dyslipidemia: managing a key cardiovascular risk factor

Dyslipidemia: Managing a Key Dyslipidemia: Managing a Key Cardiovascular Risk FactorCardiovascular Risk Factor

AIMGP Clinic SeminarAIMGP Clinic Seminar

Updated by R. CavalcantiUpdated by R. Cavalcanti

Sep 2006Sep 2006

OutlineOutline

Current Practice GuidelinesCurrent Practice Guidelines CasesCases Global Risk AssessmentGlobal Risk Assessment Whom to Screen for Dyslipidemia?Whom to Screen for Dyslipidemia? Risk Categories & Lipid TargetsRisk Categories & Lipid Targets Factors Influencing Risk AssessmentFactors Influencing Risk Assessment Selected Recent TrialsSelected Recent Trials ManagementManagement Cases RevisitedCases Revisited

Current Practice GuidelinesCurrent Practice Guidelines

Canadian GuidelinesCanadian Guidelines– ““Recommendations for the management of Recommendations for the management of

dyslipidemia and the prevention of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 cardiovascular disease: summary of the 2003 update” CMAJ 169(9):921-4, 28 Oct 2003update” CMAJ 169(9):921-4, 28 Oct 2003

– Full text of 2003 update is only online, at: Full text of 2003 update is only online, at: www.cmaj.ca/cgi/content/full/169/9/921/DC1www.cmaj.ca/cgi/content/full/169/9/921/DC1

– ““Recommendations for the management and Recommendations for the management and treatment of dyslipidemia” CMAJ treatment of dyslipidemia” CMAJ 162(10):1441-7, 16 May 2000162(10):1441-7, 16 May 2000

Current Practice GuidelinesCurrent Practice Guidelines

American GuidelinesAmerican Guidelines– ““Implications of Recent Clinical Trials for the National Implications of Recent Clinical Trials for the National

Cholesterol Education Program Adult Treatment Panel Cholesterol Education Program Adult Treatment Panel III Guidelines” Circulation 110:227-39, 13 July 2004III Guidelines” Circulation 110:227-39, 13 July 2004

– ““Executive Summary of the Third Report of the Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)” JAMA 285(19):2486-97, 16 May 2001Panel III)” JAMA 285(19):2486-97, 16 May 2001

Case 1Case 1

56 M56 M– Acute MI 4 months agoAcute MI 4 months ago– No current cardiovascular symptomsNo current cardiovascular symptoms– Tested for DM post-MITested for DM post-MI

» NegativeNegative

– Non-smoker, no HTNNon-smoker, no HTN Lipids measured while in hospital post-MI:Lipids measured while in hospital post-MI:

– TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2)TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2) What is his estimated risk of a cardiovascular event What is his estimated risk of a cardiovascular event

in the next 10 years?in the next 10 years? How should you manage his lipids?How should you manage his lipids?

Case 2Case 2

45 F45 F– ‘‘Healthy’, BP 125/80Healthy’, BP 125/80

– Non-smoker, EtOH: 3 standard drinks/weekNon-smoker, EtOH: 3 standard drinks/week

– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)

What is her estimated risk of a cardiovascular What is her estimated risk of a cardiovascular event in the next 10 years?event in the next 10 years?

How should you manage her lipids?How should you manage her lipids?

Case 3Case 3

55 F55 F– DM Type 2 x 10 years (HbA1c 9.7%), HTNDM Type 2 x 10 years (HbA1c 9.7%), HTN– post menopausal, BMI 33post menopausal, BMI 33– Non-smoker, EtOH: 4 standard drinks/dayNon-smoker, EtOH: 4 standard drinks/day– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)

What is her estimated risk of a cardiovascular What is her estimated risk of a cardiovascular event in the next 10 years?event in the next 10 years?


