new concepts in the evaluation and treatment of dyslipidemia
TRANSCRIPT
New Concepts in the EvaluationNew Concepts in the Evaluation and and
Treatment of DyslipidemiaTreatment of Dyslipidemia
Nathan D. Wong, PhD, FACCNathan D. Wong, PhD, FACC
Professor and DirectorProfessor and Director
Heart Disease Prevention Heart Disease Prevention ProgramProgram
Division of CardiologyDivision of Cardiology
University of California, IrvineUniversity of California, Irvine
Learning ObjectivesLearning Objectives
Discuss the role of cholesterol, lipoproteins, and the Discuss the role of cholesterol, lipoproteins, and the metabolic syndrome in coronary heart diseasemetabolic syndrome in coronary heart disease
Examine the results of important cholesterol lowering Examine the results of important cholesterol lowering clinical trials and understand their relevance in clinical clinical trials and understand their relevance in clinical practicepractice
Review current NCEP goals for lipid managementReview current NCEP goals for lipid management
Evaluate the efficacy and safety profiles of various Evaluate the efficacy and safety profiles of various cholesterol lowering strategies including diet and lifestyle cholesterol lowering strategies including diet and lifestyle regimens and pharmacologic agentsregimens and pharmacologic agents
Most Myocardial Infarctions Are CausedMost Myocardial Infarctions Are Causedby Low-Grade Stenosesby Low-Grade Stenoses
Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.(Adapted from Falk et al.)(Adapted from Falk et al.)
Falk E et al, Circulation, 1995.
LipoproteinsLipoproteins
Water-soluble way to transport hydrophobic lipidsWater-soluble way to transport hydrophobic lipids
• Envelope of phospholipids and free cholesterol
• Triglyceride and cholesteryl ester-rich core
• Vary in size and density
From: Braunwald et al, Heart Disease: A Textbook of Cardiovascular Medicine 6th ed., 2001
1.20
1.100
1.063
1.019
1.006
0.95
5 10 20 40 60 80 1000
ChylomicronRemnants
VLDL
LDL-R
HDL2
HDL3DL3
Particle Size (nm)
Den
sity
(g/
ml)
Chylomicron
VLDLRemnants
Lipoprotein ParticlesLipoprotein Particles
Lp(a)
IDL
Only these lipoprotein particles found in plaque at biopsy.
1.050
Lipid Atherogenesis
HDL
Liver
Advancedfibrocalcific
lesion
Oxidativemodification
of LDL
LDL+
VLDL
Cholesterolexcreted
Endothelialinjury
Adherenceof platelets
Releaseof PDGF
High plasmaLDL
LDL infiltrationinto intima
+Macrophages
Foam cells
Fatty streak
LCATAPO-A1
Othergrowthfactors
Genetic Causes of DyslipidemiaGenetic Causes of Dyslipidemia
Type I – Familial HyperchylomicronemiaType I – Familial Hyperchylomicronemia Fasting triglycerides > 1000 mg/dlFasting triglycerides > 1000 mg/dl Defect in lipoprotein lipase or apo CIIDefect in lipoprotein lipase or apo CII Not necessarily at increased risk of CADNot necessarily at increased risk of CAD
Type II - Familial Hypercholesterolemia (type II)Type II - Familial Hypercholesterolemia (type II) LDL-C > 95LDL-C > 95thth percentile for age and gender percentile for age and gender CAD in men by 3CAD in men by 3rdrd or 4 or 4thth decade decade Defect in LDL receptorDefect in LDL receptor Autosomal dominant inheritanceAutosomal dominant inheritance Prevalence 1:500Prevalence 1:500
Familial Defective apo B 100Familial Defective apo B 100 Defective apo B alters LDLr handlingDefective apo B alters LDLr handling Previously undetecable from FHPreviously undetecable from FH
Genetic Causes of DyslipidemiaGenetic Causes of Dyslipidemia
Type III – HyperlipoproteinemiaType III – Hyperlipoproteinemia Increased TC, VLDL, decreased HDL; Increased VLDL:TG Increased TC, VLDL, decreased HDL; Increased VLDL:TG Defect in apo E results in increased concentration of remnant particlesDefect in apo E results in increased concentration of remnant particles RareRare
Type IV – Familial HypertriglyceridemiaType IV – Familial Hypertriglyceridemia Increased TC (due to VLDL), TG, decreased LDL, HDLIncreased TC (due to VLDL), TG, decreased LDL, HDL Results from hepatic overproduction of VLDLResults from hepatic overproduction of VLDL Prevalence 1:100 – 1:50; Association with CAD not as strong as FHPrevalence 1:100 – 1:50; Association with CAD not as strong as FH Heterogeneous inheritanceHeterogeneous inheritance Very sensitive to diet and EtOHVery sensitive to diet and EtOH
Type VType V Increase in chylomicrons and VLDLIncrease in chylomicrons and VLDL RareRare
Genetic Causes of DyslipidemiaGenetic Causes of Dyslipidemia
Familial Combined HyperlipidemiaFamilial Combined Hyperlipidemia Increased TC, LDL and/or triglycerides; decreased HDL Increased TC, LDL and/or triglycerides; decreased HDL Most common genetic dyslipidemia: prevalence 1:50Most common genetic dyslipidemia: prevalence 1:50 Heterogenous inheritanceHeterogenous inheritance Accounts for 10-20% of patients with premature CADAccounts for 10-20% of patients with premature CAD
Defects in HDL MetabolismDefects in HDL Metabolism Most often low HDL is secondary to other dyslipidemiaMost often low HDL is secondary to other dyslipidemia Not all associated with increased CAD risk (e.g. apo AINot all associated with increased CAD risk (e.g. apo AIMilanoMilano)) Tangier’s DiseaseTangier’s Disease CETP defects result in increased HDLCETP defects result in increased HDL
Compliance with Lipid Treatment GuidelinesCompliance with Lipid Treatment Guidelines
About half U.S. population has LDL-CAbout half U.S. population has LDL-C >130 >130 mg/dLmg/dL
Less than half those eligible undertake Less than half those eligible undertake treatmenttreatment
Only a third of those treated achieve their LDL-Only a third of those treated achieve their LDL-C goalsC goals
40%40% of patients surveyed who saw a physician of patients surveyed who saw a physician in preceding 2 years were unaware of their in preceding 2 years were unaware of their lipid statuslipid status
Only 20-25% of CVD patients in the U.S. are Only 20-25% of CVD patients in the U.S. are reported to be on treatment for dyslipidemiareported to be on treatment for dyslipidemia
AHA Heart Disease and Stroke Statistics: 2004 UpdateAHA Heart Disease and Stroke Statistics: 2004 Update
NHANES II Behavioral Risk Factor SurveyNHANES II Behavioral Risk Factor Survey
_______________________________________________________________
______________________________________________________________
__________________________________________________________________
Total Cholesterol Distribution: Total Cholesterol Distribution: CHD vs Non-CHD PopulationCHD vs Non-CHD Population
Castelli WP. Atherosclerosis. 1996;124(suppl):S1-S9.1996 Reprinted with permission from Elsevier Science.
