2021 CCS Guidelines for management of dyslipidemia. A simplified approach

Review of the 2021 CCS Guidelines for
the Management of Dyslipidemia.
A simplified approach.
Dept. of Medicine, WCGH. June 23, 2021
Alfi Moris Beshay, MD, MSc, FRCPC

DISCLOSURE
• Speaker Honoraria: Amarin, Sanofi, Astra Zeneca
• Stock owner: Amarin (producer of Vascepa)

Learning objectives:
 Review of the 2021 CCS Lipid Guidelines.
 Is there really any change in the dyslipidemia management in 2021?
 How much different Is the new CCS Dyslipidemia Guidelines from the
ACC/AHA and the ESC Lipid Guidelines.

2021 Canadian
Cardiovascular
Society Guidelines
for the Management
of Dyslipidemia for
the Prevention of
Cardiovascular
Disease in the Adult
Pearson et al, 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular
Disease in the Adult, Canadian Journal of Cardiology; https://doi.org/10.1016/j.cjca.2021.03.016

Primary Prevention:
•Who & How to screen.
•Health Behaviour Interventions.
•Pharmacologic Treatment.
• Statin indicated Conditions
•Risk Assessment.
• Modified FRS (10Y)
• Cardiovascular Life Expectancy Model (CLEM) (30Y)

Secondary Prevention:
•Health Behaviour Interventions.
•Pharmacologic Treatment.
•Statin indicated Conditions
•Non-Statin add on

What’s Not New?
7
 Statin therapy continues to be recommended in subjects with:
• clinical atherosclerosis
• abdominal aortic aneurysm
• most subjects with diabetes or chronic kidney disease
• Low density lipoprotein cholesterol (LDL-C) ≥5 mmol/L

What’s Not New? Contd.
8
• intermediate-risk individuals with: LDL-C ≥ 3.5 mmol/L or Non-HDL-C≥ 4.2 mmol/L or ApoB ≥ 1.05 g/L or
Men ≥50 yrs and women ≥ 60 yrs with one additional risk factor: low HDL-C, IFG, high waist circumference, smoker or
HTN.
 Health behaviour modification, including regular exercise and a heart healthy diet, remain the
cornerstone of cardiovascular disease prevention

What’s New?
9
• Primary Prevention:
• Lipoprotein(a) measurement is now recommended once in a patient's lifetime as part of initial lipid
screening to assess cardiovascular risk

Apoprotein
NONPOLAR
LIPID
CORE
Cholesterol Ester
Triglyceride
POLAR
SURFACE COAT
Phospholipid
Free cholesterol
Lipoprotein Structure
Apoprotein
Apoprotein
Adapted from Treatment of Heart Diseases:1992, Etiologies and Treatment of Hyperlipidemia-Scott Grundy, MD, PhD

Lipoprotein Sub-Classes
1.20
1.10
1.06
1.02
1.006
0.95
5 10 20 40
Particle Size (nm)
60 80
1000
Chylomicron
Remnants
VLDL
LDL
HDL2
HDL3DL3
Density
(g/ml)
Chylomicron
VLDL
Remnants
Lp(a)
IDL
Atherogenic
(found in plaque)
pre-β2 HDL
pre-β1 HDL

Lp(a) Structure
Plasminogen
Plasmin
Apoprotein a
TG
CE
Polar
Surface Coat
(Phospholipids,
FC,
Apoproteins)
Apo B -
100

What’s New?
13
• Primary Prevention:
• Lipoprotein(a) measurement is now recommended once in a patient's lifetime as part of initial lipid
screening to assess cardiovascular risk
• For any patient with triglycerides 1.5 mmol/L
˃ , the preferred lipid parameter for screening, rather than
LDL-C is/are:
• non-high-density lipoprotein cholesterol, or
• apolipoprotein-B
• Updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision
tool to aid the decision to initiate statin therapy
• New recommendations on the preventative care of women with hypertensive disorders of pregnancy
• The CV benefit of icosapent ethyl in patients with TG ≥1.5 mmol/L who has DM & additional risk factor.

