Guidance in CV Risk management: How to deal with international - - PowerPoint PPT Presentation

▶
guidance in cv risk management
SMART_READER_LITE
LIVE PREVIEW

Guidance in CV Risk management: How to deal with international - - PowerPoint PPT Presentation

Mar 17, 2023 335 likes •670 views

Guidance in CV Risk management: How to deal with international guidelines? Philip Barter School of Medical Sciences University of New South Wales Sydney, Australia Disclosures Received honorariums for participating as a consultant or as a

slide-1
SLIDE 1

Guidance in CV Risk management: How to deal with international guidelines?

Philip Barter School of Medical Sciences University of New South Wales Sydney, Australia

slide-2
SLIDE 2

Received honorariums for participating as a consultant or as a member of advisory boards for AMGEN, AstraZeneca, CSL-Behring, Lilly, Merck, Novartis, Pfizer and Sanofi and for giving lectures for AMGEN, AstraZeneca, Merck and Pfizer.

Disclosures

slide-3
SLIDE 3
  • Smoking
  • Elevated LDL-C
  • Elevated triglyceride-rich lipoproteins
  • Reduced HDL-C
  • Elevated blood pressure
  • Diabetes
  • Abdominal obesity

Modifiable risk factors for Atherosclerotic Cardiovascular Disease (ASCVD)

slide-4
SLIDE 4
  • Smoking
  • Elevated LDL-C
  • Elevated triglyceride-rich lipoproteins
  • Reduced HDL-C
  • Elevated blood pressure
  • Diabetes
  • Abdominal obesity

Modifiable risk factors for Atherosclerotic Cardiovascular Disease (ASCVD)

slide-5
SLIDE 5

Treatment with statins reduces the risk of having an atherosclerotic cardiovascular event

slide-6
SLIDE 6

In these statin trials, the more the LDL-C is reduced, the greater is the reduction in risk of having an event.

slide-7
SLIDE 7

CTT Collaboration. Lancet 2005; 366:1267-78; Lancet 2010;376:1670-81.

Relationship of CVD events to LDL-C reduction achieved in statin clinical trials

slide-8
SLIDE 8

And the lower the achieved level of LDL-C, the lower the risk of having an event

slide-9
SLIDE 9

10 20 30

CARE-Pra LIPID-Pra 4S-Sim CARE-Plac LIPID-Plac 4S-Plac

Secondary Prevention Statin Trials

Achieved LDL-C Levels vs Events

210 90 110 130 150 170 190

LDL-C (mg/dL) % with CHD event

70

TNT-Ator10 TNT-Ator80 HPS-Plac HPS-Sim IDEAL-Sim IDEAL-Ator

slide-10
SLIDE 10
  • ESC/EAS (2016)
  • NICE (UK) (2014)
  • IAS recommendations (2013)
  • ACC/AHA (2013)

Recent Lipid Guidelines

ESC-EAS Lipid Guidelines. Eur Heart J. 2016; On line 27 August National Institute for Health and Care Excellence (UK); 2014 2013 ACC/AHA Lipid Guidelines. Circulation2014 Jun 24;129(25 Suppl 2):S1-45. IAS Lipid Management Recommendations. J Clin Lipidol. 2014; 8:29

slide-11
SLIDE 11

Recent Lipid Guidelines

These guidelines agree on almost all important points

  • ESC/EAS (2016)
  • NICE (UK) (2014)
  • IAS recommendations (2013)
  • ACC/AHA (2013)
slide-12
SLIDE 12

10 points of general agreement

slide-13
SLIDE 13

The decision to use lipid lowering drugs should be based on an assessment of

  • verall cardiovascular (CV) risk rather

than simply on a perceived need to treat an abnormal lipid level

Points of Agreement - 1

slide-14
SLIDE 14

High risk people include those with:

  • Manifest atherosclerotic

cardiovascular disease (ASCVD)

  • Familial hypercholesterolemia (FH)
  • Diabetes

Points of Agreement - 2

slide-15
SLIDE 15

In people without ASCVD, FH or diabetes, global risk should be calculated and used to guide treatment decisions. (Note that the method for calculating risk will vary widely from country to country)

Points of Agreement - 3

slide-16
SLIDE 16

Points of Agreement - 4

Calculation of global risk should take account of both lipid and non-lipid risk factors

slide-17
SLIDE 17

There should be a major emphasis on lifestyle intervention whether or not drug therapy is used