35% of CHD 35% of CHD Occurs in Occurs in People with People with TC<200 mg/dLTC<200 mg/dL
150 200
Total Cholesterol (mg/dL)
250 300
No CHD
CHD
Framingham Heart Study—26-Year Follow-up
0
2
4
6
8
10
12
Inci
den
ce (
%)
>4940-49<40<133 133-163 >163 <105 105-166 >166
HDL-CLDL-C TG
Assmann et al. Eur Heart J. 1998;19(suppl A):A2.
mg/dL
Lipid Parameters and Risk of Lipid Parameters and Risk of CAD Over 8 Years (PROCAM) CAD Over 8 Years (PROCAM)
Low HDL-C Levels Increase CHD Risk Even Low HDL-C Levels Increase CHD Risk Even When Total-C Is NormalWhen Total-C Is Normal
Risk of CHD by HDL-C and Total-C levels; aged 48–83 yCastelli WP et al. JAMA 1986;256:2835–2838
02468
101214
< 40 40–49 50–59 60< 200
230–259200–229
260
HDL-C (mg/dL) Tota
l-C (m
g/dL
)
14
-y in
cid
en
ce
rate
s (%
) fo
r C
HD
11.24
11.91
12.50
11.91
6.56
4.67
9.05
5.53
4.85
4.153.77
2.782.06
3.83
10.7
6.6
Lp(a) in Atherogenesis: Another Culprit?Lp(a) in Atherogenesis: Another Culprit?
Identical to LDL particle except for addition of apo(a)Identical to LDL particle except for addition of apo(a)
Plasma concentration predictive of atherosclerotic Plasma concentration predictive of atherosclerotic disease in many epidemiologic studies, although disease in many epidemiologic studies, although not allnot all
Accumulates in atherosclerotic plaqueAccumulates in atherosclerotic plaque
Binds apo B-containing lipoproteins and proteoglycansBinds apo B-containing lipoproteins and proteoglycans
Taken up by foam cell precursorsTaken up by foam cell precursors
May interfere with thrombolysisMay interfere with thrombolysis
Maher VMG et al. JAMA. 1995;274:1771-1774.Stein JH, Rosenson RS. Arch Intern Med. 1997;157:1170-1176.
Lp(a): An Independent CHD Risk Factor in Men of the Lp(a): An Independent CHD Risk Factor in Men of the Framingham Offspring CohortFramingham Offspring Cohort
RR=relative risk; HT=hypertension; GI=glucose intolerance.
Bostom AG et al. JAMA. 1996;276:544-548.
1.9 1.8 1.81.2
2.73.6
RR
0.1
1
10
2
5
0.2
0.5 Lp(a) TC HDL-C HT GI Smoking
LDL Particle Size Subclass: LDL Particle Size Subclass:
Fasting triglycerides of 175 mg/dl or greater or TG/HDL Fasting triglycerides of 175 mg/dl or greater or TG/HDL ratio >3 is a good surrogate of small, dense LDL ratio >3 is a good surrogate of small, dense LDL
particle sideparticle side
IDLIDL L3L3 L2L2 L1L1
large, large, buoyantbuoyant
small, densesmall, dense
AA BBABAB
Accumulation of Other Risk Factors Accumulation of Other Risk Factors Compound Effects of Dyslipidemia on Risk Compound Effects of Dyslipidemia on Risk
of CHDof CHD
0
5
10
15
20
25
30
35
40
185 210 235 260 285 310 335
Low HDL
Smoking
Hyperglycemia
Hypertension
No Other Risk Factors
Schaefer EJ, adapted from the Framingham Heart Study
CH
D R
isk
Per
100
0 (i
n 6
yea
rs)
Serum Cholesterol (mg/dL)
Adapted from Ballantyne CM. Am J Cardiol. 1998;82:3Q-12Q.
Primary and Secondary Prevention Trials With Statins
2° prevention placebo
2° prevention statin
1° prevention placebo
1° prevention statin
0
5
10
15
20
25
30
80 90 100 110 120 130 140 150 160 170 180 190 200
LDL-C Achieved (mg/dL)
AFCAPS
AFCAPS
WOSCOPS
WOSCOPS
CARECARE
LIPID LIPID
4S
4S
Eve
nt
Rat
e (%
)
HPSHPS
Cholesterol Treatment Trialists’ (CCT) Collaboration: Efficacy and safety of Cholesterol Treatment Trialists’ (CCT) Collaboration: Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis fo data from cholesterol-lowering treatment: prospective meta-analysis fo data from
90,056 participants in 14 randomized trials of statins 90,056 participants in 14 randomized trials of statins (The Lancet 9/27/05)(The Lancet 9/27/05)
Over average 5 year treatment period (per mmol/L reduction—Over average 5 year treatment period (per mmol/L reduction—approx 40 mg/dl in LDL-C):approx 40 mg/dl in LDL-C): 12% reduction in all-cause mortality12% reduction in all-cause mortality 19% reduction in coronary mortality19% reduction in coronary mortality 23% reduction in MI or CHD death23% reduction in MI or CHD death 17% reduction in stroke17% reduction in stroke 21% reduction in major vascular events21% reduction in major vascular events No difference in cancer incidence (RR=1.00).No difference in cancer incidence (RR=1.00).
Statin therapy can safely reduce 5-year incidence of major coronary Statin therapy can safely reduce 5-year incidence of major coronary events, revascularization, and stroke by about 20% per mmol/L events, revascularization, and stroke by about 20% per mmol/L (about 38 mg/dl) reduction in LDL-C(about 38 mg/dl) reduction in LDL-C
Meta-analysis of Statin Trials
HDL-C
LaRosa JC et al. JAMA. 1999;282:2340-2346.
5
0
-5
-10
-15
-20
-25
-30
-35
-28
+5
-13
-31-29
-21
LDL-C TGCoronary
EventsFatal CHD
Total Mortality
Ch
an
ge
(%
)
Statin Trials: Therapy Reduces Statin Trials: Therapy Reduces Major Coronary Events in WomenMajor Coronary Events in Women
n = number of women enrolled.* 4S = primarily CHD death and nonfatal MI;
CARE = coronary death, nonfatal MI, angioplasty, or bypass surgery;AFCAPS/TexCAPS = fatal/nonfatal MI, unstable angina, or sudden cardiac death.
Miettinen TA et al. Circulation. 1997;96:4211-4218.Lewis SJ et al. J Am Coll Cardiol. 1998;32:140-146.Downs JR et al. JAMA. 1998;279:1615-1622.
4S (n=827) CARE (n=576) AFCAPS/TexCAPS (n=997)
2 Prevention 1 Prevention
-50-45-40-35-30-25-20-15-10-505
10
Major coronary events*
-34
-46 -46
%
P=0.012
P=0.001
-15
-32*
-27*
-40
-30
-20
-10
0
Crouse JR et al. Arch Intern Med. 1997;157:1305-1310.
*P=0.001.†95% confidence interval of percentage of relative reduction.
Effects of Statins on Stroke: A Meta-analysis of Effects of Statins on Stroke: A Meta-analysis of Primary- and Secondary-Prevention TrialsPrimary- and Secondary-Prevention Trials
Relativereductionin rates
(%)
1° Prevention (-42 to -27)†
2° Prevention (13-45)†
Combined (11-40)†
HPS: First Major Coronary Event
0.4 0.6 0.8 1.0 1.2 1.4
Nonfatal MI
Coronary death
Subtotal: MCE
Coronary
Noncoronary
Subtotal: any RV
Any MVE
Coronary events
Revascularizations
Type of Major Vascular Event
Statin-Allocated
(n = 10269)
Placebo-Allocated
(n = 10267)
357 (3.5%) 574 (5.6%)
587 (5.7%) 707 (6.9%)
898 (8.7%) 1212 (11.8%)
513 (5.0%) 725 (7.1%)
450 (4.4%) 532 (5.2%)
939 (9.1%) 1205 (11.7%)
2033 (19.8%) 2585 (25.2%)
0.73 (0.670.79)P < 0.0001
0.76 (0.700.83)P < 0.0001
0.76 (0.720.81)P < 0.0001
Statin Better Placebo Better
Heart Protection Study Collaborative Group. Lancet. 2002;360:722.
