Professional Documents
Culture Documents
StatsCan/Canada
Stakeholders in the
Elaboration
of Canadian Lipid Guidelines
Æ C-Change: Canadian Cardiovascular Harmonization
of National Guidelines Endeavor.
Class II
Conflicting evidence and /or a divergence of opinion about the usefulness /efficacy of the treatment
Class II a Weight of evidence in favor
A
Class III
Evidence that the treatment is not useful and in some cases may be harmful
C
Level of Evidence
Level
A
Data derived from multiple randomized clinical trials (RCT) or meta-analysis
Guiding Principles
Determine Cardiovascular
Risk
Institute Lifestyle
Changes
• Central obesity:
Æ Europids Men 94 cm Women 80 cm
§ South Asians Men 90 cm Women 80 cm
§ Chinese Men 90 cm Women 80 cm
§ Japanese Men 90 cm Women 80 cm
§ Ethnic south and central Americans: Use South Asian
recommendations
§ First Nations: Use South Asian recommendations until more specific
data are available.
§ Sub-Saharan African: Use European data until more specific data are
available
§ Eastern Mediterranean and middle east (Arab) populations: Use
European data
Determine Cardiovascular
Risk
Institute Lifestyle
Changes
imperfect
Canadians
FRS 10-19% at 10 years
o Family history and high hsCRP
modulate risk
o Reynolds Risk Score potentially
useful
Requires lifestyle changes
May require pharmacological
therapy
•
Moderate Risk Level
Pharmacological therapy indicated if:
§ LDL-C > 3.5 mmol/L (apoB > 1.00
A g/L)
§ TC/HDL-C ratio > C5.0
§ hsCRP > 2mg/L in men over 50, B
women over 60
– hsCRP should be performed selectively
•
Consider cost/benefit of preventative
therapy
Discuss and weigh patient’s desire
•
Treatment for the Moderate Risk
Supported by Primary Prevention
Data
The indications for pharmacological
interventions are based on the statin
primary prevention studies including:
è AFCAPS/TexCAPS
è WOSCOP
è ASCOT
è HPS
è JUPITER
6
Hazard Ratio 0 . 56
5 ( 95 % CI 0 . 46 - 0 . 69 )
P < 0 . 00001 Rosuvastatin 20 mg
primary endpoint
4
3
2
1
0
0 1 2 3 4 5 Years
Number at risk
RSV 8901 8412 3893
1353 538 157
Placebo 8901 8353 3872
1333 531 174
genetic dyslipidemia
§ Use clinical judgment, proper timing
§ Careful family history for added risk
factors
§ RRS can re-classify low-risk patients
•
Guiding Principles
Determine Cardiovascular
Risk
Institute Lifestyle
Changes
ÆSmoking cessation
ÆDiet: fruit, vegetables,
decreased saturated fats,
decreased salt intake
ÆCalorie restriction for ideal body
weight
ÆDaily exercise (30-60 min)
ÆStress management
Guiding Principles
Determine Cardiovascular
Risk
Institute Lifestyle
Changes
A A
Target Levels
Risk Level Primary
Initiate treatment if : Primary
High Consider treatment in < 2 mmol
LDL - C /L
all patients Or Alternate
↓50% LDL-C
Moderate
CAD,PVD (strive towards ) ApoBmmol
< 2 /L
<0.80
FRS 10-19% LDL-C>3.5 mmol/L
Atherosclerosis Or ↓50% LDL-C
Most Pts with Diabetes TC/HDL >5.0 ApoB<0.80
FRS>20% hsCRP >2 Class I Level A
RRS>20% men Class I Level A
50+, women 60+ A A
Family history and hsCRP modulate
risk Class IIA Level A
Class IIA Level A
Low ↓50% LDL-C
FRS<10% LDL-C>5.0mmol/L
A A
A
Residual Risk (When LDL-C at
target)
OPTIONAL Secondary Targets
Test Cut-point Intervention
TC/HDL-C >4.0 Niacin
Fibrate
Fibrate
Ezetimibe
Abourbih S and Eisenberg M. 2009 Am J Med (2009 Aug 19. [Epub ahead of print])
Fibrates and Mortality
Abourbih S and Eisenberg M. 2009 Am J Med (2009 Aug 19. [Epub ahead of print])
Pharmacotherapy (HDL-
Cholesterol)
Apo AI Prod
LxR agonists
Torcetrapib
Dalcetrapib (RO4607381/JTT-705)
Anacetrapib
HIGH CAD
FRS > 20% PVD
RRS > 20% Atherosclerosis
Family history
(strive towards )
LOW LDL-C > 5.0mmol/L ↓ LDL-C 50%
FRS < 10%
A
* Only screen for hsCRP in men ≥ 50 and women ≥ 60 if they do NOT already have CVD, diabetes, multiple risk factors, family history or hyperlipidemia