USE OF THE LIPID OPTIMIZATION TOOL (LOT) TO ACHIEVE VARIOUS LDL TARGETS IN COMMUNITY PRACTICE

Statin Cost Efficacy

Statin Cost Efficacy

© Continuing Medical Implementation® Inc. May 2006 www.cvtoolbox.com

Lipid Optimization Tool

© Continuing Medical Implementation® Inc. March 2005 www.cvtoolbox.com

Lipid Optimization Tool

© Continuing Medical Implementation® Inc. March 2005 www.cvtoolbox.com

Revised March 2006

PROVE-IT/TNT/IDEAL/AtoZ ASTEROID

PATIENT: _________________________________ PHARMACY: _________________________________

Responsible for Lipid Management: Family Physician Cardiologist Endocrinologist

LIPID FLOW SHEET 1 – Use the following Table to Guide Intervention:NB: UPPER STRATUM* exceeds CWG on Hypercholesterolemia and other Dyslipidemias Recommendations

1. Count Risk Factors: Age M > 45 F > 55 Family Hx CAD Smoking HPT DM LVH HDL < 0.9 mmol/l

2. Identify Metabolic Syndrome ( > 3 parameters):Abdominal obesity (Waist circumference: Male >102 cm (40 in.) / Female > 88 cm (34.6 in.) TG > 1.7 mmol/L HDL < 1 mmol/L (male)/< 1. 3 mmol/L (female) BP > 130/85 FBG 6.2-7 mmol/L

3. Identify secondary causes: Diabetes Hypothyroidism Renal disease Liver disease Drugs & Alcohol4. Record Indication: Risk Factors CAD: _ angina, _ post MI, _ post PTCA, _ post CABG Cerebrovascular Disease PVD

1 Monitor lipid profile, ALT and CK at baseline, 2 months then every 6 to 12 months2 Diabetes carries the same CV risk as manifest CAD. DM+CAD impart much higher risk for subsequent CV events.3 Chronic Kidney Disease

Authors: J. Niznick, C. Boutin, Suzanne DugasOttawa Cardiovascular Centre (OCC), Ottawa, Ontario, Canada

Background (Objectives)Lipid optimization has the potential to signi�cantly reduce cardiovascular events and CHD death in various at risk populations. Failure to reach LDL target is commonplace and compromises cardiovascular outcomes. Our objective was to audit the effectiveness of the Lipid Optimization Tool as available on www.cvtoolbox.com, in achieving dyslipidemia control measured as LDL target achievement, in the high volume community practice at OCC.

MethodsOCC provides comprehensive follow-up to approximately 27,000 cardiovascular patients and structured lipid management and Telemonitoring for approximately 7000 dyslipidemia patients. The LOT has been used to guide lipid management at OCC since 1999. LOT �ow sheets for patients of the 9 OCC specialists (6 cardiologists and 3 internists) were sequentially analyzed from July to December 2005. LDL control rates were calculated for the current Canadian Working Group (CWG) targets of 4.5 mmol/L for low risk (LR), 3.5 mmol/L for moderate risk (MR) and 2.5 mmol/L for high risk (HR) patients as well as the antici-pated revised CWG LDL HR target of 2.0 mmol/L and the optional very high risk (VHR) NCEP ATP-III LDL target of 1.8 mmol/L.

ResultsData was collected on 963 patients; 78 LR, 87 MR, 62 HR and 736 VHR. LDL control rates were LR 94% (target < 4.5 mmol/L), MR 77% (target < 3.5 mmol/L), HR 68% (target < 2.5 mmol/L) and VHR 81% (target < 2.5 mmol/L), 59% (target < 2.0 mmol/L) and 46% (target 1.8 mmol/L).

ConclusionsUse of the LOT management protocol in contempory community practice at OCC achieves amongst the best lipid control rates in the world.

Funding: Dyslipidemia management at OCC is supported by unrestricted grants from AstraZeneca, Merck Frosst and P�zer.

Secondary Prevention: % LDL (mmol/L) change to reach LDL target by risk category.

Dose response to Medication (statins & fibrates) % LDL Reduction

Protocol: Initiate lipid lowering immediately in high-risk patients (concomitant with dietary/therapeutic lifestyle modification).1. Target initial medication dose to attain LDL of < 2.5 mmol/l. Consider LDL target of < 1.8 mmol/L for established CVD or DM > age 30.

Initiate therapy with the medication dose required to achieve target LDL.• NB: Initiate rosuvastatin at 10 mg (5 mg in Asians/CKD3). *40 mg. contraindicted in Asian population.• NB: Caution with simvastatin 80 mg. A to Z Trial.

2. If initial LDL at target, raise HDL and lower triglycerides to target values with appropriate intervention: diet, exercise, weight loss, refined carbohydrate restriction, moderate alcohol intake or medication: niacin, fibrate or salmon oil (1gm TID).

