Goals Guidelines A summary of international guidelines for

Goals & Guidelines A summary of international guidelines for CHD

International guidelines: summary • Guidelines developed for the prevention of CHD • Based on major clinical trial evidence • Help assess and assist in the management of patients at risk of CHD Risk Category NCEP LDL-C goal European LDL-C goal CHD or CHD risk equivalents (10 -year risk >20%) 100 mg/dl ( 2. 6 mmol/l) 115 mg/dl ( 3. 0 mmol/l) 2+ risk factors (10 -year risk 20%) <130 mg/dl ( 3. 4 mmol/l) 115 mg/dl ( 3. 0 mmol/l) Reference: National Cholesterol Education Program. JAMA 2001; 285: 2486 -97; Wood D et al. EHJ 1998; 19: 1434 -1503.

NCEP guidelines LDL-C Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy Risk Category LDL-C Goal (mg/d. L) LDL-C Level at which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/d. L) LDL-C Level at which to Consider Drug Therapy (mg/d. L) CHD or CHD Risk Equivalents (10 -year risk >20%) <100 ³ 130 (100– 129: drug optional) 2+ Risk Factors (10 -year risk £ 20%) <130 ³ 130 10 -year risk 10– 20%: ³ 130 10 -year risk <10%: ³ 160 0– 1 Risk Factor <160 ³ 190 (160– 189: LDL-C lowering drug optional)

NCEP guidelines LDL-C Lowering Therapy in Patients with CHD and CHD Risk Equivalents • Baseline LDL-C ³ 130 mg/d. L – Intensive lifestyle therapies – Maximal control of other risk factors – Consider starting LDL-C lowering drugs simultaneously with lifestyle therapies • Baseline (or On-Treatment) LDL-C 100– 129 mg/d. L – – LDL-C lowering therapy • Initiate or intensify lifestyle therapies and/or LDL-C lowering drugs Treatment of metabolic syndrome • Emphasise weight reduction and increased physical activity Drug therapy for other lipid risk factors – – – Further LDL-C lowering not required Therapeutic Lifestyle Changes (TLC) recommended Consider treatment of other lipid risk factors (raised TG, low HDL-C) – • Baseline LDL-C: <100 mg/d. L

NCEP guidelines LDL-C Lowering Therapy in Patients With 2+ Risk Factors and 10 -Year Risk £ 20% • 10 -Year Risk 10– 20% – – LDL-C goal <130 mg/d. L Aim: reduce both short-term and long-term risk Immediate initiation of Therapeutic Lifestyle Changes (TLC) if LDL-C is ³ 130 mg/d. L Consider drug therapy if LDL-C is ³ 130 mg/d. L after 3 months of lifestyle therapies • 10 -Year Risk <10% – – LDL-C goal: <130 mg/d. L Therapeutic aim: reduce long-term risk Initiate therapeutic lifestyle changes if LDL-C is ³ 130 mg/d. L Consider drug therapy if LDL-C is ³ 160 mg/d. L after 3 months of lifestyle therapies

NCEP guidelines LDL-Lowering Therapy in Patients With 0– 1 Risk Factor • • Most persons have 10 -year risk <10% Therapeutic goal: reduce long-term risk LDL-C goal: <160 mg/d. L Initiate therapeutic lifestyle changes if LDL-C is ³ 160 mg/d. L • If LDL-C is ³ 190 mg/d. L after 3 months of lifestyle therapies, consider drug therapy • If LDL-C is 160– 189 mg/d. L after 3 months of lifestyle therapies, drug therapy is optional

Canadian guidelines Target lipid values by level of risk Level of risk (definition) LDL-C level mmol/L TC: HDL-C ratio Triglyceride level mmol/L Very high* <2. 5 <4 <2. 0 High* <3. 0 <5 <2. 0 Moderate† <4. 0 <6 <2. 0 <5. 0 <7 <3. 0 (10 -year risk of CAD > 30%, or history of CVD or diabetes) (10 -year risk 20%-30%) (10 -year risk 10%-20%) Low‡ (10 -year risk<10%) *Start medication and lifestyle changes concomitantly if values are above target values †Start medication if target values are not achieved after 3 months of lifestyle modification ‡Start medication if target values are not achieved after 6 months of lifestyle modification Recommendations for the management and treatment of dyslipidemias CMAJ 2000; 162 (10): 1441 -7