HPS—Simvastatin: Vascular Events by Baseline LDL-C
Baseline Baseline
LDL-C (mg/dL)LDL-C (mg/dL)Statin Statin
(n = 10,269)(n = 10,269)Placebo Placebo
(n = 10,267)(n = 10,267)
<100<100 282 (16.4%)282 (16.4%) 358 (21.0%)358 (21.0%)
100–129100–129 668 (18.9%)668 (18.9%) 871 (24.7%)871 (24.7%)
130130 1083 (21.6%)1083 (21.6%) 1356 (26.9%)1356 (26.9%)
All patientsAll patients 2033 (19.8%)2033 (19.8%) 2585 (25.2%)2585 (25.2%)
Event Rate Ratio (95% CI)Statin Better Statin Worse
0.4 0.6 0.8 1.0 1.2 1.4
www.hpsinfo.org
0.76 (0.72–0.81)P < 0.0001
HPS: Incidence of MI and HPS: Incidence of MI and stroke in diabetic patients stroke in diabetic patients
without prior diseasewithout prior disease
<0.0001<0.0001
p valuep value
369 (18.7%) 369 (18.7%)
Placebo Placebo (n=1976)(n=1976)
28%28%
Relative Relative reduction reduction (adjusted)(adjusted)
279 (13.9%) 279 (13.9%)
Simvastatin Simvastatin (n=2006)(n=2006)
Collins R et al. Presented at the American Heart Association Scientific Sessions. November 13, 2001.
Collaborative Atorvastatin Diabetes Collaborative Atorvastatin Diabetes Study (CARDS)Study (CARDS)
2838 patients aged 40-75 with type 2 diabetes, 2838 patients aged 40-75 with type 2 diabetes, no prior CVD, but at least 1 of the following: no prior CVD, but at least 1 of the following: retinopathy, albuminuria, smoking, or retinopathy, albuminuria, smoking, or hypertensionhypertension
Randomization to 10 mg atorvastatin or placeboRandomization to 10 mg atorvastatin or placebo
Mean follow-up 3.9 yearsMean follow-up 3.9 years
Reduction in all CVD events of 37% (p=0.001), Reduction in all CVD events of 37% (p=0.001), all cause mortality 27% (p=0.059). CHD events all cause mortality 27% (p=0.059). CHD events reduced 36% and stroke 48%.reduced 36% and stroke 48%.
Colhoun HM et al., The Lancet 2004; 364: 685-696
ASCOT: Primary Endpoint: Nonfatal MI/Fatal CHD
0
1
2
3
4
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Years
Cu
mu
lati
ve I
nci
den
ce (
%)
36% reduction
HR = 0.64 (0.50-0.83)
Atorvastatin 10 mg Number of events 100
Placebo Number of events 154
P = 0.0005
Sever PS et al, for the ASCOT Investigators. Lancet. 2003;361:1149-1158.
0
5
10
15
20
25
30
60 80 100 120 140 160 180 200
TNT: RationaleTNT: Rationale
(1.6)(1.6) (2.1)(2.1) (2.6)(2.6) (3.1)(3.1) (3.6)(3.6) (4.1)(4.1) (4.7)(4.7) (5.2)(5.2)
Atorvastatin 80 mgAtorvastatin 80 mg
Atorvastatin 10 mgAtorvastatin 10 mg
ScreeningScreening
TNTTNT
??
Adapted from LaRosa et al. Adapted from LaRosa et al. N Engl J Med. N Engl J Med. 2005:352:1425-1435. 2005:352:1425-1435.
LDL-C, mg/dL (mmol/L)LDL-C, mg/dL (mmol/L)
Pat
ien
ts W
ith
CH
D E
ven
ts (
%)
Pat
ien
ts W
ith
CH
D E
ven
ts (
%)
0
20
40
60
80
100
120
140
160 Atorvastatin 10 mg (n=5006)
Atorvastatin 80 mg (n=4995)
TNT: Changes in LDL-C by TNT: Changes in LDL-C by Treatment GroupTreatment Group
TNT: Changes in LDL-C by TNT: Changes in LDL-C by Treatment GroupTreatment Group
FinalFinalScreenScreen 00 33 1212 2424 3636 4848 6060
PP<.001<.001
BaselineBaseline
4.04.0
3.53.5
3.03.0
2.52.5
2.02.0
1.51.5
1.01.0
0.50.5
00
Mean
LD
L-C
(mm
ol/L
)M
ean L
DL
-C (m
mo
l/L)
Mean LDL-C level = 101 mg/dL (2.6 mmol/L)Mean LDL-C level = 101 mg/dL (2.6 mmol/L)
Mean LDL-C level = 77 mg/dL (2.0 mmol/L) Mean LDL-C level = 77 mg/dL (2.0 mmol/L)
LaRosa et al. LaRosa et al. N Engl J Med.N Engl J Med. 2005;352:1425-1435. 2005;352:1425-1435.
Mea
n L
DL
-C (
mg
/dL
)M
ean
LD
L-C
(m
g/d
L)
Study Visit (Months)Study Visit (Months)
TNT: Primary Efficacy Outcome Measure: Major TNT: Primary Efficacy Outcome Measure: Major Cardiovascular Events*Cardiovascular Events*
** CHD death, nonfatal nonCHD death, nonfatal non––procedure-related MI, resuscitated cardiac arrest, procedure-related MI, resuscitated cardiac arrest, fatal or nonfatal stroke.fatal or nonfatal stroke.LaRosa et al. LaRosa et al. N Engl J Med.N Engl J Med. 2005;352:1425-1430. 2005;352:1425-1430.
HR=0.78 (95% CI 0.69, 0.89); HR=0.78 (95% CI 0.69, 0.89); PP<.001<.001
Pro
po
rtio
n o
f P
atie
nts
Exp
erie
nci
ng
P
rop
ort
ion
of
Pat
ien
ts E
xper
ien
cin
g
Maj
or
Car
dio
vasc
ula
r E
ven
tM
ajo
r C
ard
iova
scu
lar
Eve
nt
00
0.050.05
0.100.10
0.150.15
Atorvastatin 10 mgAtorvastatin 10 mg
Atorvastatin 80 mgAtorvastatin 80 mg Relative Relative risk risk
reduction reduction
22% 22%
00 11 22 33 44 55 66Time (Years)Time (Years)
Mean LDL-C level = 77 mg/dL Mean LDL-C level = 77 mg/dL
Mean LDL-C level = 101 mg/dL Mean LDL-C level = 101 mg/dL
Are LDL and HDL Effects Additive?Are LDL and HDL Effects Additive?
R2 = 0.8512
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80
% Absolute Change in LDL+HDL
% C
V E
ven
t R
RR
HATS
FATS
FATS F/U
4SVA HIT DAIS
BIP
AFCAPS/TexCAPS
WOSCOPS
LIPIDCARE, HPS
HHS
CDP
ASCOT
ALLHAT
PROSPER
2nd Order Relationship
HATS: Percent Change in StenosisHATS: Percent Change in Stenosis
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Ch
ang
e (%
)
*P = 0.16 for comparison with placebo; †P < 0.001; ‡P = 0.004.HATS = HDL-Atherosclerosis Treatment Study.
Adapted from Brown BG et al. N Engl J Med. 2001;345:1583-1592.
Placebo Antioxidant Simvastatin/ Simvastatin /Vitamins* Niacin† Niacin/
Antioxidants‡
Simvastatin-niacin97%
All placebos
76%RR = 0.10P = 0.03
0 1 2 30
70
80
90
100
HATS = HDL-Atherosclerosis Treatment Study.Adapted from Brown BG et al. N Engl J Med. 2001;345:1583-1592.
