update lipide diabetes - swisscardio.ch · georg noll herzklinik hirslanden update lipide diabetes...
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Effects of Mediterranean Diet���on AMI, Stroke, and CV Death
Estruch R et al: NEJM 2013 (PREDIMED)
Age: 67 y BMI: 30 DM: 48% HT: 82%
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n–3 Fatty Acids and Cardiovascular Events after Myocardial Infarction
Alpha Omega Trial
Kromhout D et al: NEJM 2010
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Dietary linoleic acid for secondary prevention of CAD ���Sydney Diet Heart Study
Ramsden CE et al: BMJ 2013
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PUFAs for secondary prevention of CV death ���Metaanalysis
Ramsden CE et al: BMJ 2013
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7
Chocolate Consumption and Nobel Prizes
Messerli F: NEJM 2012
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Dal Moro F: Maturitas 2013
Coffee Consumption and Nobel Prizes
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1 mmol/L LDL-Reduction is associated with…..
CTT Collaborators. Lancet 2005
LDL-Reduction with statins and vascular events
50
40
30
20
10
0 0.5 1.0 1.5 2.0
-10 LDL-Reduction in mmol/L
50
40
30
20
10
-10
0 0.5 1.0 1.5 2.0
LDL-Reduction in mmol/L
Prospective metaanalysis of 90,056 patients from 14 studies1
…. 23% Reduction of coronary events
…. 21% Reduction of vascular events
Pro
prtio
nal r
educ
tion
of
eve
nts
(%±S
E)
Pro
porti
onal
redu
ctio
n
of e
vent
s (%
±SE
)
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Adapted from Rosensen RS. Exp Opin Emerg Drugs 2004;9(2):269-279
LDL-C achieved mg/dL (mmol/L)
WOSCOPS – Placebo AFCAPS - Placebo
ASCOT - Placebo AFCAPS - Rx WOSCOPS - Rx
ASCOT - Rx
4S - Rx
HPS - Placebo
LIPID - Rx
4S - Placebo
CARE - Rx
LIPID - Placebo
CARE - Placebo
HPS - Rx
0
5
10
15
20
25
30
40 (1.0)
60 (1.6)
80 (2.1)
100 (2.6)
120 (3.1)
140 (3.6)
160 (4.1)
180 (4.7)
Eve
nt ra
te (%
)
6
Secondary Prevention
Primary Prevention
Rx - Statin therapy PRA – pravastatin ATV - atorvastatin
200 (5.2)
PROVE-IT - PRA
PROVE-IT – ATV
TNT – ATV10 TNT – ATV80
The lower the better!
JUPITER - Pl
JUPITER - Rx
POSCH
POSCH
Works in everybody except heart failure
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EMPFEHLUNGEN NACH IAS 2003 modifiziert und aktualisiert für die Schweiz 2012
EAS/ESC EMPFEHLUNGEN 2011
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EAS/ESC EMPFEHLUNGEN 2011
EMPFEHLUNGEN NACH IAS 2003 modifiziert und aktualisiert für die Schweiz 2012
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Medikamentöse Behandlung der Dyslipidämie
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Effects of PCSK9 Antibody on LDL
Lancet 2012
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Effects of PCSK9 Antibody on top of Statins on LDL
Lancet 2012
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Effects of a monoclonal antibody to PCSK9, REGN727 on LDL in familial hypercholesterolaemia on statin dose +/- ezetimibe
Stein EA et al: Lancet 2012
(n=15) (n=15) (n=16)
(n=16) (n=15)
LDL 3.6 - 4.4 mmol/l
71% on ezetimibe, 42% CAD
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(≥4.9 mmol/l)
AHA Guideline on the Treatment of Blood Cholesterol���to Reduce Atherosclerotic Cardiovascular Risk
Stone NJ et al: Circulation 2013
(1.8-4.9 mmol/l)
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LDL <4.9 mmol/l
Stone NJ et al: Circulation 2013
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Intensity of Statin Therapy
Stone NJ et al: Circulation 2013
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Statins an New Onset of Diabetes
Sattar N et al: Lancet 2010
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CV Benefit > Risk of diabetes (9:1)
9 CV events prevented vs
1 case of diabetes
By treating for 4 years 255 patients with a
standard dose of statins
Adapté de Sattar et al. Lancet 2010; 375: 735-42. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials.
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Hohe Triglyzeride (>2.3 mmol/l) Tiefes HDL (<0.9 mmol/l)
Normale Triglyzeride Normales HDL (<0.9 mmol/l)
Studien mit Fibraten - Odds Ratio für ein koronares Ereignis ist abhängig von den Ausgangs-Lipidwerten
Sacks et al: NEJM 2010
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Therapie der arteriellen Hypertonie
RAS-Blocker
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Effects of intensive Blood Pressure Control in Diabetics ACCORD
NEJM 2010
Goal <140 mmHg
Goal <120 mmHg
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BP: 139 -> 134
BP: 139 -> 119
Effects of Intensive vs Standard BP Control on Stroke MI, and CV Death in Type II Diabetes (ACCORD)
NEJM 2010
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Messerli, F. H. et al. J Am Coll Cardiol 2009;54:1827-1834
Incidence of MI and Stroke Stratified by Diastolic Blood Pressure in the INVEST Study
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Aged under 55 years
Aged over 55 years or black person of African or
Caribbean origin of any age
A C
A + C
A + C + D
Resistant hypertension consider further diuretic
alpha or betablocker consider seeking expert advise
Step 1
Step 2
Step 3
Step 4
A=ACEI or ARB C=CCB D=Thiazide diuretic
NICE 2011
ESH: Zielwert für alle <140/90 mmg ausser Diabetiker <140/85 mmHg
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Long-term Effect of Renal nerve Denervation on Blood Pressure in Resistant Hypertension
p <0,01 für Δ gegenüber der Baseline für alle Zeitpunkte
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Effects of Renal Denervation on Office BP (Zurich Experience, N= 36)
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Effects of Renal Denervation on ABPM (Zurich Experience, N= 36)
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Take home messages
• Diät wirkt v.a. primärpräventiv
• Cholesterin ist ein behandelbarer Risikofaktor
• Hochrisikopatienten aggressiv behandeln (Zielwerte?)
• Grenzen der Statine: Herzinsuffizienz.
• Zur Senkung der Triglyzeride: Fibrat
• Blutdruckzielwert bei Hypertonie: <140/90 mmHg ausser: Betagte: <150/90 mmHg Diabetiker: <140/85 mmHg
• Bei resistenter Hypertonie renale Denervation erwägen