What’s New?
14
• Primary Prevention (Contd.):
• The introduction of the concept of CV Risk Modifiers which include:
• hsCRP ≥2.0 mmol/L,
• family history of premature CAD,
• high lipoprotein(a) [Lp(a)] ≥ 50 mg/dL (≥100 nmol/L) or
• CACS > 0

What’s New?
15
• Secondary Prevention:
• The concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with
non-statin agents.
• The secondary prevention patients have been shown to derive the largest benefit from
intensification of therapy with these agents.
• The CV benefit of icosapent ethyl in patients with TG ≥1.5 mmol/L and a prior CV event.
• The lack of CV benefit of omega-3 fatty acids from dietary sources or other
formulations/supplements.

Copyright © 2016, Canadian Cardiovascular Society
Anderson T, et al., Canadian Journal of Cardiology, DOI: http://dx.doi.org/10.1016/j.cjca.2016.07.510
Who to Screen

Who to screen
for dyslipidemia
in adults at
risk.1,
*
Men ≥40 years of age;
Women ≥40 years of age
(or post-menopausal)
Consider earlier in ethnic groups at
increased risk such as South Asian or
Indigenous individuals.
All patients with any of the following
conditions, regardless of age:
• clinical evidence of atherosclerosis
• abdominal aortic aneurysm (AAA)
• diabetes mellitus
• arterial hypertension
• current cigarette smoking
• stigmata of dyslipidemia (corneal arcus,
xanthelasma, xanthoma)
• family history of premature CVD†
• family history of dyslipidemia
• chronic kidney disease (eGFR ≤60
mL/min/1.73 m2
or ACR ≥3 mg/mmol)
• obesity (BMI ≥30 kg/m2
)
• inflammatory diseases (RA, SLE, PsA, AS,
IBD)
• HIV infection
• erectile dysfunction
• COPD
• history of hypertensive disorder of
pregnancy
Adapted from the 2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult.
† Men younger than 55 years of age and women younger than 65 years of age in first degree relatives.CVD =cardiovascular disease; eGFR =estimated glomerular filtration rate; ACR =albumin-to-creatinine ratio; BMI =body mass index; RA =rheumatoid
arthritis; SLE=systemic lupus erythematous; PsA =psoriatic arthritis; AS =ankylosing spondylitis; IBD=inflammatory bowel disease; HIV =human immunodeficiency virus; COPD =chronic obstructive pulmonary disease

How to Screen
For all:
history and physical examination.
standard lipid profile†
: TC, LDL-C, HDL-C, non-HDL-C*, TG
FPG or A1c
eGFR
lipoprotein(a) – once in patient's lifetime, with initial screening.
Optional:
Apolipoprotein B (ApoB)
Urine ACR (if eGFR <60 mL/min/1.73 m2
, hypertension, or diabetes)

Recommendations
1. Among women who have had a pregnancy complication such as hypertensive disorders of pregnancy,
gestational diabetes, pre-term birth, stillbirth, low birthweight infant, or placental abruption, we
recommend screening with a complete lipid panel in the late postpartum period, since these
women have a higher risk of premature CVD and stroke with onset 10-15 years after index delivery.
(Strong Recommendation; Moderate Quality Evidence).
2. We recommend counselling women who have any of these pregnancy-related complications of the
increased lifetime risk of ASCVD, and reinforcing the importance of healthy behaviours (i.e.
maintaining a healthy body weight, 150 weekly minutes of moderate intensity aerobic physical activity,
avoiding tobacco consumption, no more than moderate alcohol consumption, stress management, and
adopting a healthy dietary pattern, such as the Mediterranean diet) (Strong Recommendation; Low
Quality Evidence).
3. To assist with decisions about lipid-lowering pharmacotherapy in this patient population, we
recommend favouring CV age, over 10-year risk calculators (Strong Recommendation; Low
Quality Evidence)

