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Management
of Dyslipidaemias
European Society of Cardiology
and the
European Atherosclerosis Society
Guidelines on Dyslipidaemia
2011
Professor David A Wood
What are the PRIORITIES for CVD
prevention in clinical practice?
1.
Patients with established atherosclerotic CVD
2.
Asymptomatic individuals who are at increased risk
of CVD because of
2.1 Multiple risk factors resulting in raised total CVD risk
(≥5% 10-year risk of CVD death)
2.2 Diabetes type 2 and type 1 with microalbuminuria
2.3 Markedly increased single risk factors especially if
associated with end-organ damage
3
Close relatives of subjects with premature
atherosclerotic CVD or of those at particularly high
risk
SCORE
• Gender
• Smoking
status
• Age
• Systolic blood
pressure
• Total
cholesterol
10 year risk
of fatal CVD
The rest of Europe
High Risk Chart
Based on Conroy et al, Eur Heart J, 2003, 24:987-1003 Copyright©: 2003 European Society of Cardiology. All rights reserved.
Low Risk Chart
Based on Conroy et al, Eur Heart J, 2003, 24:987-1003 Copyright©: 2003 European Society of Cardiology. All rights reserved.
Belgium, France, Greece, Italy,
Luxembourg, Spain, Switzerland, Portugal
Conroy R M, et al Eur Heart J 2003; 24: 987-1003
What are the OBJECTIVES of
CVD prevention?
1.
To achieve more rigorous risk factor control in high
risk subjects, especially those with established CVD
or diabetes:
3.1 Blood pressure under 130/80 mmHg if feasible
3.2 Total cholesterol <4.5 mmol/L (~175 mg/dL) with
an option of <4 mmol/L (~155 mg/dL) if feasible
3.3 LDL cholesterol <2.5 mmol/L (~100 mg/dL) with
an option of <2mmol/L (~80 mg/dL) if feasible
3.4 Fasting blood glucose <6 mmol/L (~110 mg/dL)
and HbA1c <6.5% if feasible
2.
To consider cardioprotective drug therapy in these
high risk subjects especially those with established
atherosclerotic CVD
Lipids and cardiovascular risk
Systematic coronary risk evaluation
Lipids and lifestyle
Lifestyle interventions to
reduce total and LDL-C
Lipids and drugs
Lipid modification drug therapies
1.
HMG – CoA reductase inhibitors (statins)
2.
Bile acid sequestrants
3.
Cholesterol absorption inhibitors
4.
Nicotinic acid
5.
Fibrates
6.
n-3 fatty acids
7.
Cholesterol ester transfer protein (CETP) inhibitors
Major vascular events:
more versus less statin
CTT Collaboration Lancet 2010; 376: 1670-81
Major vascular events per 1.0 mmol/l
reduction in LDL-cholesterol by baseline
prognostic factors
CTT Collaboration Lancet 2010; 376: 1670-81
Major vascular events per 1.0 mmol/l
reduction in LDL cholesterol by baseline
LDL concentrations
CTT Collaboration Lancet 2010; 376: 1670-81
Cause specific mortality
Cause specific cancer incidence
CTT Collaboration Lancet 2010; 376: 1670-81
Diabetes and major vascular events
CTT Collaboration Lancet 2008; 371: 117-25
Combination therapy (statin +
fenofibrate) in type 2 diabetes
ACCORD Study Group NEJM 2010; 362: 1563-1574
SHARP: Major Atherosclerotic Events
Proportion suffering event (%)
25
20
Risk ratio 0.83 (0.74-0.94)
Logrank 2P=0.0021
15
Placebo
Simv/Eze
10
5
0
0
1
2
3
Years of follow-up
4
5
Sharp Collaborative Group Am Heart J 2010; 160: 785-794
Lipids and targets
Lipids and the reality of clinical practice
EUROASPIRE III
8966 coronary patients from 22 countries
Netherlands
Finland
Russia
Ireland
UK
Latvia
Lithuania
Germany
Czech Republic
France
Croatia
Poland
Hungary
Belgium
Slovenia
Romania
Bulgaria
Greece
Spain
Italy
Turkey
Cyprus
K Kotseva, et al. Eur J Cardiovasc Prev Rehabilitation 2009; 16:121-37
EUROASPIRE III Coronary patients
**SBP/DBP ≥ 140/90 mmHg for non-diabetics or ≥ 130/80 mmHg for diabetes
****Self-reported and/or glucose ≥ 7.0 mmol/l; **** in patients with self reported diabetes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
BP>140/90mmHg**
TC>4.5 mmol/l
LDL-C>2.5 mmol/l
Diabetes***
HbA1c<6.5% ****
ALL
56.0%
51.1%
55%
35%
35%
MEN
54.4%
47.5%
52%
34%
39%
WOMEN
60.6%
61.5%
61%
38%
26%
EUROASPIRE III PRIMARY CARE
4366 high risk individuals
Germany
Finland
UK
Latvia
Belgium
Poland
Slovenia
Romania
Spain
Croatia
Italy
Bulgaria
K Kotseva, et al. Eur J Cardio Prev and Rehab 2010
EUROASPIRE III PRIMARY CARE
**SBP/DBP ≥ 140/90 mmHg for non-diabetics or ≥ 130/80 mmHg for diabetes
****Self-reported and/or glucose ≥ 7.0 mmol/l; **** in patients with self reported diabetes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
BP>140/90mmHg**
TC>4.5 mmol/l
LDL-C>2.5 mmol/l
Diabetes***
HbA1c<6.5% ****
ALL
70.8%
78.9%
81%
43%
53%
MEN
72.6%
72.5%
77%
39%
61%
WOMEN
69.5%
83.6%
83%
39%
46%
Cardiovascular Disease
Prevention
European Society of Cardiology
www.escardio.org/prevention
www.escardio.org/guidelines