Guidelines Update
Management Algorithm for Statin-Induced Muscle Symptoms
Anderson
TJ, Gregoire
J et al., Can
J Cardiol
Feb;29(2):
151-167
Mancini
GBJ,
Baker S, Bergeron
J, et
al. Can2013
J Card
2011; 27:635–662
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
62
2012 CCS Dyslipidemia Guidelines Update
Canadian Lipid Guidelines: Summary
• FRS doubled with positive family history
• Primary target: - absolute LDL-C ≤ 2 mmol/L
- relative decrease in LDL-C ≥ 50%
• Alternates:
- non-HDL-C ≤ 2.6 mmol/L
- apo B ≤ 0.8 g/L
• 5-9% risk:
- monitor yearly
• Secondary markers:
- biochemical:
Lp(a), hsCRP, HbA1c, ACR
- non-invasive:
GXT, IMT, ABI, CAC
• Lifestyle recommendations
• Statin intolerance recommendations
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
63
Case Discussions
Jean Grégoire MD
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
64
2012 CCS Dyslipidemia Guidelines Update
Case # 1
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
65
2012 CCS Dyslipidemia Guidelines Update
Case # 1
•
•
•
•
54 year old woman
Treated hypertension x 12 years, otherwise healthy
Non-smoker, non-diabetic, no relevant family history
BP 132/90, TC 5.4, HDL 1.3, LDL 3.3
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
66
2012 CCS Dyslipidemia Guidelines Update
What is her FRS?
1. < 5 %
2. 5-9%
3. 10-19%
4. >20%
FRS is 10%
LDL is 3.3
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
67
2012 CCS Dyslipidemia Guidelines Update
Should she receive a statin?
1. Yes
2. No
3. I need more
information in
order to decide
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
68
2012 CCS Dyslipidemia Guidelines Update
High risk hypertension (ASCOT)
HT plus any 3 of these risk factors equates to high risk:
•
•
•
•
•
•
•
•
Male gender
Age >55
Smoking
LVH
TC:HDL > 6
Family history premature CHD
Abnormal ECG
Microalbuminuria
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
69
ASCOT Primary Endpoint: Non-fatal MI
and Fatal CHD
Cumulative Incidence (%)
44
Atorvastatin 10 mg
Number of events
100
Placebo
Number of events
154
36%
reduction
33
22
11
HR = 0.64 (0.50-0.83)
00
0.0
0.0
0.5
0.5
1.0
1.0
1.5
1.5
2.0
2.0
2.5
2.5
3.0
3.0
3.5
3.5
Years
Years
Sever PS, Dahlöf B, Poulter N, Wedel H, et al, for the ASCOT Investigators. Lancet 2003;361:1149-58
p=0.0005
2012 CCS Dyslipidemia Guidelines Update
Case # 1 – Additional information
•
•
•
•
Weight 66 kg, BMI 25.8, waist circumference 85 cm
FPG 5.3, A1c 0.058
hsCRP 1.2
Creatinine 168, eGFR 40
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
71
2012 CCS Dyslipidemia Guidelines Update
Case # 1
• She has chronic kidney disease (eGFR < 45)
This is considered a high risk equivalent
• She should therefore be considered for statin therapy to a
target LDL < 2.0
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
72
2012 CCS Dyslipidemia Guidelines Update
Alberta Kidney Disease Network
Tonelli et al. Lancet 2012
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
73
2012 CCS Dyslipidemia Guidelines Update
SHARP: Major Atherosclerotic Events in Patients with CKD
Proportion suffering event (%)
25
20
Risk ratio 0.83 (0.74-0.94)
Logrank 2P=0.0021
15
Placebo
Simv/Eze
10
5
0
0
1
2
3
Years of follow-up
4
5
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
74
2012 CCS Dyslipidemia Guidelines Update
Case # 1
• She is started on atorvastatin 20 mg daily
• LDL falls to 2.4 and the drug is well-tolerated
• The dose is titrated to 40 mg daily but she develops
bothersome muscle aches with a CK of 450
• Renal function remains stable
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
75
2012 CCS Dyslipidemia Guidelines Update
Muscle aches on atorvastatin 40 mg, suboptimal LDL
What next?