HATS: Patients Free of EventsHATS: Patients Free of Events
Pa
tie
nts
Fre
e o
f E
ven
ts (
%)
Years
ARBITER 2: Primary Endpoint ARBITER 2: Primary Endpoint Carotid IMT Across 12 MonthsCarotid IMT Across 12 Months
CIMT at 12 months
• Statin vs ER niacin + statin P = 0.08
• Intent-to-treat analysis of statin vs. ER niacin + statin P = 0.048
• Non-Insulin resistant pts only: statin vs. ER niacin P = 0.026
Taylor AJ, et al. ARBITER 2: A double-blind, placebo-controlled study of extended-release niacin on Atherosclerosis progression in secondary prevention patients treated with statins. Circulation. 2004
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
Ch
ang
e i
n C
IMT
(m
m +
/- S
EM
)
ER Niacin Placebo
68% decrease in progression
How low to go? Recent Findings from How low to go? Recent Findings from PROVE-IT and REVERSALPROVE-IT and REVERSAL
PROVE-IT PROVE-IT (Cannon CP et al., NEJM 2004; 350: 1495-1504)(Cannon CP et al., NEJM 2004; 350: 1495-1504)
randomized 4162 ACS pts to 80 mg atorvastatin vs. 40 randomized 4162 ACS pts to 80 mg atorvastatin vs. 40 mg pravastatinmg pravastatin
median on-treatment LDL-C of 62 mg/dl vs. 95 mg/dl. median on-treatment LDL-C of 62 mg/dl vs. 95 mg/dl. 16% reduction of combined death, MI, unstable angina 16% reduction of combined death, MI, unstable angina
req. hosp., stroke, and revas in 30 days on atorvastatin req. hosp., stroke, and revas in 30 days on atorvastatin
REVERSAL REVERSAL (Nissen SE et al., JAMA 2004; 291: 1071-80)(Nissen SE et al., JAMA 2004; 291: 1071-80)
randomized 654 pts to atorvastatin 80 mg vs. randomized 654 pts to atorvastatin 80 mg vs. pravastatin 40 mg; 502 and evaluable IVUS at pravastatin 40 mg; 502 and evaluable IVUS at baseline and after 18 mos on treatment.baseline and after 18 mos on treatment.
On-treatment LDL-C 79 mg/dl on atorvastatin and 110 On-treatment LDL-C 79 mg/dl on atorvastatin and 110 mg/dl on pravastatin. mg/dl on pravastatin.
Those on atorvastatin showed significantly less Those on atorvastatin showed significantly less progression of atheroma volumeprogression of atheroma volume
Late Breaking Clinical Trial, ACC 3/8/05Late Breaking Clinical Trial, ACC 3/8/05Treating to New Targets (TNT) StudyTreating to New Targets (TNT) Study
10,001 pts with CAD randomized to 10 mg 10,001 pts with CAD randomized to 10 mg atorvastatin (n=5006) vs. 80m mg atorvastatin atorvastatin (n=5006) vs. 80m mg atorvastatin (n=4995) for 4.9 years, reducing LDL-C to 101 (n=4995) for 4.9 years, reducing LDL-C to 101 mg/dl and 77 mg/dl, respectivelymg/dl and 77 mg/dl, respectively
Total major cardiovascular events were 10.9% on Total major cardiovascular events were 10.9% on low dose atorvastatin vs. 8.7% on high dose low dose atorvastatin vs. 8.7% on high dose atorvastatin, representing a 22% reduction in riskatorvastatin, representing a 22% reduction in risk
Provides evidence that treatment to a lower target Provides evidence that treatment to a lower target below the recommended 100 mg/dl goal will below the recommended 100 mg/dl goal will provide additional benefit in preventing provide additional benefit in preventing cardiovascular eventscardiovascular events
N Engl J Med, 3/8/05
NCEP ATP III: Evaluation—NCEP ATP III: Evaluation—Major Risk Factors for CADMajor Risk Factors for CAD
Age (men Age (men 45 y; women 45 y; women 55 y)55 y)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
Cigarette smokingCigarette smoking
Hypertension (BP Hypertension (BP 140/90 mm Hg or 140/90 mm Hg or antihypertensive medication)antihypertensive medication)
HDL-C <40 mg/dLHDL-C <40 mg/dL
Family history of premature CADFamily history of premature CAD <55 y in first-degree male relative<55 y in first-degree male relative <65 y in first-degree female relative<65 y in first-degree female relative
NCEP ATP III: Evaluation—NCEP ATP III: Evaluation—CAD Risk EquivalentsCAD Risk Equivalents
DiabetesDiabetes
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
Atherosclerotic diseaseAtherosclerotic disease Peripheral artery diseasePeripheral artery disease Abdominal aortic aneurysmAbdominal aortic aneurysm Symptomatic carotid artery diseaseSymptomatic carotid artery disease
CAD 10-year risk >20%CAD 10-year risk >20%
NCEP ATP III: EvaluationNCEP ATP III: Evaluation——Need for Framingham CalculationNeed for Framingham Calculation
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
NoNo>20%>20%CAD or CAD risk CAD or CAD risk equivalentequivalent
YesYes0%-10%0%-10%2 RF2 RF
NoNo<10%<10%1 RF1 RF
Need for Need for Framingham Framingham CalculationCalculation
10-Year Risk for 10-Year Risk for CADCADRisk ProfileRisk Profile
YesYes10%-20%10%-20%
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Assessing CHD Risk in MenAssessing CHD Risk in MenStep 1: Age
YearsPoints
20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13
Step 2: Total CholesterolTC Points at Points at Points at Points at
Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69
Age 70-79 <160 0 0 0 0
0160-199 4 3 2 1
0200-239 7 5 3 1
0240-279 9 6 4 2
1280 11 8 5 3
1
HDL-C(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
Step 3: HDL-Cholesterol
Systolic BP PointsPoints
(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points atPoints at
Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79
Nonsmoker 0 0 0 00
Smoker 8 5 3 11
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Point Total 10-Year Risk Point Total 10-Year Risk
<0 <1% 118%
0 1% 1210%
1 1% 1312%
2 1% 1416%
3 1% 1520%
4 1% 1625%
5 2% 1730%
6 2%7 3%8 4%9 5%
10 6%
Step 7: CHD Risk
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Point Total 10-Year Risk Point Total 10-Year Risk
<9 <1% 2011%
9 1% 2114%
10 1% 2217%
11 1% 2322%
12 1% 2427%
13 2% 25 30%
14 2%15 3%16 4%17 5%18 6%19 8%
Assessing CHD Risk in WomenAssessing CHD Risk in Women
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Step 1: Age
YearsPoints
20-34 -735-39 -340-44 045-49 350-54 655-59 860-64 1065-69 1270-74 1475-79 16
TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69
Age 70-79 <160 0 0 0 0
0160-199 4 3 2 1
1200-239 8 6 4 2
1240-279 11 8 5 3
2280 13 10 7 4
2
HDL-C(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
Step 3: HDL-Cholesterol
Systolic BP PointsPoints
(mm Hg) if Untreated if Treated
<120 0 0120-129 1 3130-139 2 4140-159 3 5160 4 6
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points atPoints at
Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79
Nonsmoker 0 0 0 00
Smoker 9 7 4 21
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Step 7: CHD Risk
Step 2: Total Cholesterol
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
1 RF
2 RFs
equivalent
CAD or CAD risk
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
Risk Category
<160
<130
<100
<130
LDL-C Goal
(mg/dL)
160
130
100
130
LDL-C Level to Initiate
TLC (mg/dL)
LDL-C Level to Initiate
Drug Therapy(mg/dL)
190
160
130
130
(10-year risk0%-10%)
(10-year risk10%-20%)
NCEP ATP III Guidelines: TreatmentNCEP ATP III Guidelines: Treatment
1 RF <190
2 RFs(CAD risk 20%) <160
CAD or CAD risk equivalent <130
(CAD risk >20%)
NCEP ATP III: Setting Goals—NCEP ATP III: Setting Goals—SecondarySecondary––Non-HDL-CNon-HDL-C
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
Risk Category Non–HDL-C Goal (mg/dL)
(Patients With TG (Patients With TG 200)200)
NCEP ATP III Guidelines: TreatmentNCEP ATP III Guidelines: Treatment
TherapeuticLifestyle Change (TLC)
Improve diet
Weight reduction
Physical activity
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
PharmacologicTreatment
Statins (HMG-CoA reductase inhibitors)
Fibrates
Niacin
Bile acid sequestrants
I have some bad news for you. While your cholesterol has remained the same, the research
findings have changed.
