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Introduction module
Supported by an educational grant from MSD Pharmaceuticals Pvt. Ltd.
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Faculty
PROGRAM DIRECTORS
Jeffrey A. Brinker, MDProfessor of Medicine, CardiologyProfessor of Medicine, RadiologyJohns Hopkins University School of MedicineBaltimore, Maryland
Gary Gerstenblith, MDProfessor of Medicine, Division of CardiologyDirector of Clinical TrialsDirector, Clinical Translation UnitJohns Hopkins University School of MedicineBaltimore, Maryland
PRESENTING FACULTY
PROGRAM ADVISORSoneil Guptha, MD FESC FCCP Dip Pharm Med
Consulting Physician-Scientist
Chairman: 4H-CARE LLC (USA);
Founder Director: I-SAVE (India)
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Dr. Brinker has indicated that he has no financialrelationships to disclose
Dr. Gerstenblith has indicated that he has no financialrelationships to disclose
Dr. Mala has indicated that she has no financialrelationships to disclose
Dr. Iyengar has indicated that he has no financialrelationships to disclose
Disclosure
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ACCREDITATION STATEMENT
This activity has been planned and implemented in accordance with the
Essential Areas and policies of the Accreditation Council for Continuing
Medical Education through the joint sponsorship of the Johns Hopkins
University School of Medicine and CME Universe. The Johns Hopkins
University School of Medicine is accredited by the ACCME to provide continuingmedical education for physicians.
Credit Designation Statement
The Johns Hopkins University School of Medicine designates this educational
activity for a maximum of 4.75AMA PRA Category 1 Credit(s). Physicians
should only claim credit commensurate with the extent of their participation in
the activity.
Accreditation & Credit Designation Statements
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Johns Hopkins would like to
acknowledge educational
grants from MSD Pharmaceuticals
Pvt. Ltd. which helped to make this
program possible
Educational Grant
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Learning Objectives:
Describe strategies to modify risk factors for coronary heart disease (CHD)
in Indian patients
Implement evidence-based treatment and monitoring practices in patients
at risk for CHD
Apply lipid-lowering therapy in specific clinical scenarios, such as acute
coronary syndrome (ACS), diabetic dyslipidemia and mixed dyslipidemia
Identify the low- to moderate-risk patients likely to benefit frommanagement of dyslipidemia
The Johns Hopkins University School of Medicine takes responsibility for thecontent, quality, and scientific integrity of this CME activity.
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Agenda
INTRODUCTION FROM PROGRAM DIRECTOR
IMPROVING LIPID MANAGEMENT OUTCOMES IN INDIA AN INTRODUCTION
CHD A Leading Cause of Mortality and Morbidity
Dyslipidemia as a Major Risk Factor
Prevalence of Dyslipidemia
Concept of Residual Risk of CHD after Statin Treatment
Module 1 CHD
Lipid-lowering Interventional Trials in Management of ACS
Management of Patients with CHD
Comprehensive Lipid Management in CHD
BREAK
Module 2 DIABETES
Recognize Diabetes Carries a Similar Risk as CHD
Lipid Management in Diabetes
Trials and Guidelines in Practice
Module 3 DYSLIPIDEMIA WITH LOW/INTERMEDIATE CHD RISK
Identification of Low- to Moderate- risk Patient
Choice of Appropriate Management Options
DISCUSSION AND CLOSING REMARKS/PROGRAM EVALUATION
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Introduction from program director
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At the end of the Module, participantsshould be able to:
Explain the burden of dyslipidemia in the Indiansubcontinent
Identify and discuss the significance of different lipidparameters in health and disease
Describe the residual risk factors in patients with CHD andother associated diseases
Discuss the importance of comprehensive dyslipidemiamanagement
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Presentation Outline
Coronary heart disease (CHD) is a leading cause of cardiovascularmorbidity and mortality
Dyslipidemia is a modifiable risk factor present in more than half ofthe CHDs in Indians
Dyslipidemia is highly prevalent in India and characterised by lowHDL-C with elevated triglycerides & LDL-C
Despite guidelines, dyslipidemia is not being treated adequately inmany patients.
Despite significant progress in the management of dyslipidemia inpatients with CHD, residual risk of CHD still persists even afteroptimal statin treatment and thus may lessened by additional lipidstrategies.