1.
2.
3.
4.
5.
6.
Reduce atorvastatin to 20 mg daily, accept LDL 2.4
Change to rosuvastatin 10 mg and titrate as tolerated
Change to simvastatin 20 mg and add ezetimibe 10 mg
Reduce to atorvastatin 20 mg and add ezetimibe 10 mg
Leave atorvastatin at 40 mg and add coenzyme Q10
Other
While the correct answer is 4, 2 and 3 could be used as second
choices.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
76
2012 CCS Dyslipidemia Guidelines Update
Canadian Journal of Cardiology 2011; 27:635-662
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
77
2012 CCS Dyslipidemia Guidelines Update
Non-Statin Lipid Lowering Strategies
Fibrates
Ezetimibe
Lowers LDL 15-20%
Well tolerated
May be added to
low dose statin
Bile acid sequestrants
Lowers LDL 15%
May prevent diabetes
Colesevalam better
tolerated
 TG LDL little change
 ? Benefit when HDL low
Niacin
 Flushing/pruritus may limit
tolerance
 Lowers LDL 20%
 TG40%, HDL30%
Ezetimibe + Bile acid
sequestrant
40-45% LDL reduction
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
78
2012 CCS Dyslipidemia Guidelines Update
What if she was already on hemodialysis?
Should she receive lipid-lowering therapy?
1. Yes
2. No
3. Uncertain
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
79
2012 CCS Dyslipidemia Guidelines Update
SHARP: Major Atherosclerotic Events by renal status
Simv/Eze
(n=4650)
Placebo
(n=4620)
Non-dialysis (n=6247)
296
(9.5%)
373 (11.9%)
Dialysis (n=3023)
230 (15.0%)
246 (16.5%)
Major Atherosclerotic Event
526 (11.3%)
619 (13.4%)
No significant heterogeneity between
non-dialysis and dialysis patients (p=0.25)
Risk ratio & 95% CI
16.6% SE 5.4
reduction
(p=0.0021)
0.6
0.8
Simv/Eze better
1.0
1.2
1.4
Placebo better
The treatment of dyslipidemia in subjects on hemodialysis remains
controversial and individual judgment is required.
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
80
2012 CCS Dyslipidemia Guidelines Update
Case # 2
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
81
2012 CCS Dyslipidemia Guidelines Update
Case # 2
•
•
•
•
36 year old South Asian man
Non-smoker, non-diabetic, normotensive
Father had MI at age 46
BP 128/84, TC 5.8, HDL 1.0, LDL 4.1
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
82
2012 CCS Dyslipidemia Guidelines Update
What is his FRS?
1. < 5 %
2. 5-9%
3. 10-19%
4. >20%
FRS is 3.9%
Family history  FRS 7.8%
LDL is 4.1
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
83
2012 CCS Dyslipidemia Guidelines Update
Ten-Year vs. Lifetime Risk
Men
(n = 3564)
70
Women
69
60
(n = 4362)
70
60
50
46
50
Adjusted
cumulative 40
incidence 30
of CVD (%)
20
36
50
50
40
39
30
27
20
10
5
10
8
0
0
50
60
70
80
90
50
Attained age (years)
60
≥2 Major RFs
≥1 Elevated RF
1 Major
RF TJ, Gregoire J et al., Can
≥1 JNot
optimal
RF 151-167
Anderson
Cardiol
2013 Feb;29(2):
70
80
90
All optimal RFs
Lloyd-Jones DM et al. Circulation. 2006;113:791-8.
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
84
2012 CCS Dyslipidemia Guidelines Update
Lifestyle Recommendations
• Mediterranean, Portfolio or Dash diets: including foods high in
plant sterols, soy protein, high viscous fiber, omega 3 fatty
acids and nuts
• Moderate alcohol intake 1-2 drinks/day
• 150 min of moderate to vigorous aerobic activity per week
• Healthy body weight with BMI 20-25 kg/m(2)
• 0-5-30 approach to counselling:
– 0 cigarettes
– 5 servings of fruits/vegetables/day
– 30 min of exercise per day
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
85
2012 CCS Dyslipidemia Guidelines Update
Should he receive a statin?