Current Challenges in Current Challenges in Cardiovascular Risk ReductionCardiovascular Risk Reduction

Aging PopulationAging Population– >20% Canadians will be >65 years old by 2011>20% Canadians will be >65 years old by 2011– 1,900,000 Canadians >80 years old by 20261,900,000 Canadians >80 years old by 2026

ObesityObesity– 31% of Canadians are obese31% of Canadians are obese– Especially if abdominal adiposity, associated with increased Especially if abdominal adiposity, associated with increased

prevalence of metabolic syndrome features (DM, HTN, prevalence of metabolic syndrome features (DM, HTN, ↑TGs, ↓HDL, insulin resistance)↑TGs, ↓HDL, insulin resistance)

– Associated with Associated with ↑inflammatory markers (CRP, IL-6)↑inflammatory markers (CRP, IL-6) DiabetesDiabetes

– 60,000 new cases per year in Canada60,000 new cases per year in Canada– 3,000,000 Canadians with DM by 20103,000,000 Canadians with DM by 2010

Global Risk AssessmentGlobal Risk Assessment

Since hyperlipidemia is important as a risk Since hyperlipidemia is important as a risk factor, it should be used to assess overall factor, it should be used to assess overall cardiac risk, and that risk should in turn be cardiac risk, and that risk should in turn be used to assess treatment goals and used to assess treatment goals and modalitiesmodalities

Cardiac endpoints?Cardiac endpoints?– non-fatal MInon-fatal MI– death due to CADdeath due to CAD


Risk assessment model adapted from the Risk assessment model adapted from the Framingham Heart StudyFramingham Heart Study

This model is only:This model is only:– For non-diabetic patientsFor non-diabetic patients– For patients without clinically evident For patients without clinically evident

cardiovascular disease (including prior CAD, cardiovascular disease (including prior CAD, ischemic stroke, and/or peripheral arterial ischemic stroke, and/or peripheral arterial disease) or CRFdisease) or CRF


Which patients are automatically considered Which patients are automatically considered high risk (>20% 10-year risk)? high risk (>20% 10-year risk)?

All adult patients with:All adult patients with:» DMDM

» History of CADHistory of CAD

» Ischemic strokeIschemic stroke

» Peripheral arterial diseasePeripheral arterial disease

» CRFCRF


What are the risk factors in Framingham What are the risk factors in Framingham risk calculator?risk calculator?– AgeAge– GenderGender– Smoking historySmoking history– Lipid profile (TC, HDL)Lipid profile (TC, HDL)– Systolic BPSystolic BP

If the calculated 10-year risk is:

≥20% - ‘High Risk’

11-19% - ‘Moderate Risk’

≤10% - ‘Low Risk’

Whom to Screen for Whom to Screen for Dyslipidemia?Dyslipidemia?

Influenced by cardiac risk factors:Influenced by cardiac risk factors: By age alone:By age alone:

– Men over age 40Men over age 40– Women over age 50 (or post-menopausal)Women over age 50 (or post-menopausal)

Other risk factors (at any age):Other risk factors (at any age):– DM, HTN, Smoking, Abdominal ObesityDM, HTN, Smoking, Abdominal Obesity– Family history of early cardiovascular diseaseFamily history of early cardiovascular disease

Physical signs of hyperlipidemia (at any age):Physical signs of hyperlipidemia (at any age):– Xanthomata, xanthelasmas, arcus corneae, etcXanthomata, xanthelasmas, arcus corneae, etc

Evidence of existing atherosclerosis (at any age)Evidence of existing atherosclerosis (at any age)

Manifestations of DyslipidemiaManifestations of Dyslipidemia

Eruptive xanthomata on the forearm of a patient with severe ↑TGs↑TGs

Xanthelasmas and tendon xanthomata in patients with severe ↑LDL ↑LDL (the patient at (the patient at the bottom the bottom has has heterozygous heterozygous familial familial hyperchol-hyperchol-esterolemia)esterolemia)

Diagnosis of Asymptomatic Diagnosis of Asymptomatic AtherosclerosisAtherosclerosis

To aid in risk stratificationTo aid in risk stratification Recommended:Recommended:

– Physical examinationPhysical examination– Ankle-Brachial IndexAnkle-Brachial Index

Possibly useful in patients already known to be at Possibly useful in patients already known to be at ‘moderate risk’:‘moderate risk’:– Carotid ultrasonographyCarotid ultrasonography– EKGEKG– Exercise stress testing in men >40 years old with Exercise stress testing in men >40 years old with

established cardiovascular risk factorsestablished cardiovascular risk factors

Risk Categories & Lipid TargetsRisk Categories & Lipid Targets

More about LDL targets to come later – for high-risk patients, these are minimum targets – they should be lower if at all possible

Lipid Targets: TriglyceridesLipid Targets: Triglycerides

There is no longer a discrete triglyceride There is no longer a discrete triglyceride goal in each category, but the optimal level goal in each category, but the optimal level is set at TG <1.7is set at TG <1.7