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Coronary Heart Disease1,2
Coronary heart disease(CHD): 7.2 million deathsa year globally (2001estimate)1
The CHD burden2 is
proposed to rise from 47million DALYs* in 1990 to82 million DALYs in 2020
More than 60% of the CHDburden occurs indeveloping countries2
*DALY: Disability-adjusted life year
(2002)
Total deaths: 16.7 million
Global deaths from CVD
Inflammatoryheartdisease 0.4 m
Rheumaticheart disease0.4 m
heart disease0.9 m
Hypertensive
Stroke5.5 m
Coronary heartdisease 7.2 m
Other forms of
heart disease2.4 m
1. Types of cardiovascular disease. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_01_types.pdf. Accessed September 29, 2009.2. Global burden of coronary heart disease. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdf. Accessed September
29, 2009.
http://www.who.int/cardiovascular_diseases/en/cvd_atlas_01_types.pdfhttp://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdfhttp://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdfhttp://www.who.int/cardiovascular_diseases/en/cvd_atlas_01_types.pdf8/22/2019 Improving Lipid Management Outcomes in India_Introduction_JHU_ver 2 04
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Clinical Challenge
Indians are at a high risk ofdeveloping CHD because:
A. They are genetically predisposedB. Lipid profiles are different from the western population
C. There is higher contribution by novel risk factors
D. They have smaller coronaries
E. Indian diet is very different from western population
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Coronary Heart Disease in India1-2
Risk of CHD is higher in Indians compared with other ethnicities
3 to 4 times higher than Americans1
6 times higher than Chinese1
20 times higher than Japanese1
High rate of DALY: 20 to 29 DALYs lost per 1000 population due to CHD2
There is higher propensity toward the young1
Incidence in the young is 12% to 13% as compared with 5% in the westernpopulation
Up to 40% of the patients are below 45 years of age
1. Rissam HS, Kishore S, Trehan N. Coronary artery disease in young Indians - The Missing Link.JIACM. 2001;2(3):128-132.2. Global burden of coronary heart disease. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdf. Accessed September
29, 2009.
http://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdfhttp://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdf8/22/2019 Improving Lipid Management Outcomes in India_Introduction_JHU_ver 2 04
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Indians Consistently Have a Higher Burden ofMortality from CHD vs. Other Ethnic Groups
Rates are age-standardized per 100,000/year
1. Enas EA, Senthilkumar A. Coronary Artery Disease In Asian Indians: An Update And Review . The Internet Journal of Cardiology. 2001:1
(http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html.
Accessed October 21, 2010.
Indians Whites Chinese Blacks Malays
0
100
200
300
400
500
600
700 Men
Canada England Singapore S Africa 0
50
100
150200
250
300 Women
Canada England Singapore S Africa
*Age-standardized per 100,000/year
http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html.%20Accessed%20October%2021http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html.%20Accessed%20October%2021http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html.%20Accessed%20October%2021http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html.%20Accessed%20October%2021http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html.%20Accessed%20October%2021http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html.%20Accessed%20October%20218/22/2019 Improving Lipid Management Outcomes in India_Introduction_JHU_ver 2 04
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CHD in Urban and Rural Populations1
14%
7%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Urban Rural
%p
revalence
ofCHD
There is a higher prevalence of CHD in the urban population
1. Rissam HS, Kishore S, Trehan N. Coronary artery disease in young Indians - The Missing Link.JIACM. 2001;2(3):128-132.
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CHD in South India and North India1
North India
The CHD prevalence in North India increased from 1% during the 1960s to10.5% in 1998*
The prevalence in South India was 7.4% in 1993, which increased to 14.2% in
2001*
South India
*These studies do not represent the entire region. The North Indian data are obtained from Jammu and Kashmir and the
South Indian data are obtained from Kerala.
1. Sharma M, Ganguly NK. Premature coronary artery disease in Indians and its associated risk factors. Vasc Health Risk Manag. 2005;1(3):217-225.
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No.
inth
ousands
Trends in CHD Mortality in India1
1. Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ. 2004;328(7443):807-810.