Lipid Management GoalLipid Management Goal
LDL-C should be less than 100 mg/dL
Further reduction to LDL-C to < 70 mg/dL is reasonable
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
*Non-HDL-C = total cholesterol minus HDL-C
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
If TG >200 mg/dL, non-HDL-C should be < 130 mg/dL*
Risk Category LDL-C and non-HDL-C Goal
Initiate TLCConsider
Drug Therapy
High risk: CHD or CHD risk equivalents (10-year risk >20%)
and
<100 mg/dL
if TG > 200 mg/dL,
non-HDL-C should be < 130 mg/dL
100 mg/dL >100 mg/dL (<100 mg/dL: consider drug
options)
Very high risk:
ACS or established CHD
plus: multiple major risk factors (especially diabetes) or severe and poorly controlled risk factors
<70 mg/dL,
non-HDL-C < 100 mg/dL
All patients >100 mg/dL (<100 mg/dL: consider drug
options)
Grundy, S. et al. Circulation 2004;110:227-39.
Lipid Management Goals: NCEPLipid Management Goals: NCEP
ATP=Adult Treatment Panel, CHD=Coronary heart disease, LDL-C=Low-density lipoprotein cholesterol, TLC=Therapeutic lifestyle changes
Lipid Management Lipid Management RecommendationsRecommendations
Start dietary therapy (<7% of total calories as saturated fat and <200 mg/d cholesterol)
Adding plant stanol/sterols (2 gm/day) and viscous fiber (>10 mg/day) will further lower LDL
Promote daily physical activity and weight management.
Encourage increased consumption of omega-3 fatty acids in fish or 1 g/day omega-3 fatty acids in capsule form for risk reduction.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
For all patients
Lipid Management Lipid Management RecommendationsRecommendations
If baseline LDL-C > 100 mg/dL, initiate LDL-lowering drug therapy
If on-treatment LDL-C > 100 mg/dL, intensify LDL-lowering drug therapy (may require LDL lowering drug combination)
If baseline is LDL-C 70 to 100 mg/dL, it is reasonable to treat to LDL < 70 mg/dL
Assess fasting lipid profile in all patients, and within 24 hours of hospitalization for those with an acute event. For patients hospitalized, initiate lipid-lowering medication as recommended below prior to discharge according to the following schedule:
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
When LDL lowering medications are used, obtain at least a 30-40% reduction in LDL-C levels.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Lipid Management Lipid Management RecommendationsRecommendations
If TG are 200-499 mg/dL, non-HDL-C should be < 130 mg/dL
Further reduction of non-HDL to < 100 mg/dL is reasonable
Therapeutic options to reduce non-HDL-C: More intense LDL-C lowering therapy I (B) orNiacin (after LDL-C lowering therapy) IIa (B) orFibrate (after LDL-C lowering therapy) IIa (B)
If TG are > 500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy. Achieve non-HDL-C < 130 mg/dL, if possible
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
Baseline Baseline
LDL-C (mg/dL)LDL-C (mg/dL)Statin Statin
(n = 10,269)(n = 10,269)Placebo Placebo
(n = 10,267)(n = 10,267)
<100<100 282 (16.4%)282 (16.4%) 358 (21.0%)358 (21.0%)
100–129100–129 668 (18.9%)668 (18.9%) 871 (24.7%)871 (24.7%)
130130 1083 (21.6%)1083 (21.6%) 1356 (26.9%)1356 (26.9%)
All patientsAll patients 2033 (19.8%)2033 (19.8%) 2585 (25.2%)2585 (25.2%)
Event Rate Ratio (95% CI)Statin Better Statin Worse
0.4 0.6 0.8 1.0 1.2 1.4
0.76 (0.72–0.81)P<0.0001
Heart Protection Study (HPS)
HMG-CoA Reductase Inhibitor: HMG-CoA Reductase Inhibitor: Secondary PreventionSecondary Prevention
20,536 patients with CAD, other occlusive arterial disease, or DM randomized to 20,536 patients with CAD, other occlusive arterial disease, or DM randomized to simvastatin (40 mg) or placebo for 5.5 yearssimvastatin (40 mg) or placebo for 5.5 years
CAD=Coronary artery disease, CI=Confidence interval, DM=Diabetes mellitus,
HPS Collaborative Group. Lancet 2002;360:7-22
Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT)—TIMI 22 Study
3 6 9 12 15 18 21 24 27 30
Follow-up (months)
30
25
20
15
10
5
0
P =0.005
Rec
urre
nt M
I or
Car
diac
Dea
th
16% RRRAtorvastatin
Pravastatin
ACS=Acute coronary syndrome, CV=Cardiovascular, MI=Myocardial infarction, RRR=Relative risk reduction
Cannon CP et al. NEJM 2004;350:1495-1504
HMG-CoA Reductase Inhibitor: HMG-CoA Reductase Inhibitor: Secondary PreventionSecondary Prevention
4,162 patients with an ACS randomized to atorvastatin (80 mg) or pravastatin (40 mg) for 24 months
LaRosa JC et al. NEJM. 2005;352:1425-1435
LDL-C=Low density lipoprotein cholesterol; TNT=Treating to New Targets; HPS=Heart Protection Study; CARE=Cholesterol and Recurrent Events Trial; LIPID=Long-term Intervention with Pravastatin in Ischaemic Disease; 4S=Scandinavian Simvastatin Survival Study.
30
25
20
15
10
5
00 70 90 110 130 150 170 190 210
LDL-C (mg/dL)
TNT (atorvastatin 80 mg/d)
TNT (atorvastatin 10 mg/d)HPS
CARE
LIPIDLIPID
CAREHPS
Eve
nt (
%) 4S
4SStatinPlacebo
Relationship between LDL Levels and Event Rates in Secondary Prevention Trials of Patients with Stable CHD
HMG-CoA Reductase Inhibitor: HMG-CoA Reductase Inhibitor: Secondary PreventionSecondary Prevention
Therapeutic Lifestyle Changes in Therapeutic Lifestyle Changes in LDL-Lowering Therapy: Major FeaturesLDL-Lowering Therapy: Major Features
Saturated fats <7% of total caloriesSaturated fats <7% of total calories
Dietary cholesterol <200 mg per dayDietary cholesterol <200 mg per day
Plant stanols/sterols (2 g per day)Plant stanols/sterols (2 g per day)
Viscous (soluble) fiber (10–25 g per day)Viscous (soluble) fiber (10–25 g per day)
Weight reduction Weight reduction Increased physical activityIncreased physical activity
Plant Sterol and Stanol EstersPlant Sterol and Stanol Esters
Low absorptionLow absorption
Reduce LDL-C by 10%-15%Reduce LDL-C by 10%-15%
May interfere with absorption of lipid-soluble May interfere with absorption of lipid-soluble vitaminsvitamins
Plant stanol estersPlant stanol esters Saturated derivatives of plant sterol estersSaturated derivatives of plant sterol esters Very low absorptionVery low absorption
Nguyen. J Nutr. 1999;129:2109.
