Goals

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• Goals GuidelinesA summary of international
  guidelines for CHD

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International guidelines summary

• Guidelines developed for the prevention of CHD
• Based on major clinical trial evidence
• Help assess and assist in the management of
  patients at risk of CHD

Risk Category NCEP LDL-C goal European LDL-C goal
CHD or CHD risk equivalents(10-year risk gt20) ?100mg/dl(?2.6mmol/l) ?115mg/dl(?3.0mmol/l)
2 risk factors (10-year risk ?20) lt130mg/dl(?3.4mmol/l) ?115mg/dl(?3.0mmol/l)
Reference National Cholesterol Education
Program. JAMA 2001 285 2486-97 Wood D et al.
EHJ 1998 19 1434-1503.
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NCEP guidelines
LDL-C Goals and Cutpoints for Therapeutic
Lifestyle Changes (TLC) and Drug Therapy
LDL-C Level at which to ConsiderDrug Therapy
(mg/dL)
LDL-C Level at which to Initiate Therapeutic
Lifestyle Changes (TLC) (mg/dL)
LDL-C Goal(mg/dL)
Risk Category
³130 (100129 drug optional)
³100
lt100
CHD or CHD Risk Equivalents(10-year risk gt20)
10-year risk 1020 ³130 10-year risk lt10
³160
³130
lt130
2 Risk Factors (10-year risk 20)
³190 (160189 LDL-C lowering drug optional)
³160
lt160
01 Risk Factor
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NCEP guidelines
LDL-C Lowering Therapy in Patients with CHD and
CHD Risk Equivalents

• Baseline LDL-C ³130 mg/dL
• Intensive lifestyle therapies
• Maximal control of other risk factors
• Consider starting LDL-C lowering drugs
  simultaneously with lifestyle therapies
• Baseline (or On-Treatment) LDL-C 100129 mg/dL
• LDL-C lowering therapy
• Initiate or intensify lifestyle therapies and/or
  LDL-C lowering drugs
• Treatment of metabolic syndrome
• Emphasise weight reduction and increased physical
  activity
• Drug therapy for other lipid risk factors
• Baseline LDL-C lt100 mg/dL
• Further LDL-C lowering not required
• Therapeutic Lifestyle Changes (TLC) recommended
• Consider treatment of other lipid risk factors
  (raised TG, low HDL-C)

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NCEP guidelines
LDL-C Lowering Therapy in Patients With 2 Risk
Factors and 10-Year Risk 20

• 10-Year Risk 1020
• LDL-C goal lt130 mg/dL
• Aim reduce both short-term and long-term risk
• Immediate initiation of Therapeutic Lifestyle
  Changes (TLC) if LDL-C is ³130 mg/dL
• Consider drug therapy if LDL-C is ³130 mg/dL
  after 3 months of lifestyle therapies
• 10-Year Risk lt10
• LDL-C goal lt130 mg/dL
• Therapeutic aim reduce long-term risk
• Initiate therapeutic lifestyle changes if LDL-C
  is ³130 mg/dL
• Consider drug therapy if LDL-C is ³160 mg/dL
  after 3 months of lifestyle therapies

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NCEP guidelines
LDL-Lowering Therapy in Patients With 01 Risk
Factor

• Most persons have 10-year risk lt10
• Therapeutic goal reduce long-term risk
• LDL-C goal lt160 mg/dL
• Initiate therapeutic lifestyle changes if LDL-C
  is ³160 mg/dL
• If LDL-C is ³190 mg/dL after 3 months of
  lifestyle therapies, consider drug therapy
• If LDL-C is 160189 mg/dL after 3 months of
  lifestyle therapies, drug therapy is optional

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Canadian guidelines
Target lipid values by level of risk

Level of risk (definition) LDL-C levelmmol/L TCHDL-C ratio Triglyceride level mmol/L
Very high (10-year risk of CAD gt 30, or history of CVD or diabetes) High (10-year risk 20-30) Moderate (10-year risk 10-20) Low (10-year risklt10) lt2.5 lt3.0 lt4.0 lt5.0 lt4 lt5 lt6 lt7 lt2.0 lt2.0 lt2.0 lt3.0
Start medication and lifestyle changes
concomitantly if values are above target
values Start medication if target values are not
achieved after 3 months of lifestyle
modification Start medication if target values
are not achieved after 6 months of lifestyle
modification
Recommendations for the management and
treatment of dyslipidemias CMAJ 2000 162
(10)1441-7
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European guidelines