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Current Status of Dyslipidemia
Coronary heart disease (CHD) is a leading cause of cardiovascularmorbidity and mortality
Dyslipidemia is a risk factor contributing to more than half of theCHDs in Indians
Dyslipidemia is highly prevalent in India and characterised by lowHDL-C with elevated triglycerides & LDL-C
Despite guidelines, dyslipidemia is not being treated adequately orappropriately
Despite significant progress in the management of dyslipidemia inpatients with CHD, residual risk of CHD still persists even afteroptimal statin treatment
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Role of Dyslipidemia in CHD1
WHO estimates that dyslipidemia contributes to more than 50% of thecases of CHD
49%
31%
22%
56%
0%
10%
20%
30%
40%
50%
60%
Systolic BP >115 mmHg Dyslipidaemia Dietary factors Physical inactivity
%
contribution
toC
HD
1. Risk Factors. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atla_03_risk_factors.pdf. Accessed September 29, 2009.
http://www.who.int/cardiovascular_diseases/en/cvd_atla_03_risk_factors.pdfhttp://www.who.int/cardiovascular_diseases/en/cvd_atla_03_risk_factors.pdf8/22/2019 Improving Lipid Management Outcomes in India_Introduction_JHU_ver 2 04
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Clinical Challenge
A. LDL-C
B. LDL-C and HDL-C
C. LDL-C and TGs
D. LDL-C, HDL-C, and TGs
Which of the following are risk factors that contribute tothe development of coronary artery disease?
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Clinical Challenge
According to the ATP III guidelines, which one of thefollowing is the most important risk factor that contributesto development of coronary artery disease?
A. LDL-C
B. HDL-C
C. NonHDL-C
D. ApoBE. Triglycerides
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Association of Various Risk Factors with CHD1
1. Adapted from Simons LA, Simons J, Friedlander Y, McCallum J. A comparison of risk factors for coronary heart disease and ischaemic stroke: the
Dubbo study of Australian elderly. Heart Lung Circ. 2009;18(5):330-333.
ADL: Activities of daily living
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Hazardr
atio
Age Female Sex Smoking,
current
Diabetes SBP 160-199
Or DBP 95-99
SBP 200
Or DBP 100+
LDL
cholesterol
1.05
0.56
1.31
1.59
1.43
1.08 1.11
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*P
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30-dayriskdeath,
MI,
orrecurrentASC(%)
Role of Triglycerides in CVD Risk: PROVE IT-TIMI* Trial1
Elevated triglyceride level 200 mg/dL increases the risk of death,
myocardial infarction or acute coronary syndrome significantly
*PROVE IT-TIMI: Pravastatin or Atorvastatin Evaluation and Infection TherapyThrombolysis In Myocardial Infarction 22 trial
LDL-C
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Role of HDL-C in CVD Risk: The TNT* Study1
* TNT: Treating to New Targets study
1. Fruchart JC, Sacks F, Hermans MP, et al. The Residual Risk Reduction Initiative: a call to action to reduce residual vascular risk in patients with dyslipidemia. AmJ Cardiol.2008;102(10 Suppl):1K-34K.
5yearrisk
ofmajor
cardiovascula
revents(%)
39% relative increaserisk (Q1 vs Q5)
LDL-C
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CHD
Mortality
Rate
per 1,000
0
25
50
75
100
125
150
Framingham Study (n=5,209)2
Serum Cholesterol, mg/dL
295
Serum Cholesterol, mg/dL
100 150 200 250 300
16
14
12
10
8
6
4
2
0
MRFIT (n=356,222) 1
1. Stamler J et al. JAMA. 1986;256:28232828.2. Reprinted from Am J Med. Castelli WP. Epidemiology of coronary heart disease: the Framingham Study. 1984:412, with permission from Excerpta Medica Inc.
CHD
Incidence
per 1,000
CHD Risk Increases as Plasma Cholesterol Increases
MRFIT=Multiple Risk Factor Intervention Trial.
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Seven Countries Study
CHD Mortality is linearlyrelated to serumcholesterol levels
Absolute differences exist
from culture to culture JAMA. 1995;274:131-136.
