02 metabolic cv lipids final 16jun16
TRANSCRIPT
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CasePresentation
Moderator:SharonLiu,DOAssociateInternalMedicineChief
AustinRegionalClinicAustin,Texas
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Izzy(2006)• 51y/oHispanicwomanwithahistoryofdiabetesandobesity.• Herdiabeteshasnotbeenwell-controlledasshecravessweet
candy,carbohydratesandprocessedfoods.• Shedrinkssocially,onaverage6drinksaweek,smokes½pack
ofcigarettesaday.Shedeniesdruguse.Shehas2tattoos,obtainedintheearly1980s.
• PMHispositiveforHTN,hypothyroidismandhyperlipidemia.• BMIis32;waistcircumferenceis36.5inches.• Worksasadministrativeassistantforadoctorintown.• Marriedandhas2adultchildren.
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Izzy• Substernalburningpainforthepast6weeksforwhichherPCPprescribedaPPI.SymptomspersisteddespitePPI.
• ReturnedtoPCP.• Labs– CMP:LFTsweremildlyelevated,otherwisenormal– CBCnormal– Fastinglipidpanel:LDL170,HDL32,triglycerides352– HgA1c9.4
• BP:140/90• ReferredtoDr.Dlabal
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CardiovascularComplicationsofMetabolicSyndrome
PaulW.Dlabal,M.D.
Austin,Texas
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MetabolicSyndrome: DefinitionsofNCEP,WHO,EGIRandACE
JACC Vol. 59,No.72012- February 14,2012; 665-72
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Circulation. 2005;112:666-673
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PrevalenceofIndividualMetS Abnormalities
Circulation. 2004;110:1245-1250
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MetabolicSyndrome:Definitions/HazardRatios/Risk
Circulation. 2005;112:666-673
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NumberofMetabolicSyndromeAbnormalitiesbyNCEP
Circulation. 2005;112:666-673
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UnadjustedKaplan-MeierHazardCurves
JAMA December 4, 2002– Vol 288,No.21(Reprinted)
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AgeandGenderAdjustedCHD,CVD,andTotalMortalityRates
Circulation. 2004;110:1245-1250
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MetabolicSyndromeandAge-adjustedRisk
Circulation. 2005;112:3066-3072
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MetabolicSyndrome/AgeAdjustedRisk
Circulation. 2005;112:666-673
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Four-yearKaplan-MeierPlotsofSurvival
Circulation. 2004;109:714-721
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WomenWithoutSignificantCAD
Circulation. 2004;109:714-721
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WomenWithSignificantCAD
Circulation. 2004;109:714-721
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IncidenceRateofMajorCVEvents
Circulation. 2010;121; 230-236; originally published December 28, 2009
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RisksinOverweightorObesePatients:With/WithoutMetabolicSyndrome
Circulation. 2010;121; 230-236; originally published December 28, 2009R
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ISTHEREHOPE?
• TheproblemconsistsofMODIFIABLE riskfactorsforCAD/CHD/CVMortality
• ThesolutionistoMODIFYtheserisks:–WeightLoss– IncreasedCardiorespiratoryFitness–DirectIntervention
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Correlations BetweenChangesinFitnessorFatness
JACC Vol. 59,No.72012- February 14,2012; 665-72
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HRsofIncidentCardiovascularDiseaseRisk(1)
JACC Vol. 59,No.72012- February 14,2012; 665-72
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HRsofIncidentCardiovascularDiseaseRisk(2)
JACC Vol.59,No.72012- February 14,2012; 665-72
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HRsofIncidentCardiovascularDiseaseRisk(3)
JACC Vol.59,No.72012- February 14,2012; 665-72
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Summary
• TheprevalenceofmetabolicsyndromeintheUSandotherindustrializedcountriesissubstantial,andcontributesgreatlytotheburdenofCVD.– Affects:Upto25%oftheUSpopulation.– CVRisk:Increasesupto2fold.– Diabetes&MetS increasetheriskupto4fold.– CV&MetS syndromeincreasetheriskmorethan4fold.
– Improvementinfitness&fatnessconfersexpectedbenefit.
