2012 Dyslipidemia Update from CCC 2012 Workshop

2012 Dyslipidemia Update from CCC 2012 Workshop

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Copyright 2013, Canadian Cardiovascular Society 1 Canadian Cardiovascular Society Guidelines 2012 UPDATE Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 2 2012 CCS Dyslipidemia Guidelines Update Revision/Correction History Date

Revision April 25, 2013 Adjusted ranges in slide 24 and 27 to be inclusive (IE , ) to match publication Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 3 2012 CCS Dyslipidemia Guidelines Update Primary Panel Todd J Anderson MD, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta Jean Grgoire MD, Institut de Cardiologie de Montral, Universit de Montral, Qubec Robert A. Hegele MD, Robarts Research Institute, London, Ontario Patrick Couture MD, Centre Hospitalier Universitaire de Qubec, Qubec City, Qubec G. B. John Mancini MD, University of British Columbia, Vancouver, British Columbia Ruth McPherson MD, PhD, University of Ottawa Heart Institute, Ottawa, Ontario

Gordon A. Francis MD, St Pauls Hospital, University of British Columbia, Vancouver, British Columbia Paul Poirier MD, PhD, Institut Universitaire de cardiologie et de Pneumologie de Qubec, Quebec City, Qubec David C. Lau MD, PhD, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta Steven Grover MD, McGill University Health Center, Montreal, Quebec Jacques Genest Jr., MD, McGill University Health Center, Montreal, Quebec Andr C. Carpentier MD, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qubec Robert Dufour MD, Institut de Recherches Cliniques de Montral, Montral, Qubec Milan Gupta MD, Department of Medicine, McMaster University, Hamilton, Ontario Richard Ward MD, University of Calgary, Alberta Lawrence A. Leiter MD, St Michaels Hospital, University of Toronto, Ontario Eva Lonn MD, Population Health Research Institute, McMaster University, Hamilton, Ontario Dominic S. Ng MD, PhD, St Michaels Hospital, University of Toronto, Ontario Glen J. Pearson Pharm D, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta Gillian M. Yates MN, NP, QE II Health Sciences Centre, Halifax, Nova Scotia James A. Stone MD, PhD, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta Ehud Ur MB, University of British Columbia, Vancouver, British Columbia Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 4

2012 CCS Dyslipidemia Guidelines Update Introduction Todd J Anderson, MD Who to screen & risk assessment Robert Dufour, MD Levels of Risk Milan Gupta, MD Secondary testing Todd Anderson, MD Health Behaviours Gillian M. Yates, MN NP Statin intolerance Glen J. Pearson, Pharm D Cases Jean Grgoire MD Open questions Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society

5 2012 CCS Dyslipidemia Guidelines Update Changes since 2009 GRADE recommendations Addition of CKD definitions and treatment Lower age for treatment in diabetes CDA harmonization Addition of non-HDL C as alternative target Recommendation for secondary testing in selected patients More explicit recommendations for health behaviour changes Statin intolerance approach Cardiovascular Age determination Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 6 2012 UPDATE Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult Who to Screen & Risk Assessment Robert Dufour, MD Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 7 2012 CCS Dyslipidemia Guidelines Update Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 8 2012 CCS Dyslipidemia Guidelines Update Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 9 2012 CCS Dyslipidemia Guidelines Update Risk assessment 1. We recommend that a cardiovascular risk assessment using the 10 Year Risk provided by the Framingham model be completed every 3 to 5 years for men age 40 to 75, and women age 50 to 75. This should be modified (percent risk doubled) when family history of premature CVD is positive (i.e. 10 relative <55 years for men; <65 years for women). A risk assessment may also be

completed whenever a patients expected risk status changes. Younger individuals with >1 risk factor for premature CVD may also benefit from a risk assessment to motivate them to improve their lifestyle. (Strong Recommendation, Moderate-quality Evidence) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 10 2012 CCS Dyslipidemia Guidelines Update Risk assessment and Framingham Model Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 11

2012 CCS Dyslipidemia Guidelines Update Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 12 2012 CCS Dyslipidemia Guidelines Update CVD Cardiovascular risk for men POINTS RISK POINTS RISK POINTS