0
5
10
15
20
25
USA South Europe
Serum Total cholesterol
CHDMortalityRates,
%
North Europe
175-200 200-225 225-250 250-275 275-300
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Lipid Research Clinics Prevalence Study
LDL-cholesterol was stronglyassociated with CAD death
HDL- cholesterol inverselyassociated with CAD death
NEJM. 1990;322:1700-1707.
0
2
4
6
810
12
14
159 44
Deaths/1000Person-Years
HDL
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Johns Hopkins Precursor Study
Serum Cholesterol levelmeasured early in adult lifecorrelated withcardiovascular disease inmidlife
NEJM. 1993;328:313-318.
0
5
10
15
20
25
30
35
118-172 190-208
40
40YearE
vents
MI CAD CVD
Cholesterol
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Effect of Reduction of LDL-C on CHD Event Rate
Opie et al. Lancet 2006; 367: 69-78
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Current Status of Dyslipidemia
Coronary heart disease (CHD) is a leading cause of CV morbidity andmortality
Dyslipidemia is a risk factor responsible for more than half of theCHDs in Indians
Dyslipidemia is highly prevalent in India and characterised by lowHDL-C with elevated triglycerides & LDL-C
Despite guidelines, dyslipidemia is not being treated adequately orappropriately
Despite significant progress in the management of dyslipidemia inpatients with CHD, residual risk of CHD still persists even afteroptimal statin treatment
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Prevalence of Dyslipidemia1
1. Karthikeyan G, Teo KK, Islam S, et al. Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: an analysis fromthe INTERHEART study.J Am Coll Cardiol. 2009;53(3):244-253.
South Asia: India, Pakistan, Bangladesh, Nepal, Sri Lanka
Low HDL-C; HDL-C
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Authors No. of patients
withTG >200 mg/dL(%)
No of patients with
HDL< 40 mg/dL (M) &< 50 mg/dL (F) (%)
Patients with >2 RF or
CVD or DM andLDL>100 mg/dL (%)
Patients with >2 RF
and LDL>130 mg/dL(%)
Patients with 160mg/dL (%)
Kasliwal et al,1 2006 (n=1000) 338 (37)* (n=913) 662 (72.5) (n=913) 213 (23.3) (n=913) -- --
Chadha et al,2 2006 (n=245) 52 (21) 43 (18)# -- -- --
Gupta et al,3 2004 (n=458) 89 (19.4)* 324 (70.7)# -- 167 (36.5) --
Ashavaid et al,4 2004 (n=4466) 68 (1.52) 1013 (22.68)# -- -- --
Gupta et al,5 2003 (n=1123) 331 (30.3)*(n=1091) 796 (73) (n=1091) -- -- --
Reddy et al,6 2002 (n=3307) 751 (23) 764 (23)# -- 845 (26) 239 (07)
Misra et al,7 2001 (n=532) 69 (13.7) (n=503) 80 (16.4) (n=488) -- 119 (25.6) (n=465) --
Gupta et al,8 2001 (n=257) 77 (30) -- -- 82 (31.9) --
Misra et al,9 2001 (n=227) 26 (13.2)*(n=197)
86 (43.9) (n=197)# 96 (48.7) (n=197) -- --
Udawat et al,10 2001 (n=650) -- (22) -- (18.5) -- (28) -- (48) --
Singh et al,111998 (n=1806) 396 (22)* 170 (9)# -- -- --
Gupta et al,12 1997 (n=401) 33 (8.2) 96 (23.9)# -- 55 (13.7) 33 (8.3)
Gupta et al,13 1994 (n=300) -- 89 (29.7)# -- 45 (15) 20 (6.7)
Note: It is difficult to compare observations of the above studies due to different sampling procedures, heterogeneity in the population samples, different methodologies used forestimations of lipoproteins and different cut-offs taken to define dyslipidemia. *TG
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Current Status of Dyslipidemia
Coronary heart disease (CHD) is a leading cause of CV morbidity andmortality
Dyslipidemia is a risk factor responsible for more than half of theCHDs in Indians
Dyslipidemia is highly prevalent in India and characterised by lowHDL-C with elevated triglycerides & LDL-C
Despite guidelines, dyslipidemia is not being treated adequately orappropriately
Despite significant progress in the management of dyslipidemia inpatients with CHD, residual risk of CHD still persists even afteroptimal statin treatment
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Clinical Challenge
Do you believe that guidelines by variousscientific bodies have provided adequateweightage to all risk factors (LDL-C, HDL-C, TG) ?