Statin therapy not recommended for most low risk individuals
• exceptions include:
1. LDL-C ≥ 5.0 mmol/L (or non-HDL-C ≥5.8 mmol/L or ApoB ≥ 1 .45 g/L);
2. FRS is 5%-9.9% with LDL-C ≥ 3.5 mmol/L (or non-HDL-C ≥ 4.2 mmol/L or ApoB ≥1.05 g/L):
• particularly with other CV risk modifiers :
 Family history of premature CAD
 Lp(a) ≥ 50 mg/d [or ≥100 nmol/L]
 CACs >0 AU

Next Slide

LDL Cholesterol > 5 mmol/L
Rule out secondary causes
Positive Family History
First degree relative with LDL cholesterol
> 5 mmol/L
OR
Early coronary heart disease (<65 years in
women, <55 years in men)
OR
Physical findings in patient
• Obstructive liver disease
• Hypothyroidism
• Nephrotic syndrome
• Anorexia
+
-
+
CCS Position Statement on Familial Hypercholesterolemia (FH):
Diagnostic and Treatment Flow when FH is Suspected
Genest J et al. Canadian Journal of Cardiology 2014 30, 1471-1481DOI: (10.1016/j.cjca.2014.09.028)

When to Consider Pharmacological Treatment in Risk
Management
RECOMMENDATIONS
• Statin indicated conditions: We recommend management that includes statin therapy in
high risk conditions including clinical atherosclerosis, abdominal aortic aneurysm, most
diabetes mellitus, chronic kidney disease (age >50 years) and those with LDL-C ≥5.0 mmol/L
to lower the risk of CVD events and mortality (Strong Recommendation, High Quality
Evidence).
• Primary prevention:
a) We recommend management that does not include statin therapy for individuals at low risk
(modified FRS < 10 %) to lower the risk of CVD events (Strong Recommendation, High
Quality Evidence).
b) We recommend management that includes statin therapy for individuals at high risk
(modified FRS ≥ 20%) to lower the risk of CVD events (Strong Recommendation, High
Quality Evidence).
c) We recommend management that includes statin therapy for individuals at intermediate risk
(IR; modified FRS 10-19%) with LDL-C ≥3.5 mmol/L to lower the risk of CVD events. Statin
therapy should also be considered for IR persons with LDL-C <3.5 mmol/L but with apo B
≥1.2 g/L or non-HDL-C ≥4.3 mmol/L or in men ≥50 and women ≥60 years of age with ≥1 CV
risk factor (Strong Recommendation, High Quality Evidence).
Values and preferences - This recommendation applies to individuals with an LDL-C ≥1.8 mmol/L.
Any decision regarding pharmacological therapy for CV risk reduction in IR persons needs to include a
thorough discussion of risks, benefits, and cost of treatment, alternative nonpharmacological methods
for CV risk reduction and each individual’s preference. The proportional risk reduction associated with
statin therapy in RCTs in (IR) persons is of similar magnitude to that attained in high-risk persons.
Moreover, irreversible severe side effects are very rare and availability of generic statins results in low
cost of therapy. However, the absolute risk reduction is lower. Statin therapy may be considered in
persons with FRS of 5%-9% with LDL-C ≥3.5 mmol/L or other CV risk factors as the proportional
benefit from statin therapy will be similar in this group as well.

Lp(a): What is It ?
Why is It Dangerous ?
• Abnormal protein attached to LDL
• Genetic inheritance on
Chromosome #6
• One of the best predictors of
• Heart attack
• Coronary bypass surgery failure
• Carotid artery disease
• 50% of brothers/sisters and sons/daughters will have it
• Particularly bad if another abnormality is also present
• Difficult to measure accurately

Tsimikas, S. (2017). A Test in Context: Lipoprotein(a) Diagnosis, Prognosis, Controversies, and Emerging Therapies. Journal of the American College of Cardiology, 69(6), 695.
http://dx.doi.org/10.1016/j.jacc.2016.11.042

2021 CCS Guidelines for management of dyslipidemia. A simplified approach

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