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HYPERLIPIDEMIA
DR L RABANYE
DEFINITION
• Major risk factor for atherosclerosis as a
result of elevated levels of serum
cholesterol
• Major component of Serum Cholesterol
- LDL-C ( Low density level lipoprotein)
- HDL-C (High density level lipoprotein)
- TG
( Triglycyrides)
Objective of Treatment Guidelines
• Identify patients at cardiovascular risk
– In-line with advances in diagnosis
– Incorporating newly identified/quantified risk factors
• Metabolic syndrome
• Diabetes
• Treatment guidelines based on evidence pool available
at the time of publication
– Can be expected to change with the emergence of new evidence
• As evidence accumulates that greater LDL-C reductions
are associated with greater reductions in CVD risk,
guidelines are updated to reflect lowered LDL-C goals
Developmental Process of
Atherosclerosis
Burden of Diseases (CV)
The three leading causes of disease in 2030
HIV/ AIDS
Unipolar depressive disease
Ischaemic heart Disease
Prevalence of Chronic Conditions in Registered Schemes
The most prevalent conditions (per 1000 beneficiaries):
• Hypertension (86)
• Hyperlipidaemia (42)
• Asthma (24)
• T2DM (19)
• CAD (17)
Multiple Risk Factors Cause
Cumulative Increase in Risk
for CVD
RISK FACTORS
•
•
•
•
•
•
Obesity
Smoking
Diabetes Mellitus
Lack of physical Exercise
Hypertension
Genetics
Types Of Lipid Lowering Drugs
•
•
•
•
•
Statins
Fibrates
Niacin
Resins
Selective cholesterol inhibitor
Primary Prevention:
Are We Identifying the Right Patients?
Billions of Dollars
Economic Burden of
Cardiovascular Disease in the US
393.5
Estimated for 2005
400
300
254.8
200
142.1
100
56.8
59.7
27.9
0
Heart
disease
Coronary
heart
disease
Stroke
Hypertensive Congestive
disease
heart
failure
American Heart Association. Heart Disease and Stroke Statistics—2005 Update.
Total
CVD*
Effect of Long-Term Modest Reductions
in CV Risk Factors
10%
Reduction
in BP
+
10%
Reduction
in TC
Emberson et al. Eur Heart J. 2004;25:484-491.
=
45%
Reduction
in CVD
Heart of Soweto Study
Cross-Sectional Study at Chris Hani Baragwanath
• Objective: Describe recent ↑ in ACS among urban black South Africans
• Epidemiological transition due to urbanization
– adoption of Western lifestyle and diet
– vs. traditional (cardio-protective) African lifestyle
• 1950’s: average of 3 patients/annum identified with AMI
• 1975-80: Total of 50 cases – average of 8 patients/annum
• 2004: 64 patients with ACS in one year alone
• Annual incidence of ACS (based on population size)
– 1975-80: 0.5 – 1 per 100 000
– 2004: 7 per 100 000
Rule out Secondary Causes
• LIFETSYLE FACTORS
– DIET: Triglycerides ; HDL-C and LDL-C
– SMOKING: HDL-C
– ALCOHOL: Triglycerides
• UNDERLYING DISEASES
– ↑ CHOL: Hypothyroidism, Renal disease, liver disease, DM
– ↑ TRIGS: Truncal Obesity, Diabetes, Cushing’s Syndrome
• PREGNANCY
– ↑ Cholesterol & severe hypertriglyceridaemia in susceptible
• MEDICATION
– Progestins ; Steroids ; some beta-blockers ; high dose
diuretics ; retinoids ; Protease inhibitors
Treatment Rates For Dyslipidemia in US
Are High but Few Patients Reach Goals
12
CHD
Stroke
10
8
< 50% receive treatment
6
4
2
0
Patients with
Dyslipidaemia
Patients On LipidLowering Treatment
Treated to Goal
There is more that can be done to improve quality of care
delivered to patients
NHANES 1999-2002, Home & Mec., Aged ≥20; Unweighted N = 3,655 - Weighted Sample = 211,125,161 (2004 Census)
CVD Patients in Europe:
Fewer than One-Half Reach Goal
1996
Hypertensive
– On BP Medication
– % controlled to <140/90mm Hg
55%
84%
44%
2000
54%
90%
45%
Very little improvement
Hyperlipidemic
– On statins
– % controlled to < 5.0 mmol/L
86%
19%
21%
59%
58%
49%
Some improvement, but still
large gap in treatment
And in South Africa?
The South African Not at Goal study (SA-NAG):
Evaluation of LDL-C goals achieved in patients with established
CVD and/or hyperlipidaemia receiving lipid lowering therapy
– Pts on therapy > 4mnths
– 1201 pts recruited across SA
– 41% defined as low risk, 59% defined as high risk
– SA guidelines used to define risk and evaluate
achievement of goal
Conclusion
– Majority fell into “not at goal” category
– These pts were also far above their LDL-C targets
% Achieving Guideline-specified
LDL-C Goals
120
% Patients
100
80
63
71.1
77
60
40
20
37
29.9
23
0
Low risk
High risk
Achieving goal LDL_C
Not at Goal LDL-C
The SA-NAG study. A. Ramjeeth, N. Butkow, F. Raal, M. Maholwana-Mokgatlhe, CVJA, Vol19:2, 88-94
All Pts
Low Risk vs.. High Risk Patients
LOW RISK PATIENTS
4.0
3.0
0.7
2.5
3.7
2.0
1.5
1.0
3.0
0.5
0.0
LDL-C Goal Level
Mean LDL-C of SA-NAG
Population
HIGH RISK PATIENTS
4.0
3.5
3.0
LDL-C mmol/L
LDL-C (mmol/L)
3.5
1.1
2.5
3.6
2.0
1.5
1.0
2.5
0.5
0.0
LDL-C Goal Level
Mean LDL-C of SA-NAG
Population
High Risk – LDL-C reduction needed
(by gender & age group)
The SA-NAG study. A. Ramjeeth, N. Butkow, F. Raal, M. Maholwana-Mokgatlhe, CVJA, Vol19:2, 88-94
Key points – SA-NAG Study
• Significant treatment gap exists between lipid guidelines and
goal attainment in dyslipidaemic patients with or without
established CVD
• All patient were on lipid-lowering therapy – deficit still exists
• Begs the question - how many events could be averted if
patients reached treatment goal?
• Potential reasons for the study result:
– Inadequate titration of doses
– Patient long-term compliance
– Financial constraints
• In the entire study (N= 1201) only 45 pts were using the
highest doses of statin therapy (< 4 %)
CVD Treatment Gap - Community
95
100
80
60
40
18
20
0
Dr Awareness of
Treatment Guidelines
Patient Treated
to Goal
Provider awareness does not equal successful
implementation
WHAT ARE WE DOING WRONG???
• Not identifying patients for treatment intervention
• Identifying patients but not providing treatment
• Lifestyle and/or pharmacological intervention?
• Identifying patients, initiating treatment, but lost to follow-up
• Not achieving treatment goals
• inadequate dosage
• adherence/compliance issues
THANK YOU!!!!