Therapeutic Lifestyle ChangesTherapeutic Lifestyle ChangesNutrient Composition of TLC DietNutrient Composition of TLC Diet
NutrientNutrient Recommended IntakeRecommended Intake
Saturated fatSaturated fat Less than 7% of total calories Less than 7% of total calories
Polyunsaturated fatPolyunsaturated fat Up to 10% of total caloriesUp to 10% of total calories
Monounsaturated fat Monounsaturated fat Up to 20% of total calories Up to 20% of total calories
Total fatTotal fat 25–35% of total calories25–35% of total calories
CarbohydrateCarbohydrate 50–60% of total calories50–60% of total calories
FiberFiber 20–30 grams per day20–30 grams per day
ProteinProtein Approximately 15% of total calories Approximately 15% of total calories
CholesterolCholesterol Less than 200 mg/dayLess than 200 mg/day
Total calories (energy)Total calories (energy) Balance energy intake and expenditure Balance energy intake and expenditure to maintain desirable body weightto maintain desirable body weight
Effect of Mediterranean-style diet in the Effect of Mediterranean-style diet in the metabolic syndromemetabolic syndrome
180 pts with metabolic syndrome randomized to 180 pts with metabolic syndrome randomized to Mediterranean-style vs. prudent diet for 2 yearsMediterranean-style vs. prudent diet for 2 years
Those in intervention group lost more weight (-4kg) than Those in intervention group lost more weight (-4kg) than those in the control group (+0.6kg) (p<0.01), and those in the control group (+0.6kg) (p<0.01), and significant reductions in CRP and Il-6.significant reductions in CRP and Il-6.
After 2 years, 40 pts in intervention group still had After 2 years, 40 pts in intervention group still had features of metabolic syndrome compared to 78 pts in features of metabolic syndrome compared to 78 pts in the control groupthe control group
Esposito K et al. JAMA 2004; 292(12): 1440-6.
Dietary Approaches to Stop Dietary Approaches to Stop Hypertension (DASH)Hypertension (DASH)
Diet high in fruits and Diet high in fruits and vegetables and low-fat dairy vegetables and low-fat dairy products lowers blood products lowers blood pressure more than a pressure more than a sodium-restricted dietsodium-restricted diet
7-8 servings/day of grain/grain 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy fruit, 2-3 low- or non-fat dairy products, 2 or less meat, products, 2 or less meat, poultry, and fish.poultry, and fish.
NEJM 1997; 366: 1117-24.NEJM 1997; 366: 1117-24.
Comparison of Atkins, Ornish, Weight Watchers, and Zone diets Comparison of Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized for weight loss and heart disease risk reduction: a randomized
trialtrial
160 subjects randomized, 40 to each diet, for 2 160 subjects randomized, 40 to each diet, for 2 months of maximum adherence, and self-selected months of maximum adherence, and self-selected adherence for rest of yearadherence for rest of year
After 1 year, mean wt loss 2.1 kg for Atkins, 3.2 kg After 1 year, mean wt loss 2.1 kg for Atkins, 3.2 kg for Zone, 3.0 kg for Weight Watchers, and 3.3 kg for Zone, 3.0 kg for Weight Watchers, and 3.3 kg for Ornish.for Ornish.
Dansinger et al., JAMA 2005; 293: 43-53.
Comparison of diets (cont.)Comparison of diets (cont.)
53% completed Atkins, 65% Zone, 65% Weight 53% completed Atkins, 65% Zone, 65% Weight Watchers, and 50% OrnishWatchers, and 50% Ornish
Each diet significantly reduced LDL-C/HDL-C ratio by Each diet significantly reduced LDL-C/HDL-C ratio by about 10%, no sig effects on blood pressure or glucose. about 10%, no sig effects on blood pressure or glucose.
Weight loss related to self-reported dietary adherence or Weight loss related to self-reported dietary adherence or type of diet; decreases in total/HDL-C, CRP, and insulin type of diet; decreases in total/HDL-C, CRP, and insulin significantly related to weight losssignificantly related to weight loss
Possible Benefits From Other TherapiesPossible Benefits From Other Therapies
Therapy Result
• Soluble fiber in diet (2–8 g/d) (oat bran, fruit, and vegetables)
• Soy protein (20–30 g/d)
• Stanol esters (1.5–4 g/d) (inhibit cholesterol absorption)
• Fish oils (3–9 g/d) (n-3 fatty acids)
LDL-C 1% to 10%
LDL-C 5% to 7%
LDL-C 10% to 15%
Triglycerides 25% to 35%
Jones PJ. Curr Atheroscler Rep. 1999;1:230-235.Lichtenstein AH. Curr Atheroscler Rep. 1999;1:210-214.Rambjor GS et al. Lipids. 1996;31:S45-S49.Ripsin CM et al. JAMA. 1992;267:3317-3325.
Dietary AdjunctsDietary Adjuncts
TLC for patients with LDL-C = 160TLC for patients with LDL-C = 160
Walden CE et al. Arterioscler Thromb Vasc Biol 1997;17:375-382.Jenkins DJ et al. Curr Opin Lipidol 2000;11:49-56.Cato N. Stanol meta-analysis. Personal communication, 2000.
Dietary ComponentDietary Component LDL-C LDL-C (mg/dL) (mg/dL)
Low saturated fat/dietary cholesterolLow saturated fat/dietary cholesterol ––1212
Viscous fiber (10–25 g/d)Viscous fiber (10–25 g/d) – –88
Plant stanols/sterols (2 g/d)Plant stanols/sterols (2 g/d) ––1616
TotalTotal – –36 mg/dl36 mg/dl
• Reinforce reductionin saturated fat andcholesterol
• Consider addingplant stanols/sterols
• Increase fiber intake
• Consider referral toa dietitian
• Initiate Tx forMetabolicSyndrome
• Intensify weightmanagement &physical activity
• Consider referral
to a dietitian
6 wks 6 wks Q 4-6 mo
• Emphasize
reduction insaturated fat &cholesterol
• Encouragemoderate physicalactivity
• Consider referral toa dietitian
Visit IBegin LifestyleTherapies
Visit 2Evaluate LDLresponse
If LDL goal notachieved, intensifyLDL-Lowering Tx
Visit 3Evaluate LDLresponse
If LDL goal notachieved, consideradding drug Tx
A Model of Steps in A Model of Steps in Therapeutic Lifestyle Changes (TLC)Therapeutic Lifestyle Changes (TLC)
MonitorAdherenceto TLC
Visit N
Factors Influencing NoncomplianceFactors Influencing Noncompliance
Number of daily doses and medicationsNumber of daily doses and medications
Occurrence and severity of side effectsOccurrence and severity of side effects
Incompatibility with patients’ daily routineIncompatibility with patients’ daily routine
Inadequate physician-patient communicationInadequate physician-patient communication
CostCost
Questran® Prescribing Information, Colestid ® Prescribing Information, WelChol ® Prescribing information, Niaspan ® Prescribing Information, Lopid ® Prescribing Information, TriCor ® Prescribing Information, Lipitor ® Prescribing Information, Zocor ® Prescribing Information, Mevaco ® r Prescribing Information, Lescol ® Prescribing Information, Pravacol ® Prescribing Information; Zetia ® Prescribing Information.
Effect of Lipid-modifying Therapies
TC–total cholesterol, LDL–low density lipoprotein, HDL–high density lipoprotein, TG–triglyceride. * Daily dose of 40mg of each drug, excluding rosuvastatin.
