improving lipid management outcomes in india_introduction_jhu_ver 2 04

8/22/2019 Improving Lipid Management Outcomes in India_Introduction_JHU_ver 2 04

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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.pdf


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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.pdf


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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%2021


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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


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.pdf


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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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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





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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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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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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

improving lipid management outcomes in india_introduction_jhu_ver 2 04

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