Points of Agreement - 5

slide-18
SLIDE 18

LDL-C should be a primary therapeutic target Statins are proven agents to reduce ASCVD risk in high-risk people

Points of Agreement - 6

slide-19
SLIDE 19

Statins are indicated in:

Proven high risk conditions

  • Those with manifest ASCVD
  • Those with diabetes
  • Those with FH
  • Those without ASCVD, FH or diabetes but who

are calculated to be at a high long-term risk of developing ASCVD

Points of Agreement - 7

slide-20
SLIDE 20

When the risk is high, treatment should be intensive

The ESC/EAS and IAS recommend LDL-lowering therapy to achieve LDL-C goals The ACC/AHA recommend the use of high intensity statin therapy to reduce LDL-C by >50%.

Points of Agreement - 8

slide-21
SLIDE 21

When the risk is moderately high, treatment should be moderately intensive

The ESC/EAS and IAS recommend LDL-lowering therapy to achieve LDL-C goals The ACC/AHA recommend the use of moderate intensity statin therapy to reduce LDL-C by >30%.

Points of Agreement - 9

slide-22
SLIDE 22

General agreement that non-HDL-C should be considered as an alternate to LDL-C as a therapeutic target

Points of Agreement - 10

slide-23
SLIDE 23

Minor Points of Disagreement

  • Each uses a different algorithm to calculate

risk

  • ACC/AHA version does not identify LDL-C

goals

  • ACC/AHA guidelines tend to deemphasize

non-statin drugs

  • The NICE (UK) guidelines recommend

atorvastatin as the statin of choice

ESC-EAS Lipid Guidelines. Eur Heart J. 2016; On line 27 August National Institute for Health and Care Excellence (UK); 2014 2013 ACC/AHA Lipid Guidelines. Circulation2014 Jun 24;129(25 Suppl 2):S1-45. IAS Lipid Management Recommendations. J Clin Lipidol. 2014; 8:29

slide-24
SLIDE 24
  • There are many points of agreement in

recent guidelines for the management of plasma lipids

  • All emphasize the importance of lifestyle

measures to reduce risk

  • All agree that LDL-C is a primary target for

therapy to reduce ASCVD risk

  • All agree that treatment decisions should be

based on overall CV risk rather than plasma lipid levels alone

So

slide-25
SLIDE 25

In the light of recommendations in the guidelines from the ESC/EAS, the IAS, NICE (UK) and the ACC/AHA: The question arises: What should be done in Indonesia?

slide-26
SLIDE 26

Promote a healthy lifestyle

  • Eat a healthy diet
  • Increase physical activity
  • Do not smoke

In All Patients

slide-27
SLIDE 27

High intensity statin therapy is indicated Consider adding additional LDL-lowering therapy such as ezetimibe if the LDL-C remains above 70 mg/dL or if the reduction in LDL-C is less than 50%

People at very high risk

(Those with known ASCVD, those with LDL-C >

190 mg/dL and those with diabetes in whom other risk factors are present)

slide-28
SLIDE 28

If diabetes in NOT accompanied by other risk factors, moderate statin therapy is indicated Consider adding additional LDL-lowering therapy such as ezetimibe if the LDL-C remains above 100 mg/dL or if the reduction in LDL-C is less than 30%

People with diabetes in whom other risk factors are absent

slide-29
SLIDE 29

What about people without ASCVD, FH or diabetes?

slide-30
SLIDE 30

Primary prevention

If possible, generate an Indonesian risk assessment algorithm to estimate risk in people without ASCVD, FH or diabetes Otherwise, use any of the ESC/EAS, IAS, NICE or ACC/AHA risk assessment algorithms, but recognize that none of these may be idela for Indonesia

slide-31
SLIDE 31

People without ASCVD, FH or diabetes but who are calculated to be at high long-term risk of developing ASCVD should be treated with moderate intensity statins to achieve a level of LDL-C < 100 mg/dL Again, consider additional LDL-lowering therapy if the LDL-C remains above 100 mg/dL or if the reduction in LDL-C is less than 30%

Primary prevention

slide-32
SLIDE 32

All guidelines agree that there should be a major emphasis on lifestyle intervention whether or not drug therapy is used

Final recommendation