3. If LDL and triglycerides high and HDL-C low, consider combination therapy (niacin or fibrate).4. If unable to raise HDL sufficiently, lower LDL to achieve TC/HDL < 4 and/or LDL/HDL< 3.5. If initial lipid profile normal look at other risk factors (LPa, homocysteine, apo-B and hs-CRP).6. Follow Total cholesterol, LDL, HDL, triglycerides, CK and ALT in 2 months then every 6 months.7. If LDL not at target increase statin dose to achieve target or switch to more potent statin. If LDL target not achievable on monotherapy add bile acid sequestrant

(cholestyramine or colesevelam) or cholesterol absorption inhibitor (ezetimibe). Doubling statin dose adds ~ 6% LDL reduction. See Statin Cost Efficacy Grid.

www.cvtoolbox.com

Lipid Optimization Tool

1) RT Yan et al. Guideline Oriented Approach in Lipid Lowering (GOALL)Rregistry data presented at CCC Symposium Oct 2005.2) MH Davidson et al. Results of the National Cholesterol Education (NCEP) Program Evaluation Project Utilizing Novel e-Technology (NEPTUNE) II Survey and Implications for Treatment Under the Recent NCEP Writing Group Recommendations. Am J Cardiol 2005 Aug 15;96(4):556-63. 3) A Langer et al. Targeted Dosing of Atorvastatin Achieves Cholesterol Targets Quickly in Subjects with Diabetes or the Metabolic Syndrome (The ACTFAST Studies). Can J Cardiol 2005; Vol 21 Suppl C: Abstract 826, 253C. 4) C Bourgault et al. Stain Therapy in Canadian Patients with Hypercholesterolemia: The Canadian Lipid Study – Observational (CALIPSO). Can J Cardiol 2005; 21(13):1187-1193.

Sta

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: % L

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(m

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L t

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ris

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Dos

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educ

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Prot

ocol

: Ini

tiate

lipi

d lo

wer

ing

imm

edia

tely

in h

igh-

risk

patie

nts

(con

com

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with

die

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/the

rape

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life

styl

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odifi

catio

n).

1. T

arge

t ini

tial m

edic

atio

n do

se to

att

ain

LDL

of <

2.5

mm

ol/l.

Con

sider

LD

L ta

rget

of <

1.8

mm

ol/L

for

esta

blish

ed C

VD

or

DM

> a

ge 3

0.

Initi

ate

ther

apy

with

the

med

icat

ion

dose

req

uire

d to

ach

ieve

targ

et L

DL.

• N

B: I

nitia

te r

osuv

asta

tin a

t 10

mg

(5 m

g in

Asia

ns/C

KD

3 ). *4

0 m

g. c

ontr

aind

icte

d in

Asia

n po

pula

tion.

• N

B: C

autio

n w

ith s

imva

stat

in 8

0 m

g. A

to

Z T

rial

.2.

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nitia

l LD

L at

targ

et, r

aise

HD

L an

d lo

wer

trig

lyce

ride

s to

targ

et v

alue

s w

ith a

ppro

pria

te in

terv

entio

n: d

iet,

exer

cise

, wei

ght l

oss,

refin

ed c

arbo

hydr

ate

rest

rictio

n, m

oder

ate

alco

hol i

ntak

e or

med

icat

ion:

nia

cin,

fibr

ate

or s

alm

on o

il (1

gm T

ID).

3. I

f LD

L a

nd tr

igly

ceri

des

high

and

HD

L-C

low

, con

sider

com

bina

tion

ther

apy

(nia

cin

or fi

brat

e).

4. I

f una

ble

to r

aise

HD

L su

ffici

ently

, low

er L

DL

to a

chie

ve T

C/H

DL

< 4

and/

or L

DL/

HD

L< 3

.5.

If i

nitia

l lip

id p

rofil

e no

rmal

look

at o

ther

risk

fact

ors

(LPa

, hom

ocys

tein

e, a

po-B

and

hs-

CR

P).

6. F

ollo

w T

otal

cho

lest

erol

, LD

L, H

DL,

trig

lyce

rides

, CK

and

ALT

in 2

mon

ths

then

eve

ry 6

mon

ths.

7. I

f LD

L no

t at t

arge

t inc

reas

e st

atin

dos

e to

ach

ieve

targ

et o

r sw

itch

to m

ore

pote

nt s

tatin

. If L

DL

targ

et n

ot a

chie

vabl

e on

mon

othe

rapy

add

bile

aci

d se

ques

tran

t(c

hole

styr

amin

e or

col

esev

elam

) or

cho

lest

erol

abs

orpt

ion

inhi

bito

r (e

zetim

ibe)

. Dou

blin

g st

atin

dos

e ad

ds ~

6%

LD

L re

duct

ion.

See

Sta

tin

Cos

t Ef

fica

cy G

rid

PAT

IEN

T:__

____

____

____

____

____

____

____

___

PH

AR

MA

CY:

____

____

____

____

____

____

____

____

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eter

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ale

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(40

in.)

/ Fe

mal

e >

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m (

34.6

in.)

T

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1.7

mm

ol/L

H

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< 1

mm

ol/L

(m

ale)

/< 1

. 3 m

mol

/L (

fem

ale)

B

P >

130/

85

FBG

6.2

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mol

/L3.

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ntif

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cond

ary

caus

es:

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Hyp

othy

roid

ism

Ren

al d

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Risk

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