Managment of Dyslipidemia.ppt
- 2. Presentation Objectives • State the major goals of the Adult Treatment Panel (ATP) III Guidelines. • Describe the new risk stratification process, low density lipid (LDL) goals and the Framingham assessment. • State the major medications used to lower cholesterol and their common side effects. • Describe the management of low high density lipids (HDL), elevated triglycerides (TGs) and the metabolic syndrome.
- 3. National Cholesterol Education Program (NCEP) • Adult treatment Panel I (1988) – primary prevention in those with high LDL • Adult treatment panel II(1993) – reaffirmed the above, plus emphasis on intensive management of LDL in those with established coronary heart disease (CHD) • Adult treatment panel III (2001)
- 4. New features of ATP III • Focus on multiple risk factors • Modification of lipid and lipoprotein classification • Support for implementation
- 5. Risk Group AACE 2020 NLA ESC/EAS 2019 CCS 2018 IAS Extreme LDL-C < 55 mg/dl NON-HDL-C < 80 mg/dl Very high LDL-C < 70 mg/dl NON-HDL-C < 100 mg/dl LDL-C < 70 mg/dl NON-HDL-C < 100 mg/dl LDL-C < 55 mg/dl (< 1.4 mmol/l) NON-HDL < 80 mg/dl (< 2.2 mmol/l) LDL-C < 2.0 mmol/l).Non-HDL < 2.6 mmol/l LDL-C < 70 mg/dl NON-HDL-C < 100 mg/dl High LDL-C < 100 mg/dl NON-HDL-C < 130 mg/dl LDL-C < 100 mg/dl NON-HDL-C < 130 mg/dl LDL-C < 70 mg/dl (< 1.8 mmol/l) NON-HDL < 100 mg/dl (<2.6 mmol/l) LDL-C < 2.0 mmol/l).Non-HDL < 2.6 mmol/l LDL-C < 100 mg/dl NON-HDL-C < 130 mg/dl Moderate LDL-C< 100 mg/dl NON-HDL-C < 130 mg/dl LDL-C < 100 mg/dl NON-HDL-C < 130 mg/dl LDL-C < 100 mg/dl (< 2.6 mmol/l) NON-HDL < 130 mg/dl (< 3.4 mmol/l) LDL-C < 2.0 mmol/l).Non-HDL < 2.6 mmol/l LDL-C < 100 mg/dl NON-HDL-C < 130 mg/dl Low LDL-C< 130 mg/dl NON-HDL-C < 160 mg/dl LDL-C < 100 mg/dl NON-HDL-C < 130 mg/dl LDL-C < 116 mg/dl (< 3 mmol/l) Secondary Prevention Primary Prevention Classification of LDL cholesterol
- 6. Management of Specific conditions • ATP III Classification of elevated triglycerides: • <150 normal • 150-199 borderline high • 200-499 high • >500 very high
- 7. Management of specific conditions • Treatment of elevated triglycerides: – when TGS > 500 then need to lower triglycerides first to prevent pancreatitis. – Otherwise need to reach LDL goal first, then non- HDL goal (LDL goal + 30 for VLDL). – Increase physical activity, intensify weight management first, then use fibrates or nicotinic acid to reduce VLDL and triglycerides.
- 8. The Management of Specific Conditions • Any three of the following: – 1. Abdominal Obesity • Waist circumference ( >40 in M, >35 in F) – 2. Triglycerides >150mg/dl – 3. HDL Cholesterol • <40 mg/dl in M, <50mg/dl in F – 4. Blood Pressure >130/>85 mmHg – 5. Fasting Glucose >110mg/dl 4. The Metabolic Syndrome:
- 9. Treatment of the Metabolic Syndrome: • Recognized as secondary target of risk reduction therapy after LDL cholesterol. – 1. Treat underlying causes • intensify weight management • increase physical activity – 2. Treat risk factors if they persist after lifestyle therapies. • Treat HTN, Use ASA for CHD, Treat increased triglycerides &/or Low HDL. The Management of Specific Conditions
- 10. Interventions to Improve Adherence • Simplify medication regimes. • Use good counseling techniques with patients. • Involve patients and their families in their care. • Increase visits / access to achieve goals. • Reinforce and reward compliance. • Multidisciplinary approach within the clinic. • Physician reminders to prompt attention to lipid management.
- 11. THE USE OF OMEGA-3 (EPA +DHA) IN HYPERTRIGLYCERIDEMIA, ESC 2019
- 12. Skulas-Ray AC et al. Circulation 2019 Aug 19 Prescription n-3 FAs (EPA+DHA or EPA- only) at a dose of 4 g/d (>3 g/d total EPA+DHA) are an effective and safe option for reducing triglycerides as monotherapy or as an adjunct to other lipid-lowering agents. All prescription agents appear comparably effective, but head-to-head comparisons are lacking AHA ScienceAdvisory
- 13. AHA Science Advisory 2019 Concerns have been raised that DHA-containing prescription agents may raise LDL-C in patients with HTG. We identified 9 trials of patients with HTG that reported effects on LDL-C with 4 g/d of DHA containing prescription n-3 FA (8 studies of O3AEE and 1 study of O3CA). In 8 of these 9 studies, there was no change in LDL-C versus placebo (4 of which used n-3 FA as an adjunct to statin therapy), whereas in 1 study, the median LDL-C was marginally increased by 3.5% versus placebo (P=0.052).31 This is similar to the change reported in REDUCE-IT, with a median increase in LDL-C of 3.1% from baseline (P<0.001) for EPA-only. Skulas-Ray AC et al. Circulation 2019 Aug 19
- 14. The use of Omega-3(EPA+DHA) in Hypertriglyceridemia, ESC2019
- 15. Take Home Messages • Focus on Multiple Risk Factors • New Lipid and Lipoprotein Classification • New recommendations for screening • More intensive tender loving care • New strategies for compliance
- 16. THANK YOU
Editor's Notes
- #6: While LDL-C has long remained the primary target, other markers such as non-HDL-C or apoB may offer improved ASCVD risk prediction. Clinical scenarios often arise in whichLDL-C has a "discordant" risk compared to non-HDL-C and apoB with LDL-C being relatively low but the atherogenic particle burden remaining high.11 In this situation, non-HDL-C and apoB appear to be better predictors of ASCVD events and should be considered in addition to LDL-C levels. This scenario typically occurs when patients have triglycerides above 200 mg/dL. Based upon this, both the AACE and ESC guidelines have suggested that non-HDL-C and/or apoB be assessed and targeted in patients with TG >200 mg/dL.