TherapyTherapy TCTC LDLLDL HDLHDL TGTG Patient Patient tolerabilitytolerability
Bile acid Bile acid sequestrantssequestrants
7-10%7-10% 10-18%10-18% 3%3% Neutral or Neutral or PoorPoor
Nicotinic acidNicotinic acid 10-20%10-20% 10-20%10-20% 14-35%14-35% 30-70%30-70% Poor to Poor to reasonablereasonable
Fibrates Fibrates (gemfibrozil)(gemfibrozil)
19%19% 4-21%4-21% 11-13%11-13% 30%30% GoodGood
Statins*Statins* 19-37%19-37% 25-50%25-50% 4-12%4-12% 14-29%14-29% GoodGood
EzetimibeEzetimibe 13%13% 18%18% 1%1% 9%9% GoodGood
Pharmacologic Therapy: NiacinPharmacologic Therapy: Niacin
Reduces HDL catabolism and VLDL productionReduces HDL catabolism and VLDL production
Primarily used to treat low HDL-C (15%-35%Primarily used to treat low HDL-C (15%-35%) ) and elevated TG (20%-50% and elevated TG (20%-50% ))
LDL-C LDL-C 5%-25% 5%-25%
Side effectsSide effects Hepatotoxicity, hyperglycemia, hyperuricemia,Hepatotoxicity, hyperglycemia, hyperuricemia,
upper GI distress, flushing, itchingupper GI distress, flushing, itching
Contraindicated in patients with liver disease,Contraindicated in patients with liver disease,gout, peptic ulcergout, peptic ulcer
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
Pharmacologic Therapy: FibratesPharmacologic Therapy: Fibrates
Inhibit hepatic TG production and increase HDL productionInhibit hepatic TG production and increase HDL production
Used to treat elevated TG (20%-50% Used to treat elevated TG (20%-50% ) ) and low HDL-C (10%-20% and low HDL-C (10%-20% ))
Variable effect on LDL-CVariable effect on LDL-C
Side effectsSide effects Dyspepsia, gallstones, myopathyDyspepsia, gallstones, myopathy Increased with statinsIncreased with statins
Contraindicated in patients with severe renal or hepatic Contraindicated in patients with severe renal or hepatic diseasedisease
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486.
Drug TherapyDrug Therapy
HMG CoA Reductase Inhibitors (Statins)HMG CoA Reductase Inhibitors (Statins)
Reduce LDL-C 18–55% & TG 7–30%Reduce LDL-C 18–55% & TG 7–30%
Raise HDL-C 5–15%Raise HDL-C 5–15%
Major side effectsMajor side effects
MyopathyMyopathy
Increased liver enzymesIncreased liver enzymes
ContraindicationsContraindications
Absolute: liver diseaseAbsolute: liver disease
Relative: use with certain drugsRelative: use with certain drugs
Effect of Statin Therapy on LDL-C Effect of Statin Therapy on LDL-C Levels: “The Rule of 6”Levels: “The Rule of 6”
Illingworth DR. Med Clin North Am. 2000;84:23-42.
37
19
35
27
28
18
12
12
6
12
0 10 20 30 40 50 60
Atorvastatin 10/80
Fluvastatin 20/80
Simvastatin 20/80
Pravastatin 20/40
Lovastatin 20/80
Reduction of LDL Cholesterol (%)
Starting dose LDL-C
Highestrecommended dose
AtorvastatinAtorvastatin
PravastatinPravastatin
RosuvastatinRosuvastatin
SimvastatinSimvastatin
10 mg10 mg 20 mg20 mg 40 mg40 mg 80 mg80 mg
DoseDose
*P<.002 vs atorvastatin 10 mg; simvastatin 10 mg, 20 mg, 40 mg; pravastatin 10 mg, 20 mg, 40 mg**P<.002 vs atorvastatin 20 mg, 40 mg; simvastatin 20 mg, 40 mg, 80 mg; pravastatin 20 mg, 40 mg† P<.002 vs atorvastatin 40 mg; simvastatin 40 mg, 80 mg; pravastatin 40 mg1.Jones PH, Davidson MH, Stein EA, et al. Am. J. Cardiology 2003; 93: 152-160. 2.Data on file, DA-CRS-02 AstraZeneca Pharmaceuticals LP, Wilmington, DE.
*P<.002 vs atorvastatin 10 mg; simvastatin 10 mg, 20 mg, 40 mg; pravastatin 10 mg, 20 mg, 40 mg**P<.002 vs atorvastatin 20 mg, 40 mg; simvastatin 20 mg, 40 mg, 80 mg; pravastatin 20 mg, 40 mg† P<.002 vs atorvastatin 40 mg; simvastatin 40 mg, 80 mg; pravastatin 40 mg1.Jones PH, Davidson MH, Stein EA, et al. Am. J. Cardiology 2003; 93: 152-160. 2.Data on file, DA-CRS-02 AstraZeneca Pharmaceuticals LP, Wilmington, DE.
*
**†
–60–60
–50–50
–40–40
–30–30
–20–20
–10–10
00
Mean
Perc
en
t C
han
ge F
rom
B
ase
line in
LD
L-C
(
SE
)M
ean
Perc
en
t C
han
ge F
rom
B
ase
line in
LD
L-C
(
SE
)Percentage Change From Baseline in Percentage Change From Baseline in
LDL-C at Week 6 by Dose (ITT)LDL-C at Week 6 by Dose (ITT)1,21,2
When LDL-lowering drug therapy When LDL-lowering drug therapy
is employed in high-risk or is employed in high-risk or
moderately high risk patients, moderately high risk patients,
intensity of therapy should be intensity of therapy should be
sufficient to achieve a 30–40% sufficient to achieve a 30–40%
reduction in LDL-C levels.reduction in LDL-C levels.
Grundy et al. Circulation. 2004;110:227-239.
Doses of Statins Required to Attain 30-40% Reduction of LDL-C
Dose, mg/dDose, mg/d LDL Reduction, LDL Reduction, %%
AtorvastatinAtorvastatin 1010 3939
Lovastatin Lovastatin 4040 3131
Pravastatin Pravastatin 4040 3434
Simvastatin Simvastatin 20-4020-40 35-4135-41
Fluvastatin Fluvastatin 40-8040-80 25-3525-35
Rosuvastatin 5-10 39-45
Why combination therapy?Why combination therapy?
Few patients achieve LDL-C goal on Few patients achieve LDL-C goal on monotherapymonotherapy
Uptitration of dosage is rareUptitration of dosage is rare
LDL-C goals are getting more aggressiveLDL-C goals are getting more aggressive
High-dose statins increase risk of side effectsHigh-dose statins increase risk of side effects
Can address mixed dyslipidemia (e.g., few pts Can address mixed dyslipidemia (e.g., few pts achieve adequate control of HDL-C and achieve adequate control of HDL-C and triglycerides on monotherapy)triglycerides on monotherapy)
Options for Patients who Fail to Reach Options for Patients who Fail to Reach LDL-C Goal on Statin MonotherapyLDL-C Goal on Statin Monotherapy
• Niacin• Bile acid sequestrant• Cholesterol absorption inhibitor
Addition of:Addition of:
CombinationCombination TherapyTherapy WithWith Intestinal- Intestinal- Acting Agents and Statins: RationaleActing Agents and Statins: Rationale
Statins inhibit compensatory increase in Statins inhibit compensatory increase in cholesterol synthesis induced by blockade cholesterol synthesis induced by blockade of cholesterol absorptionof cholesterol absorption
May increase ability to reach LDL-C goalsMay increase ability to reach LDL-C goals
May allow use of a lower statin doseMay allow use of a lower statin dose
Bile Acid SequestrantsBile Acid Sequestrants
Major actionsMajor actions Reduce LDL-C 15%-30%Reduce LDL-C 15%-30% Raise HDL-C 3%Raise HDL-C 3%-5%-5% May increase TGMay increase TG
Side effectsSide effects GI distress/constipationGI distress/constipation Decreased absorption of other drugs (1st generation)Decreased absorption of other drugs (1st generation)
ContraindicationsContraindications DysbetalipoproteinemiaDysbetalipoproteinemia Elevated TG (especially >400 mg/dL)Elevated TG (especially >400 mg/dL)
New Bile Acid SequestrantNew Bile Acid Sequestrant: : ColesevelamColesevelam
Lower dose for effectLower dose for effect
Fewer GI complaints than with other bileFewer GI complaints than with other bileacid sequestrantsacid sequestrants
Reduces absorption of Reduces absorption of -carotene-carotene
Requires 4-6 tablets/dayRequires 4-6 tablets/day
Davidson et al. Expert Opin Investig Drugs. 2000;9:2663.
