CV Risk guidelines for Argentina: What and how to follow? Gerardo - PowerPoint PPT Presentation

CV Risk Management 2017 Applying the latest insights to clinical care Buenos Aires - Argentina April 8, 2017 CV Risk guidelines for Argentina: What and how to follow? Gerardo Damian Elikir Argentine Society of Lipids Argentine Lipids Society Guidelines 2016

Clinical Practice Guidelines on Diagnosis and Treatment of Dyslipidemias in Adults 2016 • Background • Methodology Argentine Lipids Society Guidelines 2016 2

Authorship On behalf of Committee on Standards and Consensus Argentine Lipids Society Guidelines 2016 3

Contents 1.Introduction 1.1.Methodology 1.2.Dyslipidemia and atherosclerosis 1.2.1.Atherosclerosis 1.2.2.Atherogenic lipoproteins: estimation through non-HDL-cholesterol 1.2.3.Low HDL-cholesterol 1.2.4.Triglycerides 2.Studies and diagnosis 2.1.The clinical laboratory in the diagnosis of dyslipidemia 2.1.1.Pre analytic variables 2.1.2.Analytic variables 2.1.3.Indices 2.2.Genetic studies 2.3.Risk stratification 3.Clinical Scenarios 3.1.Menopause 3.2.Secondary dyslipidemias 3.2.1.Hypothyroidism 3.2.2.Cholestasis 3.2.3.Drugs induced dyslipidemias 3.3.Renal disease 3.4.Metabolic syndrome and diabetes mellitus 3.4.1.Metabolic syndrome 3.4.2.Diabetes mellitus 3.5.Dyslipidemia in HIV patients 4.Treatment 4.1.General considerations 4.1.1.How long should lipid-lowering treatment be sustained? 4.1.2.Life-style modifications 4.2.Lipid-lowering drugs intolerance 4.2.1.Relevance of myopathies 4.3.Treatment of hypercholesterolemia 4.3.1.Statins 4.3.2.Ezetimibe 4.3.3.Combined treatment 4.4.Treatment of mixed hyperlipidemia and low HDL-c (“Residual risk”) 4.5.Treatment of severe hypertriglyceridemia 4.5.1.Omega-3 fatty acids 4.5.2.Fibrates 4.5.3.Niacin 4.5.4.Other therapeutic modalities 4.6.Treatment of altered HDL 4.7.Algoritms 5.Conclusions 6.Bibliography Argentine Lipids Society Guidelines 2016 4

1.2.Dyslipidemia and Atherosclerosis • Lipoprotein metabolism • Atherosclerosis • Atherogenic lipoproteins: estimation through non- HDL-cholesterol • Low HDL-cholesterol • Pathogenic role for triglycerides Argentine Lipids Society Guidelines 2016 5

2.Studios and diagnosis 1. The clinical laboratory in the diagnosis of dyslipidemia 2. Genetic studies 3. Clinical assessment of cardiovascular risk Argentine Lipids Society Guidelines 2016 6

2.1. The clinical laboratory in the diagnosis of dyslipidemia • Pre analytic variables • Analytic variables • Indices Argentine Lipids Society Guidelines 2016 7

2.2. Genetic studies • There are available several genetic scores for diagnosis and for prognostic • Genetic studies are not recommended for estimating cardiovascular risk • Genetic study would be reserved to confirm the clinical diagnosis of familial hypercholesterolemia (HF) in the index case and to facilitate the diagnosis of the relatives (cascade diagnosis) Argentine Lipids Society Guidelines 2016 8

2.3. Clinical assessment of cardiovascular risk Intensity of interventions should be proportional to the total cardiovascular risk WHO / ISH cardiovascular risk prediction chart Recommended by National Ministry of Health Argentine Lipids Society Guidelines 2016 9

WHO Member States by subregion, classified according to mortality stratum (based on World Health Report 2002 ) Subregion WHO Member States Region of the Americas A Canada, Cuba, United States of America Antigua and Barbuda, Argentina , Bahamas, Barbados, Belize, Brazil, Chile, Colombia, Costa Rica, Dominica, Dominican Republic, B El Salvador, Grenada, Guyana, Honduras, Jamaica, Mexico, Panama, Paraguay Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Uruguay, Venezuela C Bolivia, Ecuador, Guatemala, Haiti, Nicaragua, Peru Prevention of Cardiovascular Disease: guidelines for assessment and management of total cardiovascular risk

