CURRICULUM VITAE - PAPDI. SAN PIN 2019 (materi...stage 3 or 4 CKD, or HeFH –History of premature...

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CURRICULUM VITAE

SALLY AMAN NASUTION, MD, FINASIM, FACP

- Born in Medan, August 8th 1967

- Internist – Cardiologist

- Faculty Member Division of Cardiology, Department of Internal Medicine at Faculty of Medicine University of

Indonesia, Jakarta

- Head of Intensive Coronary Care Unit (ICCU), Integrated Cardiac Services Cipto Mangunkusumo National General

Hospital Jakarta

- President of the Indonesian Society of Internal Medicine

Updates in Dyslipidemia Guidelines:

How to apply in clinical practice

Dr dr SALLY AMAN NASUTION, SpPD-KKV, FINASIM, FACP

Division of Cardiology Department of Internal Medicine

Faculty of Medicine Universitas Indonesia

Cipto Mangunkusumo National General Hospital

Jakarta

Prevalence of raised lipid levels

LDL-Cholesterol and Blood Presssure

Sub-analysis DYSIS (Dyslipidemia International Study) II in Indonesia

% Patients at LDL-C goals Recommended by the 2004 updated NCEP ATP III* guidelines

% of Patients at LDL-C goals recommended by 2004 updated NCEP ATP III* guidelines

Indonesia patients had the lowest LDL-C attainment rate (31.3 – 52.7%)

Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.

Management of Hypercholesterolaemia remains Sub-optimal: Pan-Asian CEPHEUS

Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.

Attainment of LDL-C

https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019

The global CVD crisis

www.who.int/global_hearts 2017

https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019Cannon B. Nature 2013; 493: S2 – S3

American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 201713

ASCVD Risk Categories and LDL-C Treatment Goals

Risk category Risk factors/10-year riskTreatment goals

(mg/dL)

Non-HDL-C

(mg/dL)

Extreme risk

– Progressive ASCVD including unstable angina in individuals after achieving an LDL-C <70 mg/dL

– Established clinical cardiovascular disease in individuals with DM, stage 3 or 4 CKD, or HeFH

– History of premature ASCVD (<55 male, <65 female)

<55 <80 <70

Very high risk

– Established or recent hospitalization for ACS, coronary, carotid or peripheral vascular disease, 10-year risk >20%

– DM or stage 3 or 4 CKD with 1 or more risk factor(s)

– HeFH

<70 <100 <80

High risk– ≥2 risk factors and 10-year risk 10%-20% – DM or stage 3 or 4 CKD with no other risk factors

<100 <130 <90

Moderate risk ≤2 risk factors and 10-year risk <10% <100 <130 <90

Low risk 0 risk factors <130 <160 NR

Barter PJ, et al. J Intern Med. 2006;259:247-258; Boekholdt SM, et al. J Am Coll Cardiol. 2014;64(5):485-494; Brunzell JD, et al. Diabetes Care. 2008;31:811-822; Cannon CP, et al. N Engl J Med. 2015;372(25):2387-2397; Grundy SM, et al. Circulation. 2004;110:227-239; Heart Protection Study Collaborative Group. Lancet. 2002;360:7-22; Jellinger P, Handelsman Y, Rosenblit P, et al. Endocr Practice. 2017;23(4):479-497; Lloyd-Jones DM, et al. Am J Cardiol. 2004;94:20-24; McClelland RL, et al. J Am Coll Cardiol. 2015;66(15):1643-1653; NHLBI. NIH Publication No. 02-5215. 2002; Ridker PM, J Am Coll Cardiol. 2005;45:1644-1648; Ridker PM, et al. JAMA. 2007;297(6):611-619; Sever PS, et al. Lancet. 2003;361:1149-1158; Shepherd J, et al. Lancet. 2002;360:1623-1630; Smith SC Jr, et al. Circulation. 2006;113:2363-2372; Stevens RJ, et al. Clin Sci. 2001;101(6):671-679; Stone NJ. Am J Med. 1996;101:4A40S-48S; Weiner DE, et al. J Am Soc Nephrol. 2004;15(5):1307-1315.

Abbreviations: ACS, acute coronary syndrome; apo, apolipoprotein; ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; DM, diabetes mellitus; HeFH, heterozygous familial hypercholesterolemia; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NR, not recommended.

Heart SCORE (Systematic Coronary Risk Estimation)

1 mmol/L = 38.67 mg/dLEuropean Heart Journal (2019) 00, 178

• Social deprivation and psychosocial stress set the scene for increased risk. For those at moderate risk, other factors—including metabolic factors such as increased ApoB, Lp(a), TGs, or C-reactive protein; the presence of albuminuria; the presence of atherosclerotic plaque in the carotid or femoral arteries; or the coronary artery calcium (CAC) score—may improve risk classification

Factors modifying heart SCORE

European Heart Journal (2019) 00, 178

Risk categories

aTarget organ damage is defined as microalbuminuria, retinopathy, or neuropathy

Intervention strategies as a function of total cardiovascular risk & untreated LDL-C levels

dThe term ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C-lowering medication.

In people who are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based on the average LDL-C-lowering efficacy of the given medication or combination of medications.

Recommendations for treatment goals for LDL-C

Treatment goal for LDL-C

Treatment algorithm for pharmacological LDL-C lowering

Recommendations for the treatment of dyslipidaemiasin metabolic syndrome & DM

Challenges in dyslipidemia management

American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 2017

Patients(%) reporting statin non-adherence behaviors in the last 12 months by statin PDC (proportion of days covered) level

Note: Weighted for sampling proportions; p<0.05

Fung V, GraetzI, Reed M, Jaffe MG (2018) Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk. PLoS ONE 13(2): e0191817.

Doubling statin dose

Statin intolerance• 20% of individuals with a clinical indication for statin therapy are unable to take a daily statin because of some

degree of intolerance, and 40–75% of patients discontinue their statin therapy within 1–2 years after initiation

Toth PP, et al. Management of Statin Intolerance in 2018: Still More Questions than Answers. Am J Cardiovasc Drugs (2018) 18:157–

Further improvement from what NLA proposed

Rosenson RS, et al. Cardiovasc Drugs Ther (2017) 31:179–186

How to apply in clinical practice

Patient : M.K.

Profile : 43 years old male

BMI : 29.7 kg/m2

BP : 140/75 mm Hg

HR : 65 bpm

Medical History:

Type 2 Diabetes Mellitus with microalbuminuria

Previous MI last month

Heavy smoker

Lab results:

TC : 210 mg/dl

LDL :135 mg/dl

HDL : 38 mg/dl

TG : 500 mg/dl

Current medication:

Chinese herbal medicine

He comes to your clinic for follow up

How would you manage this patient?

• During anamnesis, what other questions would you like to ask? Why?

• Is there any other lab tests would you order? Why?• Would you change his current medication? Why?

sanasution@yahoo.com

CURRICULUM VITAE - PAPDI. SAN PIN 2019 (materi...stage 3 or 4 CKD, or HeFH –History of premature...

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