Managing CV Risk in Argentina: How well are we doing and where can - PowerPoint PPT Presentation

Managing CV Risk in Argentina: How well are we doing and where can we improve? Alberto J. Lorenzatti, MD Chief Cardiovascular Prevention, Cardiology Dept, Hospital Córdoba, Córdoba, Argentina Co-Director of Instituto Médico DAMIC/Fundación Rusculleda for Research and Medical Education, Córdoba, Argentina Founder and Ex President of the Argentine Lipid Society Chair of the International Atherosclerosis Society Regional Americas Federation

Worlwide mortality causes – 1990 - 2020 Disorder Position Position In 1990 in 2020 Ischaemic heart disease 1 1 Cerebrovascular disease 2 2 Lower respiratory infections 3 4 Diarrhoeal diseases 4 11 Perinatal disorders 5 16 Chronic obstructive pulmonary disease 6 3 Tuberculosis 7 7 Measles 8 27 Road traffic accidents 9 6 Trachea, bronchus, and lung cancers 10 5 Malaria 11 29 Self-inflicted injuries 12 10 Cirrhosis of the liver 13 12 Stomach cancer 14 8 Diabetes mellitus 15 19 2 Murray CJL, Lopez AD. Lancet 1997;1498-504

Global Burden of Diseases: comparison 2000-2013 GBD 2013 Risk Factors Collaborators. Lancet 2015;386:2287-323

CV Mortality in developed and developing countries 2020 Developed countries 6 Developing countries 1990 1990 5 Deaths (millions) * 19 9 *9,3 million deaths in subjects 30-60 years 4 Adapted from Reddy KS. N Engl J Med.2004;350:2438-2440.

Figure 1 NCD in Latin America Global Heart 2012 7, 73-81DOI: (10.1016/j.gheart.2012.02.002) Source: 2012 World Heart Federation

Dyslipidemia in seven Latin American cities: CARMELA study Men (%) CI Women (%) CI Barquisimeto 75.5 71.9 – 79.1 48.7 45.4 – 51.9 Bogota 70.0 66.2 – 73.8 47.7 43.9 – 51.5 Buenos Aires 50.4 46.8 – 54.0 24.1 21.0 – 27.2 Lima 73.1 69.3 – 76.8 62.8 59.2 – 66.5 Mexico City 62.5 58.5 – 66.5 37.5 33.5 – 41.6 Quito 52.2 47.9 – 56.5 38.1 34.5 – 41.7 Santiago 50.8 47.1 – 54.4 32.8 29.3 – 36.3 Dyslipidemia: triglycerides≥200 mg/dL, or total cholesterol (TC)≥240 mg/dL, or HDL cholesterol <40 mg/dL, or LDL cholesterol=not optimal, or currently taking antilipemic agents. The most frequent dyslipidemia was low HDL-C followed by high triglycerides. The high TC/HDL-C ratios and non- HDL-C levels suggest a high risk of cardiovascular disease. Preventive Medicine 50 (2010) 106 – 111

The InterHeart Latam Study • INTERHEART Latam: 1,237 cases and 1,888 control subjects were from 6 Latin American countries (Argentina, Brazil, Colombia, Chile, Guatemala, and Mexico) • Obesity has become a major health problem in Latin America. Abdominal obesity PAR: 45.8% (95% CI: 35.8 to 56.2) • Dyslipidemia, assessed by the apo B/apo A-1 ratio, is the second PAR in the region: 40.8% (95% CI: 30.3 to 52.2) • Current and former smoking was the third leading cause of AMI, according to PAR: 38.4% (95% CI: 32.8 to 44.0) • The strongest association with AMI, with an odds ratio (OR) of 2.8, corresponded to a history of hypertension and permanent stress. Lanas F, et al. The Interheart Latin America Study. Circulation 2007, Mar 6;115(9):1067-74

The InterHeart Latam Study • CVD risk factors are highly prevalent in Latin America. • Prevalence varies by sex, education, and socioeconomic level. • A more intensive and integrated approach to individual and population-level prevention is needed to reduce the burden of CVD in the region. • Lessons from recent advances in CVD control in specific countries should be learned and implemented by other countries in Latin America Lanas F, et al. The Interheart Latin America Study. Circulation 2007, Mar 6;115(9):1067-74

Argentina: 3 rd National Survey on Risk Factors Tercera Encuesta Nacional de Factores de Riesgo para Enfermedades no Transmisibles. 10 de Julio de 2015. Buenos Aires, Argentina. ISBN: 978-950-38-0218-2

ENFR 2013: Smoking / HTN > 18 y/o 2005 2009 2013 Smoking % % % Prevalence 29.7 27.1 25.1 CI (28.7-30.8) (26.3-27.9) (24.2-26.2) 20% Hypertension % % % Prevalence 34.5 34.6 34.1 3/10 CI (33.3-35.7) (33.6-35.5) (32.9-35.3) Tercera Encuesta Nacional de Factores de Riesgo para Enfermedades no Transmisibles. 10 de Julio de 2015. Buenos Aires, Argentina. ISBN: 978-950-38-0218-2

ENFR 2013: Cholesterol / Diabetes > 18 y/o 2005 2009 2013 Hyperchol % % % Prevalence 27.8 29.1 29.8 7% CI (26.5-29.1) (28.1-30.2) (28.5-31.1) T2DM % % % Prevalence 8.4 9.6 9.8 17% CI (7.8-9.1) (9.1-10.1) (9.1-10.4) Tercera Encuesta Nacional de Factores de Riesgo para Enfermedades no Transmisibles. 10 de Julio de 2015. Buenos Aires, Argentina. ISBN: 978-950-38-0218-2

