2014/10/20. Management of Lipid Disorders Eric Klug Sunninghill, Sunward Park and CM JHB Academic Hospitals

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1 Management of Lipid Disorders Eric Klug Sunninghill, Sunward Park and CM JHB Academic Hospitals Sudden and unexpected deaths in an adult population, Cape Town, South Africa,

2 Sudden and unexpected deaths in an adult population, Cape Town, South Africa, Sudden and unexpected deaths in an adult population, CapeTown, South Africa,

3 Sudden and unexpected deaths in an adult population, CapeTown, South Africa, Shared aim To contribute to the health of the patient Reduce MI Reduce coronary revascularisation Reduce total mortality 3

4 Shared aim Do it safely All cause mortality by HbA1c: Metformin/SU vs insulin based groups 4

5 Intensive glycemic control reduces microvascular complications All microvascular endpoints Cataract extraction Retinopathy Microalbuminuria 25% 24% 21% 33% P= P= P= P= UKPDS Lancet 1998; 352: Disappointing effect of intensive glycemic control on macrovascular complications +17% +7% Fatal MI Non-fatal MI Fatal stroke Non-fatal stroke -6% -21% Not significant P= 0.63 Not significant P= Not significant P= 0.60 Not significant P= 0.72 UKPDS Lancet 1998 ; 352 :

6 Diastolic below 70 in a CAD patient "concerning" A J-curve for MI and diastolic BP has been found in INVEST, VALUE, TNT, ONTARGET, SYST-EUR, INSIGHT, HOT, ACTION, PROVE-IT, and other large, prospective, randomized trials. In most of them, the J-curve for coronary events and diastolic pressure was more pronounced in patients with manifest coronary artery disease than in patients without CAD." Dr Franz Messerli Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from participants in 26 randomised trials The Lancet 2010; 376:

7 Effects on 11-year mortality and morbidity of lowering LDL cholesterol with simvastatin for about 5 years in high-risk individuals: a randomised controlled trial Heart Protection Study Collaborative Group The Lancet 2011; 378: J points HbA1c 7.5% DBP below 70 mmhg in CAD patient No LDL level below which is harmful No threshold LDL level below which further reduction of no benefit 7

8 March 2012, Vol. 102, No. 3 SAMJ Guidelines Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. Guidelines are not meant to replace the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate for use in all circumstances 8

9 Factors in the Development of CVD Modifiable: Life style Tobacco Exercise Dietary habits Other risks Hypertension Non-modifiable: Type 2 diabetes Dyslipidaemia Age Male gender March 2012, Vol. 102, No. 3 SAMJ March 2012, Vol. 102, No. 3 SAMJ 9

10 March 2012, Vol. 102, No. 3 SAMJ 10

11 March 2012, Vol. 102, No. 3 SAMJ March 2012, Vol. 102, No. 3 SAMJ 11

12 March 2012, Vol. 102, No. 3 SAMJ Stone NJ, et al ACC/AHA Blood Cholesterol Guideline 12

13 Changing landscape March 2012, Vol. 102, No. 3 SAMJ 13

14 March 2012, Vol. 102, No. 3 SAMJ Supplements 14

15 Statins and diabetes Statins associated with a very modest excess risk of new onset diabetes (i.e., 0.1 excess case per 100 individuals treated 1 year with moderate-intensity statin therapy and 0.3 excess cases per 100 individuals treated for 1 year with high-intensity statin therapy. The increased risk of new onset diabetes appears to be confined to those with risk factors for diabetes. Therefore, if a statin-treated individual develops diabetes as detected by current diabetes screening guidelines, they should be counseled to adhere to a heart healthy dietary pattern, engage in physical activity, achieve and maintain a healthy body weight, cease tobacco use, and continue statin therapy to reduce their risk of ASCVD events ASCVD, atherosclerotic cardiovascular disease Stone NJ, et al ACC/AHA Blood Cholesterol Guideline March 2012, Vol. 102, No. 3 SAMJ 15

16 Heart Failure and Hemodialysis No recommendation was made regarding the initiation or continuation of statin therapy in 2 specific groups: 1) individuals with NYHA class II IV heart failure, or 2) individuals undergoing maintenance hemodialysis. There is insufficient information on which to base recommendations for or against statin treatment. Future research may identify subgroups of patients with these conditions that may benefit from statin therapy. In individuals with these conditions, the potential for ASCVD risk reduction benefit, adverse effects, and drug-drug interactions along with other cautions and contraindications to statin therapy and choice of statin dose must also be considered by the treating clinician. Stone NJ, et al ACC/AHA Blood Cholesterol Guideline Practitioner challenges Lipids special case - Beurocracy Risk scoring and when unnecessary Funder resistance to funding lipograms Up titration instead of target dose Magazine wisdom Algorithm lags significantly behind current recommendations 16

17 Ongoing therapy Use of an initial fasting lipogram(total cholesterol, triglycerides, HDL C, and calculated LDL C), followed by a second lipid panel 4 to 12 weeks after initiation of statin therapy, to determine a patient s adherence. Thereafter, assessments should be performed every 3 to 12 months as clinically indicated. After statin therapy has been initiated, some individuals experience unacceptable adverse effects. The patient should be given lower doses of the same statin or alternative appropriate statin, until a statin and dose that have no adverse effects have been identified Stone NJ, et al ACC/AHA Blood Cholesterol Guideline Together we must.. Empower Know the patient s risk! Know the patient s LDL-C goal Emphasise safety 17

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19 Peripheral Arterial Disease and Carotid Artery Disease 19

20 Guidelines Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate for use in all circumstances Mechanism In 2003 SA Heart & LASSA officially adopted the ESC Guideline for the Prevention of Cardiovascular Disease. The ESC and EAS recently updated this document with the publication of the Guideline for the Management of Dyslipidaemias In October 2011 SA Heart, LASSA and a large variety of local role players met to review the ESC/EAS Guideline Following on this meeting, the South African DyslipidaemiaGuideline Consensus Statement was developed by a Writing Committee March 2012, Vol. 102, No. 3 SAMJ 20

21 Progression to first large vesseldisease event by HbA1c Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from participants in 26 randomised trials The Lancet 2010; 376:

22 Lancet 2011;378:1670 Effects on 11 year mortality and morbidity of lowering LDL with Simvastatin for 5 years in individuals (HPS group) Lancet 2010;376:1670 Efficacy and safety of more intensive lowering of LDL : data from participants in 26 randomised trials 22