If TG >10 it needs targeted treatment (diet If TG >10 it needs targeted treatment (diet & lifestyle changes, fibrate or niacin, fish & lifestyle changes, fibrate or niacin, fish oil) to prevent pancreatitis independent of oil) to prevent pancreatitis independent of cardiovascular riskcardiovascular risk

Factors Influencing Risk AssessmentFactors Influencing Risk Assessment

Metabolic SyndromeMetabolic Syndrome Abdominal ObesityAbdominal Obesity Apolipoprotein B (apoB)Apolipoprotein B (apoB) Lipoprotein(a)Lipoprotein(a) HomocysteineHomocysteine C-Reactive Protein (CRP)C-Reactive Protein (CRP) Genetic RiskGenetic Risk Hormone Replacement Therapy (HRT)Hormone Replacement Therapy (HRT)

Factors Influencing Risk Factors Influencing Risk AssessmentAssessment

Presence of the Metabolic SyndromePresence of the Metabolic Syndrome– A clustering of cardiovascular risk factors, including A clustering of cardiovascular risk factors, including

abdominal obesity, insulin resistance, and hypertension, abdominal obesity, insulin resistance, and hypertension, as well as lipid abnormalities (as well as lipid abnormalities (↑TGs and ↓HDL↑TGs and ↓HDL))

Presence of Abdominal ObesityPresence of Abdominal Obesity– with waist circumference as a useful estimatewith waist circumference as a useful estimate


Apolipoprotein B (apoB)Apolipoprotein B (apoB)

– There is 1 molecule of apoB in each atherogenic lipid There is 1 molecule of apoB in each atherogenic lipid particle (VLDL, IDL, LDL, lp(a))’particle (VLDL, IDL, LDL, lp(a))’

– ↑↑apoB (for the same lipid levels) = smaller, denser, apoB (for the same lipid levels) = smaller, denser, more atherogenicmore atherogenic LDL particles LDL particles

– Better estimate than LDLBetter estimate than LDL of cardiovascular risk of cardiovascular risk– ApoB levels ApoB levels correlate bettercorrelate better than LDL levels than LDL levels to to

clinical outcomesclinical outcomes in statin trials in statin trials– For ‘high risk’ patients, For ‘high risk’ patients, target apoB <0.9g/Ltarget apoB <0.9g/L– Sample does not need to be fastingSample does not need to be fasting


Lipoprotein(a) (lp(a))Lipoprotein(a) (lp(a))– Appears to be an independent risk factor for premature Appears to be an independent risk factor for premature

atherosclerosis and CADatherosclerosis and CAD

– Its atherogenicity seems to depend on the presence of Its atherogenicity seems to depend on the presence of other factors, and its utility as a risk factor seems to other factors, and its utility as a risk factor seems to disappear if the LDL is markedly lowereddisappear if the LDL is markedly lowered

– Monogenic and not responsive to dietMonogenic and not responsive to diet

– Lp(a) >30mg/dL in patients with TC/HDL ratio >5.5 or Lp(a) >30mg/dL in patients with TC/HDL ratio >5.5 or other major risk factors may indicate need for earlier other major risk factors may indicate need for earlier and more intensive LDL-lowering therapyand more intensive LDL-lowering therapy


HomocysteineHomocysteine– ↑↑homocysteine levels predict adverse outcomes in homocysteine levels predict adverse outcomes in

patients with CADpatients with CAD

– Fixed-dose folate & B12 trials looking at Fixed-dose folate & B12 trials looking at cardiovascular endpoints are ongoingcardiovascular endpoints are ongoing

– No ‘treat-to-target’ trial (to homocysteine <9No ‘treat-to-target’ trial (to homocysteine <9μμmol/L)mol/L)

– No evidence yet to screen for homocysteineNo evidence yet to screen for homocysteine


C-Reactive Protein (CRP)C-Reactive Protein (CRP)– ↑↑CRP may add prognostic information to Framingham CRP may add prognostic information to Framingham

Study dataStudy data– ↑↑CRP associated with abdominal obesity and the CRP associated with abdominal obesity and the

metabolic syndromemetabolic syndrome– May be clinically useful in identifying people who are May be clinically useful in identifying people who are

at higher risk than their Global Risk Assessment would at higher risk than their Global Risk Assessment would indicate (especially for people with a indicate (especially for people with a calculated 10-year calculated 10-year risk of 11-19%, so calculated to be risk of 11-19%, so calculated to be at ‘moderate risk’)at ‘moderate risk’)


