ESC/EAS Guidelines for the Management of Dyslipidaemias Professor Željko Reiner, MD, PhD, FRCP(Lond), FESC, FACC University Hospital Center Zagreb School of Medicine, University of Zagreb, Croatia Declaration of interest: speaker for Pfizer, Abbott, AstraZeneca, Bayer,
Dyslipidemia guidelines - for whom did we write them? Primarily for cardiologists and GPs (but also for internists, lipidologists, diabetologists etc.) NOT ONLY CARDIOLOGISTS! Cardiologists, but particularly GPs are overwhelmed with different guidelines (PubMed: guidelines 206,091; guidelines - CVD 28,540; guidelines lipids 4,520!)
Dyslipidaemia guidelines important messages Prevention and treatment of dyslipidaemias should always be considered within the broader framework of CVD prevention - the assessment of total CVD risk is necessary Target values are not the most important!
Grading the evidence While it gives the highest grading to randomized control trials and meta-analyses, it inevitably favours drug treatments over lifestyle measures Different types of evidence are needed when considering, for example, lifestyle measures, causality, screening and diagnostic techniques as opposed to therapeutic interventions The concept of grading was finally accepted and implemented throughout the guidelines
Classes of recommendations
Levels of evidence
Risk levels - mortality or morbidity? CVD events instead of CVD mortality data for calculating the total CVD risk? Reliable data on CVD events for a number of European countries are lacking and non-fatal events vary by choice of criteria and/or definitions, advances in the treatment and ascertainment The SCORE risk of CVD mortality of 5 corresponds to 15 in the equations considering mortality and morbidity (1:3)
Total CVD risk estimate is part of a continuum - the cut points that are used to define high risk are in part arbitrary Previous guidelines - a split up of the asymptomatic population into 2 groups: high risk (SCORE > 5%) in whom preventive action should be maximized (interpreted often as "all on lipid-lowering drugs and/or all on antihypertensives") and SCORE < 5% in whom nothing was done Not only high risk subjects should be identified and managed but also those at moderate risk (the large majority) - professional advice regarding lifestyle changes and some of them drug therapy.
Intervention strategies as a function of total CV risk and LDL-C level
Recommendations for treatment targets for LDL-C
Diabetes In patients with type 2 diabetes lipid lowering therapy is recommended irrespective of their basal LDL-C. In patients with type 2 diabetes and CVD or CKD and in those without CVD who are over age of 40 years with one or more other CVD risk factor the recommended goal for LDL-C is < 1.8 mmol/l (< ~ 70mg/dL) and for apo B < 80 mg/dl. LDL-C < 2.5 mmol/l (< ~ 100 mg/dl) or apo B < 100 mg/dl are the recommended targets in all people with type 2 diabetes.
Familial hypercholestrolaemia In patients with familial hypercholesterolaemia (FH) irrespective of their basal LDL-C, LDL-C goal is the same as for high risk subjects (<2.5 mmol/l (<~ 100mg/dL) FH in the presence of CVD the LDL-C goal is the same as for very high risk subjects (>1.8 mmol/l (<~ 70 mg/dl) If targets cannot be reached, maximal reduction of LDL- C should be considered using appropriate drug combinations in tolerated doses
Combination therapy If LDL-C target level is not reached, statin combination with a cholesterol absorption inhibitor or bile acid sequestrant or nicotinic acid might be considered. In combined dyslipidemia an increase of HDL-C and a decrease of TG on top of the LDL-C reduction that can be achieved with a statin, may be considered. Therefore a combination of statin with niacin can be considered but the adverse effect of flushing may affect compliance. A combination of statins with fibrates can also be considered but the combination with gemfibrozil should be avoided. If TG are not controlled by diet, statins and/or fibrates, prescription of n-3 fatty acids may be considered to further decrease TG and these combinations are safe and well tolerated.