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BacktoDr.Liu
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Izzy• Acardiacstresstestwasorderedanditwaspositive.Sheunderwentaleftcardiaccath andwasfoundtohave1vesseldisease,thiswasstented.
• Treatmentplan– StartedonPlavix
• Hersubsternalpainresolvedandshefeltmuchbetter.• Labs:LDL145,HDL35,TG230• UltrasoundwasorderedsinceLFTsremainedelevated.• Dr.Dlabal,howwillyoumanageherhyperlipidemia?
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LipidManagementinMetabolicSyndrome
PaulW.Dlabal,M.D.
Austin,Texas
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MetabolicSyndrome:ConstellationofReversibleRiskFactorsforCAD
• ReducedHDL• ElevatedTG• ElevatedBPandFBS• Weightgain
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CriteriaforClinicalDiagnosis
Grundy “RiskAssessment” NCBIBookshelf, 2015
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SecondaryCausesofHyperlipidemiaMostCommonlyEncountered
AHA
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ParadigmforSubtypingMetS
JACC VOL.66,NO.9,2015 SEPTEMBER1,2015:1050–67
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Step-by-stepProcessofReviewofEvidenceintheGuideline
JACC Vol. 59,No.72012- February 14,2012; 665-72
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Cholesterol-ASCVDRelationship:TwoTypesofMeta-Analysis
JACC Vol. 59,No.72012- February 14,2012; 665-72
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SummaryofStatinInitiationRecommendations
Professional Heart.org,AHA
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FourTreatmentBenefitGroups
• ASCVD• LDL>190mg/dL• Diabetes• LDL<190mg/dL with10-yearrisk>5%
JACC Vol. 59,No.72012- February 14,2012; 665-72
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DefinitionofTreatmentIntensity
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Step-by-stepProcessofReviewofEvidenceintheGuideline
JACC Vol.59,No.72012- February 14,2012; 665-72
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JACC Vol. 59,No.72012- February 14,2012; 665-72
Step-by-stepProcessofReviewofEvidenceintheGuideline
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JACC Vol. 59,No.72012- February 14,2012; 665-72
Step-by-stepProcessofReviewofEvidenceintheGuideline
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InitiatingStatinsinIndividualswithClinicalASCVD
AHA
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AHA
InitiatingStatinsinIndividualsWithoutClinicalASCVD
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RiskCalculators
• http://my.americanheart.org/cvriskcalculator• http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx
• http://tools.acc.org/ASCVD-Risk-Estimator/
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ASCVDRiskEstimator
ACCandAHA2014
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TheAbsoluteCVDRisk/BenefitCalculator
AHA2014
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CriteriaforClinicalDiagnosisbyCAC
Grundy “RiskAssessment” NCBIBookshelf, 2015
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CholesterolLoweringDrugs
Grundy “RiskAssessment” NCBIBookshelf, 2015
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Patient1
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Patient1
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SecondaryCausesofHypertriglyceridemia
Tamrock “Risk Assessment forTG”NCBI2000
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CholesterolLoweringDrugs/AlsoGoodforTG
Grundy “RiskAssessment” NCBIBookshelf, 2015
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StatinRxvsLiverDamageinNASH
Nascimbeni Fetal.,BMJOpenGastro2016:3:e000075. doi:10.1136/bmjgast-2015-000075
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Summary:TreatmentofHyperlipidemiaisComplex!
• AfterDx,thendietandlifestylechange.• AssessriskgroupandneedforRxaswellasintensityofRx.
• SinceMetS doublesCVriskoveranybaseline,initiatestatintherapywhereindicated.
• MonitorresultsfornecessitytoaugmentRx.• AssessTGlevel,Dx andneedforRx.• Wherenecessary,obtainlipidparticlesizeandnumbertooptimizeRx.
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Izzy
• StartedonLipitor.• Shewasgivenastrictlowcholesteroldiettofollow.– Sinceshecutbackoneatingfattyfoods,shestartedeatingmoresweets.
• Labs:HgA1c10.5• ShewasthenreferredtoDr.Musi.