C-Reactive Protein (CRP)C-Reactive Protein (CRP)– Do not measure during an acute illness or in patients Do not measure during an acute illness or in patients

with chronic inflammatory diseasewith chronic inflammatory disease– Measure 2x, two weeks apart, and use the Measure 2x, two weeks apart, and use the lowerlower value value– Low risk <1 mg/ml & high risk 3-10mg/mlLow risk <1 mg/ml & high risk 3-10mg/ml– If >10mg/ml, look for infection/inflammationIf >10mg/ml, look for infection/inflammation


Genetic RiskGenetic Risk– A confirmed, unambiguous family history of early A confirmed, unambiguous family history of early

onset CAD increases the risk for first-degree relatives onset CAD increases the risk for first-degree relatives (parents, siblings, children)(parents, siblings, children)

» RRI 1.7-2.0RRI 1.7-2.0

– Early onset is defined as <55 years old for men and <65 Early onset is defined as <55 years old for men and <65 years old for women (this is the age of the index years old for women (this is the age of the index relative who had the cardiac event)relative who had the cardiac event)


Hormone Replacement Therapy (HRT):Hormone Replacement Therapy (HRT):– Should not be initiated for primary or secondary Should not be initiated for primary or secondary

prevention of CADprevention of CAD– Unless otherwise necessary (e.g. for osteoporosis Unless otherwise necessary (e.g. for osteoporosis

treatment or for severe menopausal symptoms) try to treatment or for severe menopausal symptoms) try to stop or taper HRT in women >55 years old who have stop or taper HRT in women >55 years old who have been on it for >5 yearsbeen on it for >5 years

– Consider stopping HRT in the setting of an acute Consider stopping HRT in the setting of an acute cardiovascular eventcardiovascular event

– Consider stopping HRT before an ACB, PCI, or other Consider stopping HRT before an ACB, PCI, or other surgical proceduresurgical procedure

Selected Major TrialsSelected Major Trials

MRC/BHF Heart Protection Study:MRC/BHF Heart Protection Study:– HPS: Lancet 360(9326):7-22, 6 July 2002HPS: Lancet 360(9326):7-22, 6 July 2002– 20,556 men & women aged 40-80 with TC >3.520,556 men & women aged 40-80 with TC >3.5– All at ‘high risk’ of CADAll at ‘high risk’ of CAD

» Known CAD/MI/PVD/CVSKnown CAD/MI/PVD/CVS» DM, HTN, or bothDM, HTN, or both

– RCT: Simvastatin 40mg vs. placeboRCT: Simvastatin 40mg vs. placebo» Decreased death rate by 13%Decreased death rate by 13%» Decreased combined cardiovascular end points by 24%Decreased combined cardiovascular end points by 24%

– Benefits in all subgroups, including baseline LDL <2.6Benefits in all subgroups, including baseline LDL <2.6– Very compelling, well done trialVery compelling, well done trial– Ultimate LDL target still unclear, other studies now looking Ultimate LDL target still unclear, other studies now looking

at LDL targets of <1.8at LDL targets of <1.8


Anglo-Scandinavian Cardiac Outcomes TrialAnglo-Scandinavian Cardiac Outcomes Trial– ASCOT: Lancet 361(9364):1149-58, 5 April 2003ASCOT: Lancet 361(9364):1149-58, 5 April 2003– 9000 patients aged 40-79 with baseline TC <6.59000 patients aged 40-79 with baseline TC <6.5– All hypertensiveAll hypertensive

» Had at least 3 risk factors for CADHad at least 3 risk factors for CAD» No pre-existing coronary diseaseNo pre-existing coronary disease

– RCT: Atorvastatin 10mg vs. placeboRCT: Atorvastatin 10mg vs. placebo» MI by 36%MI by 36%» stroke rate by 27%stroke rate by 27%» all cardiovascular events and procedures by 21%all cardiovascular events and procedures by 21%» total coronary events by 29%total coronary events by 29%

– Study was stopped after 3 years because of significant Study was stopped after 3 years because of significant benefit in the treatment groupbenefit in the treatment group