WHO / ISH risk prediction chart for AMR B. 10-year risk of fatal or non- fatal cardiovascular event by gender, age, systolic blood pressure, smoking status and presence or absence of diabetes mellitus This chart can only be used for countries of the WHO Region of the Americas, sub-region B, in settings where blood cholesterol can be measured CVD risk may be higher than indicated in the chart in people who are already on antihypertensive therapy, in women who have undergone premature menopause, in people approaching the next age category, and in individuals with any of the following: • obesity (including central obesity); • a sedentary lifestyle; • a family history of premature CHD or stroke in a first degree relative (male < 55 years, female < 65 years); • a raised triglyceride level (> 2.0 mmol/l or 180 mg/dl); • a low HDL cholesterol level (< 1 mmol/l or 40mg/dl in males, < 1.3 mmol/l or 50 mg/dl in females); • raised levels of C-reactive protein, fibrinogen, homocysteine, apolipoprotein B or Lp(a), or fasting glycaemia, or impaired glucose tolerance; • microalbuminuria (increases the 5-year risk of diabetics by about 5%) (38, 83, 85); • those who are not yet diabetic, but have impaired fasting glycemia or impaired glucose tolerance; • a raised pulse rate. Other risk factors not included in these risk prediction charts such as socioeconomic deprivation and ethnicity should also be taken unto account in addressing and managing a person’s overall CVD risk. Prevention of Cardiovascular Disease: guidelines for assessment and management of total cardiovascular risk

WHO / ISH risk prediction chart for AMR B. 10-year risk of fatal or non- fatal cardiovascular event by gender, age, systolic blood pressure, smoking status and presence or absence of diabetes mellitus This chart can only be used for countries of the WHO Region of the Americas, sub-region B, in settings where blood cholesterol CANNOT be measured Prevention of Cardiovascular Disease: guidelines for assessment and management of total cardiovascular risk

2.3. Clinical assessment of cardiovascular risk When can treatment decisions be made without the use of risk prediction charts? High risk conditions Disease specific Subclinical atherosclerosis ASCVD • LDL ≥ 190 mg/dL (4.9 mmol/L) • Angina pectoris • Chronic renal disease • Coronary heart disease Evidence of atherosclerosis by: • Inflammatory diseases (RA, • Myocardial infarction • Coronary angiography SLE, PSO) • Familial Hypercholesterolemia • Transient ischaemic attacks • Non-invasive imaging • Cancer survivors • Diabetes Mellitus • Stroke (from AS origin) • Coronary calcium score • Transplant recipients • Peripheral vascular disease • Altered myocardial perfusion • Metabolic syndrome • Coronary revascularization • Ankle brachial index Hypoalfalipoproteinemia • Carotid endarterectomy • Lp(a) >50 mg/dL (>75 nmol/L) Argentine Lipids Society Guidelines 2016 13

3. Clinical scenarios 1. Menopause 2. Secondary dyslipidemias 1. Hypothyroidism 2. Cholestasis 3. Drugs induced dyslipidemias 3. Renal disease 4. Metabolic syndrome and diabetes mellitus 5. Dyslipidemia in HIV patients Argentine Lipids Society Guidelines 2016 14

3.1. Menopause • Estrogens have beneficial effects on the lipid profile • Menopause is associated with increased cardiovascular risk • In post menopausal women: • Clinical assessment of CVD risk • Treat concomitant conditions (DYS, HBP, T2DM) • HRT: women 50-59 years-old w/menopause <10 years Argentine Lipids Society Guidelines 2016 15

3.2. Secondary dyslipidemias 1. Hypothyroidism • Very frequent cause of dyslipidemia • Treatment is controversial 2. Cholestasis • Treat the cause (autoinmune hepatitis, primary biliar cirrosis, vanishing bile duct syndrome) • Statins are not contraindicated 3. Drugs induced dyslipidemias • Interactions FK / FD Argentine Lipids Society Guidelines 2016 16

3.3. Chronic kidney disease • High risk condition with specific alterations on lipids • “Conventional” risk factors are very common • “Specific” risk factors can worse the prognosis: calcium-phosphorus metabolism, nutrition, anemia • Statins should start before renal replacement therapy • Adjust doses to renal function (e.g. fibrates) Argentine Lipids Society Guidelines 2016 17

3.4. Diabetes, metabolic syndrome and obesity • Metabolic syndrome identifies high risk subjects. Independent contribution of each component is controversial • Abdominal obesity is defined using regional cut points (IDF): • ♀ 80cm; ♂ 94cm • Glycemic control contribute to improve lipoprotein alterations and lipid-lowering treatment is key to reduce high risk on T2DM patients • Consider absolute risk: • <40 years and recent DM: no statins • > 40 years without risk factors: moderate efficacy statins • > 40 years with risk factors: high efficacy statins Argentine Lipids Society Guidelines 2016 18

3.5. Human immunodeficiency virus infection • Lipid profile varies according stage of HIV infection and treatment • Similar approach to dyslipidemias than general population. Drug interactions is an issue • Consider changing on antiretroviral therapy before starting lipid-lowering drugs (if suitable!) Argentine Lipids Society Guidelines 2016 19

4. Treatment: general considerations • How long should treatment be sustained? • Therapeutic life-style modifications Argentine Lipids Society Guidelines 2016 20