ENFR 2013: Overweight / Obesity > 18 y/o 2005 2009 2013 Overweight % % % Prevalence 34.4 35.4 37.1 4/10 CI (33.4-35.5) (34.6-36.3) (36.0-38.2) 34.4% Obesity % % % Prevalence 14.6 18.0 20.8 2/10 CI (13.9-15.5) (17.4-18.7) (19.9-21.8) 42.5% Tercera Encuesta Nacional de Factores de Riesgo para Enfermedades no Transmisibles. 10 de Julio de 2015. Buenos Aires, Argentina. ISBN: 978-950-38-0218-2

National Survey of ST-Segment Elevation Acute Myocardial Infarction in Argentina (ARGEN-IAM-ST) National Survey of ST-elevation Myocardial Infarction in Argentina (ARGEN-IAM-ST) Rev Fed Arg Cardiol . 2017 (46) Enero/Marzo

How do you evaluate your patient ’ s CV risk?  Using FRS, SCORE chart or similar  ASCVD risk calculator is better  Just Classical Risk Factors presence matter  I trust in my clinical judgment 14

Unmet Need: Identifying High Risk and Very High Risk Patients • Patients with LDL-C levels > 190 mg/dL • ASCVD patients • T2DM/MS plus ASCVD • Multiple risk factors • CKD • Inflammatory diseases (RA, Psoriasis, etc)

How to identify patiens at risk? Very high LDL-C HDL , LDL = ó , , LDLs&d, TG Frecuency 1/350 Frecuency 1/5 LDL-C >190mg/dL LDL-C 90mg/dL LDL-C no es categórico Familiar Hipercholesterolemia Metabolic Dyslipidemia Simple Gen Multiples Genes & Environment

Only a small fraction of those with very high LDL- C levels carry one of the known genes that cause FH FH causative genes (LDLR, APOB, PCSK9) were sequenced in 26,025 participants: 7 case- control studies (5,540 CAD cases, 8,577 CAD-free controls) and 5 prospective cohort studies (11,908 individuals). Among those with LDL- C ≥190 mg/dl, gene sequencing identified a FH mutation in <2%. FH mutation carriers were at substantially increased risk for CAD Group Odds ratio (95% CI) LDL <130 mg/dL, FH mutation negative Reference LDL >190 mg/dL, FH mutation negative 6.0 (5.2 – 6.9) LDL >190 mg/dL, FH mutation positive 22.3 (10.7 – 53.2) Khera AV, et al. J Am Coll Cardiol . 2016. doi:10.1016/j.jacc.2016.03.520

The same LDLc level… but different level of risk • Mr LAM • Mr JCR • 55 y/o Man • 55 y/o Man • LDL 90 mg/dL • LDL 90 mg/dL • HDL 55 mg/dL • HDL 25 mg/dL • SBP 120 mmHg • SBP 140 mmHg • Non smoker • Smoker • hs-CRP 2 mg/L • hs-CRP 5mg/L • No Family Hx ASCVD • Family Hx ASCVD 5 years risk = 8%; NNT 31 5 years risk = 2%; NNT 125

CKD - Dyslipidemia • Dyslipidemia and Cardiovascular morbidity – Several studies such as a the 4D study showed no benefit of statins in dialysis patients. – However, post hoc analysis of this data does suggest that the management of dyslipidemia in CKD 2 – 4 improves cardiac mortality and morbidity. – Dyslipidemia is frequently seen in glomerular disease with proteinuria (nephrotic syndrome) and its control reduces atherosclerosis related morbidity and mortality.

Very High Risk Patients Not Achieving LDL-C Goal <70mg/dL (1.81mmol/L) Mitchell et al. BMC Cardiovascular Disorders (2016) 16:74 DOI 10.1186/s12872-016-0241-3

High Risk Patients Not Achieving LDL-C Goal <100mg/dL (2.56mmol/L) Mitchell et al. BMC Cardiovascular Disorders (2016) 16:74 DOI 10.1186/s12872-016-0241-3

Lipid control in Diabetic patients: rates ranged from 40% to 50% in DM patients with no CVD hx (LDLc goal <100 mg/dL) and only 15% in DM patients with a hx of CVD (LDLc goal <70 mg/dL). De La Sierra A, et al. Adv Ther. 2015; 32(10): 944 – 961.

Challenges for CV prevention in Argentina • How to face the epidemic Obesity? • How to address metabolic dyslipidemia? • What about other risk factor control? • CV risk management in the country: How to identify high risk patients? • The future of CV Risk management: How to apply novel insights?

Challenges for CV prevention in Argentina  Set Priorities  Strengthen Primary Care  Aplying Local Clinical Guidelines  Reduce Economic Barriers to Access  Reinforce on Clinical and Population-Level Prevention (eg. Salt, Tobacco, Alcohol, etc)  Prevention Policies & Adoption of Cost- Effective Interventions

Concluding Remarks • Classical risk factors are still highly prevalent • Tobacco consumption is decreasing • There is a dramatic increase in overweight / obesity among adult general population in Argentina • Diabetes and Metabolic Syndrome is increasing as well

Concluding Remarks • The presence of high and very high cardiovascular risk is a common situation in clinical practice • The identification and treatment of commonly associated dyslipidemia is crucial for reducing unacceptable high cardiovascular morbidity and mortality