The INTERHEART studyThe INTERHEART study– Effect of potentially modifiable risk factors associated Effect of potentially modifiable risk factors associated

with myocardial infarction in 52 countries: with myocardial infarction in 52 countries: Lancet Lancet 364(9437):4999-5014, 4 Sept 2004364(9437):4999-5014, 4 Sept 2004

– Case Control: 15,152 cases & 14,820 controls in 52 Case Control: 15,152 cases & 14,820 controls in 52 countries on every inhabited continentcountries on every inhabited continent

– Findings consistent between old/young, male/female, Findings consistent between old/young, male/female, different countries with different standards of livingdifferent countries with different standards of living

– 9 risk factors 9 risk factors accounted for >90% (in men) and >94% accounted for >90% (in men) and >94% (in women) of the population attributable risk (PAR) of (in women) of the population attributable risk (PAR) of acute MIacute MI


The INTERHEART study:The INTERHEART study:– The 9 risk factors:The 9 risk factors:

» SmokingSmoking (OR 2.87 current vs. never, p<0.0001) (OR 2.87 current vs. never, p<0.0001)» ↑↑ApoB/ApoA1 ratioApoB/ApoA1 ratio (OR 3.25 1 (OR 3.25 1stst vs. 5 vs. 5thth quintile quintile, p<0.0001, p<0.0001))» History of History of HTNHTN (OR 1.91 (OR 1.91, p<0.0001, p<0.0001))» DMDM (OR 2.37 (OR 2.37, p<0.0001, p<0.0001))» Abdominal ObesityAbdominal Obesity (OR 1.12 1 (OR 1.12 1stst vs. 3 vs. 3ndnd tertile & OR 1.62 2 tertile & OR 1.62 2ndnd

vs. 3vs. 3rdrd tertile tertile, p<0.0001, p<0.0001))» psychosocial factorspsychosocial factors (OR 2.67, (OR 2.67, p<0.0001 p<0.0001))» eating fruits & vegetables dailyeating fruits & vegetables daily (OR 0.70 (OR 0.70, p<0.0001, p<0.0001))» ≥≥3 units/week of 3 units/week of alcoholalcohol (OR 0.91, p=0.03) (OR 0.91, p=0.03)» moderate/strenuous physical activitymoderate/strenuous physical activity (OR 0.86 (OR 0.86 , p<0.0001, p<0.0001))

TreatmentTreatment

TreatmentTreatment

In ‘high risk’ patients:In ‘high risk’ patients:– Start drug treatment immediately, concurrently with Start drug treatment immediately, concurrently with

diet and lifestyle modificationdiet and lifestyle modification– Priority is to get LDL <2.5 and TC/HDL <4Priority is to get LDL <2.5 and TC/HDL <4– Given HPS data:Given HPS data:

» Treat with Simvastatin 40mg or equivalent statinTreat with Simvastatin 40mg or equivalent statin» LDL target of 2.5 at mostLDL target of 2.5 at most

– If can’t reach LDL <2.5:If can’t reach LDL <2.5:» Bile acid sequestrants (cholestyramine, colestipol)Bile acid sequestrants (cholestyramine, colestipol)» Cholesterol absorption inhibitors (ezetimibe) better toleratedCholesterol absorption inhibitors (ezetimibe) better tolerated» Either can decrease LDL by another 10-20% compared with Either can decrease LDL by another 10-20% compared with

statin alonestatin alone

TreatmentTreatment

If TC/HDL ratio is still high:If TC/HDL ratio is still high:– Lifestyle modificationLifestyle modification– Increasing Statin Dose (with LDL at target)Increasing Statin Dose (with LDL at target)– Combination Drug TherapyCombination Drug Therapy

TreatmentTreatment

Lifestyle modification:Lifestyle modification:– For For ↑TGs: weight loss, restriction of refined ↑TGs: weight loss, restriction of refined

carbohydrates, no alcohol, increased exercisecarbohydrates, no alcohol, increased exercise– For ↓HDL: weight loss, increased For ↓HDL: weight loss, increased

monounsaturated fats, moderate alcohol (if TGs monounsaturated fats, moderate alcohol (if TGs normal), increased aerobic exercisenormal), increased aerobic exercise

TreatmentTreatment

Increasing Statin Dose (with LDL at target):Increasing Statin Dose (with LDL at target):– For ↓HDL and/or mild ↑TGs (TGs <5), may For ↓HDL and/or mild ↑TGs (TGs <5), may

achieve target TC/HDL ratio by increasing the achieve target TC/HDL ratio by increasing the statin dose even if the target LDL has been statin dose even if the target LDL has been reachedreached