European guidelines • Prioritisation – Absolute risk – 10 year risk • Age – 30 -74 years • Goals for primary and secondary prevention of CHD: – Lifestyle • Stop smoking • Make healthy food choices • Be physically active – Other risk factors • • Blood pressure <140/90 mm. Hg TC <5. 0 mmol/L (190 mg/d. L) LDL-C <3. 0 mmol/L (115 mg/d. L) Good glucose control in diabetes • To be achieved with changes in lifestyle and, if needed, by drug treatment

European guidelines • Use coronary risk chart to estimate a person’s absolute 10 -year risk of a CHD event • High risk: 10 year risk exceeds 20% or will exceed 20% if projected to age 60 years • CHD risk is higher than the charts indicate for those with: – FH, diabetes, family history of premature CVD, low HDL-C (<1. 0 mmol/L), raised triglycerides (>2. 0 mmol/L) or approaching next age category

European guidelines

European guidelines Primary prevention guide to lipid management Estimate absolute CHD risk* using the Coronary Risk Chart Use initial total cholesterol to estimate coronary risk Absolute coronary risk <20% TC > 5. 0 mmol/L (190 mg/d. L) Lifestyle advice with the goal of reducing TC<5. 0 mmol/L (190 mg/d. L) and LDL-C <3. 0 mmol/L (115 mg/d. L) Follow-up at a minimum of 5 year intervals Absolute risk > 20% Measure fasting lipids: TC, HDL-C, triglycerides and calculate LDL -C cholesterol Lifestyle advice for at least 3 months with repeat lipid measurements TC <5. 0 mmol/L (190 mg/d. L) and LDL-C <3. 0 mmol/L (115 mg/d. L) Maintain lifestyle advice with annual follow-up * High CHD risk >20% over 10 years or will exceed 20% if projected age 60 years TC >5. 0 mmol/L (190 mg/d. L) and LDL-C >3. 0 mmol/L (115 mg/d. L) Maintain dietary advice with drug therapy

Australian guidelines Categorisation of Risk for Coronary Heart Disease (CHD) Highest risk High risk Lower risk • Existing coronary heart disease and/or • Existing extra coronary vascular disease At least one of the following • Diabetes • Positive family history of CHD • Familial hypercholesterolaemia • Hypertension • Smoking • Others (e. g. overweight physical inactivity)

Australian guidelines Assessment Goal Interview: Routinely ask about: Dietary habits/familial hyperlipidaemia Lipid goals as per categorisation of risk for coronary heart disease Baseline fasting lipid profile for: All adults > 18 yrs Fasting lipid profile for CHD patients EITHER within 24 hours of the onset of MI OR 6/52 post MI For highest risk patients TC < 4. 5 mmol/l LDL-C < 2. 5 mmol/l TG < 2. 0 mmol/l For high risk patients TC < 5. 0 mmol/l LDL-C < 3. 0 mmol/l TG < 2. 0 mmol/l For lower risk population TC < 6. 0 mmol/l LDL-C < 4. 0 mmol/l TG < 4. 0 mmol/l

Australian guidelines Intervention Review All hyperlipidaemic patients Lifestyle: limit alcohol intake ± physical activity ± weight management]. Nutrition intervention: [as indicated below] ± referral to dietitian ± referral to Heartline teleinfo service [see below]. For high risk highest risk patients: Monitor diet fortnightly for 6/52, then retest at 68/52 until satisfactory and stable response. Ongoing follow-up for diet and possible drug intervention at 3 -6/12. Lipid lowering medication: Be more aggressive in lowering lipids in those at highest coronary risk. PBS regulations allow for drug therapy after dietary mod. in: • CHD patient, with total cholesterol (TC > 4. 0 mmol/l; • diabetes or familial hypercholesterolaemia or hypertension or family history CHD or PVD, with TC > 6. 5 mmol/l; or with HDL < 1. 0 mmol/l and TC > 5. 5 mmol/l. Statins: Consider as possible first line management. General population: Lipids at least every 5 years – including risk factor assessment.

Issues with guidelines • Goals are not reached resulting in the undertreatment of patients • Guidelines are not implemented resulting in untreated patients

Goals not reached • Evidence shows that patients are failing to reach the goals set in guidelines • 62% of patients failing to reach their goal* • NHANES data show that 82% of CHD patients are not meeting target LDL-C level* • Only 49% of patients with CHD reach total cholesterol targets (EUROASPIRE) References: Pearson TA et al. Arch Intern Med 2000; 160: 458 -67; Hoerger TJ et al. Am J Cardiol; 82: 61 -5; EUROASPIRE. EHJ 2001; 22: 54 -72. *relates to NCEP II ATP goals