1. Yes
2. No
3. I need more information in
order to decide
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
86
2012 CCS Dyslipidemia Guidelines Update
Case # 2 – Additional information
• Weight 65 kg, BMI 22.5, waist circumference 80 cm
• FPG 6.2, A1c 0.062
• Creatinine 78, eGFR 120
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
87
2012 CCS Dyslipidemia Guidelines Update
Should he receive a statin?
1. Yes
2. No
3. I need more information
in order to decide
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
88
2012 CCS Dyslipidemia Guidelines Update
Case # 2
•
•
•
•
•
•
•
36 year old South Asian man
Non-smoker, non-diabetic, normotensive
Father had MI at age 46
BP 128/84, TC 5.8, HDL 1.0, LDL 4.1
Weight 65 kg, BMI 22.5, waist circumference 80 cm
FBS 6.2, A1c 0.062
Creatinine 78, eGFR 120
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
89
2012 CCS Dyslipidemia Guidelines Update
Statins and low risk individuals
CTT Lancet 2012;379
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
90
2012 CCS Dyslipidemia Guidelines Update
Case # 2
•
•
•
•
He is at low to intermediate risk (7.8%)
He is South Asian, indicating higher risk than suggested by FRS
LDL is fairly high at 4.1, though not > 5.0
Secondary testing is reasonable to further risk stratify
• He has dysglycemia, with an abnormal A1c, which increases
his risk by 1.5 -2 fold
• He can therefore be considered for statin therapy to a target
LDL < 2.0 or a 50% reduction from baseline
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
91
2012 CCS Dyslipidemia Guidelines Update
Case # 3
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
92
2012 CCS Dyslipidemia Guidelines Update
Case # 3
•
•
•
•
56 year old white man
Non-smoker, non-diabetic, normotensive
No relevant family history
BP 124/78, TC 5.6, HDL 1.1, TG 3.2, LDL 3.0
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
93
2012 CCS Dyslipidemia Guidelines Update
What is his FRS?
1. < 5 %
2. 5-9%
3. 10-19%
4. >20%
FRS is 15.6%
LDL is 3.0
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
94
2012 CCS Dyslipidemia Guidelines Update
Should he receive a statin?
1. Yes
2. No
3. I need more
information in
order to decide
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
95
2012 CCS Dyslipidemia Guidelines Update
Case # 3 – Additional information
• Weight 86 kg, BMI 30, waist circumference 104 cm
• FBS 5.4, Creatinine 85, eGFR 90
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
96
2012 CCS Dyslipidemia Guidelines Update
Should he receive a statin?
1. Yes
2. No
3. I need more information
in order to decide
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
97
2012 CCS Dyslipidemia Guidelines Update
Is secondary testing necessary?
1. Yes
2. No
3. Uncertain
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
98
2012 CCS Dyslipidemia Guidelines Update
If secondary testing is necessary,
which test would you consider?
1.
2.
3.
4.
5.
6.
7.
8.
hsCRP
HbA1c
Urinary protein
Stress testing
Carotid ultrasound
Ankle brachial index
Coronary calcium score
Other
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
99
2012 CCS Dyslipidemia Guidelines Update
Case # 3: Secondary testing is not required
•
•
•
•
•
•
56 year old white man
Non-smoker, non-diabetic, normotensive
No relevant family history
BP 124/78, TC 5.6, HDL 1.1, TG 3.2, LDL 3.0
Weight 86 kg, BMI 30, waist circumference 104 cm
FBS 5.4, Creatinine 85, eGFR 90
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
100
2012 CCS Dyslipidemia Guidelines Update
Case # 3 – Options other than secondary testing
The role of non-HDL
• For patients with FRS 5-19% with LDL<3.5, one can consider
assessment of apoB or non-HDL
• Non-HDL = TC minus HDL
• No fasting required, no extra cost, immediately calculated
from any full lipid profile
• This patient’s non-HDL = 5.6 – 1.1 = 4.5
• If non-HDL > 4.3 with LDL < 3.5, can consider statin therapy
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
101
Thank You and Questions
Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2016-03-22
Copyright © 2013, Canadian Cardiovascular Society
102