RISK -3 or less <1% 5 3.9 % 13 15.6 % -2 1.1 % 6 4.7 % 14

18.4 % -1 1.4 % 7 5.6 % 15 21.6 % 0 1.6 % 8 6.7 % 16

25.3 % 1 1.9 % 9 7.9 % 17 29.4 % 2 2.3 % 10 9.4 % 18+

> 30 % 3 2.8 % 11 11.2 % 4 3.3 % 12 13.3 % Multiplied by 2 when family history of premature CVD is positive Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society

13 2012 CCS Dyslipidemia Guidelines Update Limitations of 10 year risk estimates Sensitive to the patients age Majority of individuals identified as being at low risk More accurate among younger individuals Competing risk increases with age (i.e cancer) Risk categories (low, inter.,high) chosen arbitrary by consensus Sub-optimal understanding and use Despite the limitations assessing total CVD risk improves management of blood pressure and blood lipids Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 14 2012 CCS Dyslipidemia Guidelines Update Adherence to Statins is Sub-Optimal Among Canadians Anderson TJ, Gregoire et al., Can J Cardiol 2013 Feb;29(2): 151-167syndromes. JAMA. 2002;288(4):462-467 Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy inJ elderly patients with and without acute coronary

20-02-22 Copyright 2013, Canadian Cardiovascular Society 15 2012 CCS Dyslipidemia Guidelines Update Risk Assessment: Recommendation 2 1. We recommend calculating and discussing a patients Cardiovascular Age to improve the likelihood that patients will reach lipid targets and that poorly controlled hypertension will be treated (Strong Recommendation, High-Quality Evidence). Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 16

2012 CCS Dyslipidemia Guidelines Update Risk Assessment: Values & preferences The primary evaluation of risk is the modified 10-year Framingham Risk Score (FRS) Given the overlap in risk factors for diabetes, a simultaneous evaluation of cardiometabolic risk for diabetes may be useful to motivate lifestyle changes It is well known that a 10-year risk does not fully account for risk in younger individuals In these individuals, the calculation of a Cardiovascular Age has been shown to motivate subjects to achieve risk factor targets Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 17 2012 CCS Dyslipidemia Guidelines Update Risk Assessment: Practical Tip For patients older than 75 years of age, the Framingham

model is not well validated. Though clinical studies are currently under way to address this group, at this point clinical judgement is required in consultation with the patient to determine the value of pharmacotherapy. One approach is extrapolation of the modified FRS, and this approach identifies most subjects as having intermediate- to high-risk based on age. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 18 2012 CCS Dyslipidemia Guidelines Update Cardiovascular Age Tables / Diabetes: NO Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 19 2012 CCS Dyslipidemia Guidelines Update Cardiovascular Age Tables / Diabetes: YES Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 20 2012 CCS Dyslipidemia Guidelines Update Cardiovascular Age Tables / Diabetes: NO Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 21 2012 CCS Dyslipidemia Guidelines Update Cardiovascular Age Tables / Diabetes: YES Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 22 2012 UPDATE Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult Levels of Risk Milan Gupta, MD Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 23 2012 CCS Dyslipidemia Guidelines Update Low risk recommendations 1. Pharmacotherapy with LDL-C 5.0 mmol/L, or evidence of genetic dyslipidemia (e.g. familial hypercholesterolemia) (Strong Recommendation, Moderate-Quality Evidence). 2. 50 % reduction of LDL-C after treatment is initiated (Strong Recommendation, Moderate-Quality Evidence) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 24

2012 CCS Dyslipidemia Guidelines Update Low risk recommendations Values and preferences: Unchanged. Less clinical trial evidence, so practice will vary and depend on patient wishes and clinical evaluation. For subjects with 5-9% risk: - more frequent monitoring of risk - discuss risks/benefits of statin therapy - judicious use of secondary testing. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 25 2012 CCS Dyslipidemia Guidelines Update Intermediate Risk Recommendations 1.