• Prioritisation
• Absolute risk
• 10 year risk
• Age
• 30-74 years
• Goals for primary and secondary prevention of
  CHD
• Lifestyle
• Stop smoking
• Make healthy food choices
• Be physically active
• Other risk factors
• Blood pressure lt140/90mmHg
• TC lt5.0mmol/L (190mg/dL)
• LDL-C lt3.0mmol/L (115mg/dL)
• Good glucose control in diabetes
• To be achieved with changes in lifestyle and, if
  needed, by drug treatment

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European guidelines

• Use coronary risk chart to estimate a persons
  absolute 10-year risk of a CHD event
• High risk 10 year risk exceeds 20 or will
  exceed 20 if projected to age 60 years
• CHD risk is higher than the charts indicate for
  those with
• FH, diabetes, family history of premature CVD,
  low HDL-C (lt1.0mmol/L), raised triglycerides
  (gt2.0mmol/L) or approaching next age category

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European guidelines
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European guidelines
Primary prevention guide to lipid management
Estimate absolute CHD risk using the Coronary
Risk Chart Use initial total cholesterol to
estimate coronary risk
Absolute coronary risk lt20 TC gt 5.0mmol/L
(190mg/dL) Lifestyle advice with the goal of
reducing TClt5.0mmol/L (190mg/dL) and LDL-C
lt3.0mmol/L (115mg/dL) Follow-up at a minimum of
5-year intervals
Absolute risk gt 20 Measure fasting lipids TC,
HDL-C, triglycerides and calculate LDL-C
cholesterol Lifestyle advice for at least 3
months with repeat lipid measurements
TC lt5.0mmol/L (190mg/dL) and LDL-C lt3.0mmol/L
(115mg/dL) Maintain lifestyle advice with annual
follow-up
TC gt5.0mmol/L (190mg/dL) and LDL-C gt3.0mmol/L
(115mg/dL) Maintain dietary advice with drug
therapy
High CHD risk gt20 over 10 years or will exceed
20 if projected age 60 years
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Australian guidelines
Categorisation of Risk for Coronary Heart Disease (CHD) Categorisation of Risk for Coronary Heart Disease (CHD) Categorisation of Risk for Coronary Heart Disease (CHD)
Highest risk High risk Lower risk
Existing coronary heart disease and/or Existing extra coronary vascular disease At least one of the following Diabetes Positive family history of CHD Familial hypercholesterolaemia Hypertension Smoking Others (e.g. overweight physical inactivity)
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Australian guidelines
Assessment Goal
Interview Routinely ask about Dietary habits/familial hyperlipidaemia Lipid goals as per categorisation of risk for coronary heart disease
Baseline fasting lipid profile for All adults gt 18 yrs Fasting lipid profile for CHD patients EITHER within 24 hours of the onset of MI OR6/52 post MI For highest risk patients TC ? lt 4.5 mmol/l LDL-C ? lt 2.5 mmol/l TG ? lt 2.0 mmol/l For high risk patients TC ? lt 5.0 mmol/l LDL-C ? lt 3.0 mmol/l TG ? lt 2.0 mmol/l For lower risk population TC ? lt 6.0 mmol/l LDL-C ? lt 4.0 mmol/l TG ? lt 4.0 mmol/l
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Australian guidelines
Intervention Review
All hyperlipidaemic patients Lifestyle limit alcohol intake ? physical activity weight management. Nutrition intervention as indicated below referral to dietitian referral to Heartline teleinfo service see below. Lipid lowering medication Be more aggressive in lowering lipids in those at highest coronary risk. PBS regulations allow for drug therapy after dietary mod. in CHD patient, with total cholesterol (TC gt 4.0 mmol/l diabetes or familial hypercholesterolaemia or hypertension or family history CHD or PVD, with TC gt 6.5 mmol/l or with HDL lt 1.0 mmol/l and TC gt 5.5 mmol/l. Statins Consider as possible first line management. For high risk ? highest risk patients Monitor diet fortnightly for 6/52, then retest at 6-8/52 until satisfactory and stable response. Ongoing follow-up for diet and possible drug intervention at 3-6/12. General population Lipids at least every 5 years including risk factor assessment.
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Issues with guidelines

• Goals are not reached resulting in the
  undertreatment of patients
• Guidelines are not implemented resulting in
  untreated patients

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Goals not reached

• Evidence shows that patients are failing to reach
  the goals set in guidelines
• 62 of patients failing to reach their goal
• NHANES data show that 82 of CHD patients are not
  meeting target LDL-C level
• Only 49 of patients with CHD reach total
  cholesterol targets (EUROASPIRE)

References Pearson TA et al. Arch Intern Med
2000 160 458-67 Hoerger TJ et al. Am J
Cardiol 82 61-5 EUROASPIRE. EHJ 2001 22
54-72. relates to NCEP II ATP goals