A. No
B. Yes
C. Not sure
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Angiographic trials(FATS, POSCH, SCOR,STARS, Ornish, MARS)
Meta-analyses
(Holme, Rossouw)
ATP I1 1988 ATP II2 1993 ATP III3 2001
HPS
PROVE IT
ASCOT-LLA
PROSPER
ALLHAT-LLT
CARDS5*
ATP III UPDATE42004
FraminghamMRFIT
LRC-CPPTCoronary
Drug ProjectHelsinki HeartCLAS
4SWOSCOPS
CARELIPID
AFCAPS/TexCAPSVAHITOthers
*Published after updated NCEP ATP III.
TNT
FIELD
JELIS
IDEAL
ASTEROID
AHA/ACCGuidelines6
2006
Evolution of the Lipid Treatment Guidelines1-6
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Monitor responseand adherencetherapy
If LDL goal is notachieved, intensifydrug therapy orrefer to a lipidspecialist
If LDL goal not
achieved, intensify
LDL-lowering
therapy
Initiate LDL-
lowering drug
therapy
Current Treatment Guidelines: Adult Treatment Panel III1
Current treatment guidelines recommend LDL-C as the primary target
of therapy
Statins are the cornerstone of drug therapy owing to their impressiveLDL-C-lowering effects
Non-HDL cholesterol is recognized as the secondary target of therapy
1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults(Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143-3421.
6 wk 6 wk Q-4-6 mo
Start statin or bileacid sequestrantor nicotinic acid
Consider higherdose of statin oradd bile acidsequestrant ornicotinic acid
If LDL goal isachieved, treatother lipid riskfactors
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Current Treatment Guidelines: European Society of Cardiology1
1. Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiology and othersocieties on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur J Cardiovasc Prev Rehabil. 2007;14 Suppl 2:S1-113.
Established
CVD
Diabetes
as above
Markedly
raised
lipid levels
Dietary and exercise advice, together with attention
to all risk factors, comes first.
Aim to reduce total cholesterol to
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Current Treatment Guidelines: American Diabetes Association1
The American Diabetes Association guidelines also consider LDLcholesterol as the primary target of therapy
Diabetes
Lifestylemodification With overt CVDWithout overt CVD
Age >40 with 1 other
CVD risk factor(s)Age 1 other CVD riskfactors
LDL-C >100 mg/dL
Statin
1. Standards of Medical Care in Diabetes-2009. Diabetes Care. 2009;32(Supplement 1):S13-S61.
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Guidelines for Management of Low HDL-C/High Triglycerides
European guidelines (2003)
1
Emphasis on lifestyle changes
(eg, reduce body weight, increase physical
activity)
Drug therapy may be needed for
hypertension, dyslipidemia, diabetes
International Diabetes Federation (2006)3
Reduce triglycerides/increase HDL-C andreduce LDL-C
Definition of metabolic syndrome includes
HDL-C 1.15 mmol/L (men)
or >1.3 mmol/L (women); lower triglyceridesto
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Clinical Challenge
In your practice are you able to implement theseguidelines ?
A. In all cases
B. In acute cases only
C. In patients with diabetes only
D. In patients with high risk or multiple risk factors
E. No, I do not believe in guidelines
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Dyslipidemia Management in ACS Patientsin India1
CREATE Registry
N=20,468
Percentage
1. Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet.2008;371(9622):1435-1442.
CREATE: Treatment and outcomes of acute coronary syndromes in India
Only 50% of ACS patients receive any kind of lipid-lowering therapy
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Dyslipidemia Management in ACS Patientsin India1
1. Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet.2008;371(9622):1435-1442.
Percentage
CREATE Registry
N=20,468
Underutilization of lipid-lowering drug therapy is significant in India
irrespective of the socioeconomic status
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Suboptimal Use of Statins for SecondaryPrevention of CHD and CVD Patients in India1
Percentage of patients on statin treatment
WHO-PREMISE Study
N=1013
1. Mendis S, Abegunde D, Yusuf S, et al. WHO study on Prevention of Recurrences of Myocardial Infarction and Stroke (WHO-PREMISE). Bull World Health Organ. 2005;83(11):820-829.