TreatmentTreatment

Combination Drug Therapy:Combination Drug Therapy:– Moderate ↑TGs -> add salmon oil (1-3g tid) to statinModerate ↑TGs -> add salmon oil (1-3g tid) to statin

– ↓↓HDL -> combine statin with niacin. Caution: 1) niacin HDL -> combine statin with niacin. Caution: 1) niacin can cause increased insulin resistance, 2) niacin-statin can cause increased insulin resistance, 2) niacin-statin combination increases risk of hepatotoxicitycombination increases risk of hepatotoxicity

– If intolerant to niacin -> consider statin-fibrate If intolerant to niacin -> consider statin-fibrate combination (simvastatin or pravastatin with combination (simvastatin or pravastatin with fenofibrate, NOT gemfibrozil)fenofibrate, NOT gemfibrozil)

» lowest possible doses of eachlowest possible doses of each

» very close follow-up watching for hepatotoxicity and myositisvery close follow-up watching for hepatotoxicity and myositis

» if no CRFif no CRF

TreatmentTreatment

If If ↑↑TGs:TGs:– Ideal target <1.7Ideal target <1.7

» 11stst line: lifestyle modification line: lifestyle modification» Treatments aimed at lowering the TC/HDL ratio usually also Treatments aimed at lowering the TC/HDL ratio usually also

help lower TGshelp lower TGs

– If TGs >6 despite lifestyle changes, need drug If TGs >6 despite lifestyle changes, need drug treatment even if the TC/HDL ratio is acceptabletreatment even if the TC/HDL ratio is acceptable

» Treatment is needed to avoid pancreatitisTreatment is needed to avoid pancreatitis» Options:Options:

FibrateFibrate NiacinNiacin Salmon oilSalmon oil

Follow-UpFollow-Up

Which blood work should be ordered Which blood work should be ordered in follow-up? How frequently?in follow-up? How frequently?

Follow-UpFollow-Up

Lipids:Lipids:– 6 weeks after start / change of dose (levels reach steady state 6 weeks after start / change of dose (levels reach steady state

within 6 weekswithin 6 weeks of start/change of medication) of start/change of medication)– Long-term follow-up every 6-12 monthsLong-term follow-up every 6-12 months

AST / ALT / CK:AST / ALT / CK:– Get baseline Get baseline – Repeat whenever you test lipids:Repeat whenever you test lipids:

» 6 weeks after a dose increase6 weeks after a dose increase» Every 6-12 monthsEvery 6-12 months

– Check more frequently:Check more frequently:» If on maximum dosesIf on maximum doses» If on combination therapy (especially a statin plus a fibrate)If on combination therapy (especially a statin plus a fibrate)

– Check if symptomaticCheck if symptomatic

Case 1 RevisitedCase 1 Revisited

56 M56 M– Acute MI 4 months agoAcute MI 4 months ago– No current cardiovascular symptomsNo current cardiovascular symptoms– Tested for DM post-MITested for DM post-MI

» NegativeNegative

– Non-smoker, no HTNNon-smoker, no HTN Lipids measured while in hospital post-MI:Lipids measured while in hospital post-MI:

– TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2)TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2) What is his estimated risk of a cardiovascular event in What is his estimated risk of a cardiovascular event in

the next 10 years?the next 10 years?– Assumed to be Assumed to be ≥20%≥20%

How should you manage his lipids?How should you manage his lipids?


45 F45 F– ‘‘Healthy’, BP 125/80Healthy’, BP 125/80– Non-smoker, 3 units EtOH/weekNon-smoker, 3 units EtOH/week– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)

What is her estimated risk of a cardiovascular What is her estimated risk of a cardiovascular event in the next 10 years?event in the next 10 years?– Calculated to be 1%Calculated to be 1%



55 F55 F– DM Type 2 x 10 years (HbA1c 9.7%), HTNDM Type 2 x 10 years (HbA1c 9.7%), HTN– post menopausal, BMI 33post menopausal, BMI 33– Non-smoker, 4 units EtOH/dayNon-smoker, 4 units EtOH/day– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)

What is her estimated risk of a cardiovascular event What is her estimated risk of a cardiovascular event in the next 10 years?in the next 10 years?– Assumed to be Assumed to be ≥20%≥20%