Insull et al. Mayo Clin Proc. 2001;76:971.
*P<0.001 vs placebo.†P=0.04 vs placebo.
5
-1
0
10
3
-15
-20
-15
-10
-5
0
5
10
15
% C
han
ge
fro
m b
asel
ine
at w
k 24
TGHDL-CLDL-C
*
†
Placebo (n=88)
Colesevelam 3.8 g/d (n=95)
Colesevelam Monotherapy: EfficacyColesevelam Monotherapy: Efficacy
Limitations of Current Limitations of Current Intestinal-Acting AgentsIntestinal-Acting Agents
Bile acid sequestrantsBile acid sequestrants NoncomplianceNoncompliance GI tolerabilityGI tolerability Reduced absorption of lipid-soluble vitaminsReduced absorption of lipid-soluble vitamins May increase TG in patients with hypertriglyceridemiaMay increase TG in patients with hypertriglyceridemia
Plant stanol and sterol estersPlant stanol and sterol esters Lack of selectivityLack of selectivity Some patients may find difficult to incorporate into Some patients may find difficult to incorporate into
dietdiet May reduce absorption of lipid-soluble vitaminsMay reduce absorption of lipid-soluble vitamins
Ezetimibe — Ezetimibe — Localizes at Brush Border of Small IntestineLocalizes at Brush Border of Small Intestine
Ezetimibe, a selective cholesterol absorption Ezetimibe, a selective cholesterol absorption inhibitor, localizes and appears to act at the inhibitor, localizes and appears to act at the brush border of the small intestine and inhibits brush border of the small intestine and inhibits cholesterol absorptioncholesterol absorption
This results inThis results in A decrease in the delivery of intestinal cholesterol to A decrease in the delivery of intestinal cholesterol to
the liverthe liver A reduction of hepatic cholesterol stores and an A reduction of hepatic cholesterol stores and an
increase in clearance of cholesterol from the bloodincrease in clearance of cholesterol from the blood
Ezetimibe and StatinsEzetimibe and StatinsComplementary MechanismsComplementary Mechanisms
Ezetimibe reduces the delivery of cholesterol to the liverEzetimibe reduces the delivery of cholesterol to the liver
Statins reduce cholesterol synthesis in the liverStatins reduce cholesterol synthesis in the liver
The distinct mechanism of ezetimibe is complementary to The distinct mechanism of ezetimibe is complementary to that of statinsthat of statins
The effects of ezetimibe, either alone or in addition to a The effects of ezetimibe, either alone or in addition to a statin, on cardiovascular morbidity or mortality have not statin, on cardiovascular morbidity or mortality have not been establishedbeen established
Knopp RH. N Engl J Med. 1999;341:498–511.
Mea
n P
erce
nt
Ch
ang
e in
L
DL
-C F
rom
Bas
elin
e
Placebo(n = 11)
-30
-20
-10
0
SIMVA 10 mg(n = 12)
SIMVA 10+EZE 10 mg
(n = 11)
-34.9*
-51.9*†
-3.2
-40
-50
-60
Coadministration:Simvastatin + Ezetimibe
*P < 0.01 vs placebo
†P < 0.01 vs simvastatin 10 mg
Stein, E. Eur Heart J. 2001;3(suppl E):E14.
17%
ENHANCEENHANCEBackgroundBackground
Patients with FH have a greatly increased risk of Patients with FH have a greatly increased risk of developing premature coronary artery disease and developing premature coronary artery disease and an increased rate of progression of intima-media an increased rate of progression of intima-media thickness (IMT)thickness (IMT)
Primary Outcome:Primary Outcome: change in the carotid IMT, an change in the carotid IMT, an average of the right and left common carotid average of the right and left common carotid arteries, carotid bulbs, and internal carotid arteriesarteries, carotid bulbs, and internal carotid arteries
Secondary Outcomes:Secondary Outcomes: regression in mean regression in mean carotid IMT, new plaque formation, and various carotid IMT, new plaque formation, and various individual measurements of the carotid arteryindividual measurements of the carotid artery
Kastelien J. N Engl J Med. 2008; 358: 1431- 43.
ENHANCEStudy Design
Simvastatin 80 mg
RANDOMIZATION
0 24Months
3 6 9 12 15 18 21
Pre-randomization Phase
FH:LDL-c ≥ 210 mg/dL
Screening and Fibrate
Washout
Placebo Lead-In/ Drug Washout
Weeks
-6-10 to -7
Ezetimibe 10 mg-Simvastatin 80 mg
IMT assessment N = 720
Kastelien J. N Engl J Med. 2008; 358: 1431- 43.
Ezetimibe 10 mg-Simvastatin 80 mgEzetimibe 10 mg-Simvastatin 80 mg
Simvastatin 80 mgSimvastatin 80 mg
ENHANCELDL Changes
SimvastatinEze-Simva
Months
-40
0 6 12 18 24
-50
-60
-70
0
-10
-20
-30
10
Perc
enta
ge c
hang
e fr
om b
asel
ine
P<0.01
-16.5 % incremental reduction in LDL
141 141 ++ 53 53319 319 ++ 65 65Eze-SimvaEze-Simva
193 193 ++ 60 60318 318 ++ 66 66Simva Simva
24 Months 24 Months (mg/dL)(mg/dL)
Baseline Baseline (mg/dL)(mg/dL)
Kastelien J. N Engl J Med. 2008; 358: 1431- 43.
ENHANCEENHANCEPrimary Outcome : Primary Outcome : MeanMean cIMT cIMT
Mean intima-media Mean intima-media thickness of carotid artery thickness of carotid artery (mm)(mm)
Simvastatin Simvastatin monotherapymonotherapy
(n=342)(n=342)
Simvastatin Simvastatin plus ezetimibeplus ezetimibe
(n=338) (n=338)
P valueP value
Mean cIMT, baselineMean cIMT, baseline 0.700.70±0.13±0.13 0.690.69±0.13±0.13 0.640.64
Mean cIMT, 24 moMean cIMT, 24 mo 0.700.70±0.14±0.14 0.710.71±0.15±0.15 0.290.29
Change from baseline (mm)Change from baseline (mm) 0.00580.0058±0.003±0.00377
0.01110.0111±0.0038±0.0038 0.290.29
Kastelien J. N Engl J Med. 2008; 358: 1431- 43.
ENHANCEENHANCEMean cIMT during 24 months of therapyMean cIMT during 24 months of therapy
Mea
n cI
MT
(mm
)
6 12 18 240.60
0.70
0.75
0.80
0.65
Months
P=0.88
SimvastatinEze-Simva
Longitudinal, repeated measures analysis
Kastelien J. N Engl J Med. 2008; 358: 1431- 43.
ENHANCEENHANCEConclusionConclusion
Despite the observed improvements in lipid parameters, Despite the observed improvements in lipid parameters, there were no significant differences in the change in there were no significant differences in the change in carotid IMT between ezetimibe/simvastatin and simvastatin carotid IMT between ezetimibe/simvastatin and simvastatin alone. alone.
Reason(s) for this discrepancy currently remains unknown, Reason(s) for this discrepancy currently remains unknown, however:however:
1. Measurement technique may not be accurate enough to 1. Measurement technique may not be accurate enough to reflect changes in atherosclerotic burdenreflect changes in atherosclerotic burden
2. Ezetimibe lacks vascular benefit despite the observed 2. Ezetimibe lacks vascular benefit despite the observed LDL-c and hsCRP reductionLDL-c and hsCRP reduction
3. The population studied may have been at too low a risk to 3. The population studied may have been at too low a risk to detect changes, limiting the ability to detect a differential detect changes, limiting the ability to detect a differential responseresponse
Kastelien J. N Engl J Med. 2008; 358: 1431- 43.