WHO-PREMISE: WHO study on Prevention of Recurrences of Myocardial Infarction and Stroke
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Current Status of Dyslipidemia
Coronary heart disease (CHD) is a leading cause of CV morbidity andmortality
Dyslipidemia is a risk factor responsible for more than half of theCHDs in Indians
Dyslipidemia is highly prevalent in India and characterised by lowHDL-C with elevated triglycerides & LDL-C
Despite guidelines, dyslipidemia is not being treated adequately orappropriately
Despite significant progress in the management of dyslipidemia inpatients with CHD, residual risk of CHD still persists even afteroptimal statin treatment
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Clinical Challenge
In your experience, do patients with dyslipidemiaachieve the lipid goal?
A. LDL goal is easily achieved
B. HDL goal is easily achievedC. TG goal is easily achieved
D. None of the goals are achieved
E. We may achieve individual goals but the residual risk still
remains
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Results of the EUROASPIRE II study demonstrated that a significantproportion of patients on statins did not achieve the cholesterol targets`
Failure to Reach Cholesterol Goals with Statins1
1. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries. Principal results from EUROASPIRE II Euro Heart Survey Programme. Eur HeartJ. 2001;22(7):554-572.
EUROASPIRE: European Action on Secondary and Primary Prevention through Intervention to Reduce Events
SwedenNetherlandsUK
FranceGermanySpainFinlandItalyIrelandCzechoslovakiaSloveniaHungaryBelgiumGreecePoland
% Reaching goal
Percentage receiving lipid-lowering medication
0 20 40 60 80
494139
394131554970
52414454
65
66
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Persistent Lipid Abnormalities by RiskCategories1
CHD or Risk Equivalentn=13,503 (70.3%)
2+ Risk Factorsn=3522 (18.3%)
0-1 Risk Factorn=2171 (11.3%)
LDL-C not at goal, %a 43.4/79.1 35.7 16.7
Non-HDL-C not at goal, %b 71.1 56.8 35.8
Low HDL-C, %c 35.9 33.6 1.4
Elevated TGs, %d
40.9 41.5 20.7High TC, %e 67.4 70.2 69.5
High TC/HDL-C ratio, %f 37.3 20.1 1.0
LDL-C at goal with normal HDL-C andnormal TG, %
26.0/8.6 29.2 67.5
a100 mg/dL (CHD/CHD equivalent), 130 mg/dL (2+ RF), 160 mg/dL (01 RF).b130 mg/dL (CHD/CHD equivalent), 160 mg/dL (2+ RF), 190 mg/dL (01 RF); % of patients with TGs >200 mg/dL (n=1507).c
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Residual Risk in Key Studies1
4S, the Scandinavian Simvastatin Survival Study; CARE, Cholesterol and Recurrent Events trial; LIPID, Long-Term Intervention with Pravastatin in Ischemic Disease trial; HPS, HeartProtection Study; PROSPER, Prospective Study of Pravastatin in the Elderly at Risk; ASCOT-LLA, Lipid-Lowering Arm of the Anglo-Scandinavian Cardiac Outcomes Study Trial;ALLHAT-LLT, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid Lowering Trial; ASPEN, the Atorvastatin Study for Prevention of Coronary HeartDisease Endpoints in Non-Insulin-Dependent Diabetes Mellitus; WOSCOPS, West of Scotland Coronary Prevention Study; AFCAPS/TexCAPS, Air Force/Texas Coronary AtherosclerosisPrevention Study; CARDS, the Collaborative Atorvastatin Diabetes Study.
1. Fruchart JC, Sacks F, Hermans MP, et al. The Residual Risk Reduction Initiative: a call to action to reduce residual vascular risk in patients with dyslipidemia.Am J Cardiol.2008;102(10 Suppl):1K-34K.
CHDri
sk
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SUMMARYResidual Risk & Comprehensive Lipid Management
CHD is highly prevalent in India
Dyslipidemia is an important risk factor for CHD
Mixed dyslipidemia is underdiagnosed and undertreated
Despite guidelines many patients are inadequately treated.
Despite adequate treatment, residual risk persists