IR category: adjusted FRS > 10% and <20% (Strong Recommendation, Moderate-Quality Evidence) 2. Treat IR individuals with LDL-C > 3.5 mmol/L (Strong Recommendation, Moderate-Quality Evidence) 3. In IR individuals with LDL-C < 3.5 mmol/L, apo B 1.2 g/L or non-HDL-C 4.3 mmol/L can help identify patients to benefit from pharmacotherapy (Strong Recommendation, Moderate-Quality Evidence) 4. Target LDL-C 2.0 mmol/L or 50% reduction once treatment is initiated (Strong Recommendation, Moderate-Quality Evidence). Alternative targets: apo B 0.8 g/L or non-HDL cholesterol 2.6 mmol/L (Strong Recommendation, Moderate-Quality Evidence). Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 26 2012 CCS Dyslipidemia Guidelines Update Non-HDL-C as an alternate target to LDL-C Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 27 2012 CCS Dyslipidemia Guidelines Update Intermediate risk and non-HDL: values and preferences Adding non-HDL-C would seem to contradict the philosophy of simplifying the guidelines.

However, apo B is not available in some jurisdictions, while non-HDL-C is available without any additional cost or testing. Also, increasing data demonstrate its potential advantages over LDL-C: superior risk predictor, fasting not required. Therefore, it was decided to increase its profile in the guidelines. Non-HDL-C would be particularly useful where apo B is unavailable and where TG 1.5 mmol/L. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 28 2012 CCS Dyslipidemia Guidelines Update High risk recommendations 1. High risk is defined in those subjects who have clinical atherosclerosis, diabetes >15 years duration and age >30 years, or age >40 years with diabetes, or adjusted Framingham Risk Score of 20%. (Strong Recommendation, High-Quality Evidence).

We now include abdominal aortic aneurysm, high risk kidney disease (eGFR < 45) and high risk hypertension in this category (Strong Recommendation, Moderate-Quality Evidence). 2. Treatment target for LDL-C 2.0 mmol/L or 50% reduction for optimal risk reduction. (Strong Recommendation, Moderate-Quality Evidence). 3. Apo B ( 0.80 g/L) or non-HDL-C ( 2.6 mmol/L) be considered as alternative (Strong Recommendation, High-Quality Evidence). Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 29 2012 CCS Dyslipidemia Guidelines Update

High risk: values and preferences Our decision to add chronic kidney disease (eGFR < 45) to the high risk category was based on significant emerging epidemiology data and the recently published Study of Heart and Renal Protection (SHARP). The treatment of dyslipidemia in subjects on hemodialysis remains controversial and individual judgment is required. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 30 2012 CCS Dyslipidemia Guidelines Update Risk stratification by Framingham Risk Score (FRS) and phenotype Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 31 2012 CCS Dyslipidemia Guidelines Update Risk stratification for intermediate risk subjects Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 32 2012 CCS Dyslipidemia Guidelines Update Levels of risk - Practical tips: LDL-C remains the primary target in the guidelines. Clinicians would be encouraged to be familiar with the use of LDL-C and one of the two alternate targets.

We do not advocate using all 3 indices regularly or testing for LDL-C, non-HDL-C and apo B concurrently in subjects. For those who have apo B available and are comfortable with using it, there are advantages that were previously addressed. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 33 2012 CCS Dyslipidemia Guidelines Update Summary of treatment thresholds and targets based on Framingham Risk Score (FRS), modified by family history Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society

34 2012 UPDATE Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult Secondary Testing Todd J Anderson MD Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 35 2012 CCS Dyslipidemia Guidelines Update Secondary Testing 1. We recommend secondary testing for further risk

assessment in intermediate risk (10-19% FRS after adjustment for family history) subjects who are not candidates for lipid treatment based on conventional risk factors or for whom treatment decisions are uncertain. (Strong Recommendation, moderate quality evidence) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 36 2012 CCS Dyslipidemia Guidelines Update Secondary Testing 2. We suggest that secondary testing may be considered for a selected subset of low to intermediate risk (5-9% FRS after adjustment for family history) subjects for whom further risk assessment is indicated, e.g. strong family history of premature CAD, abdominal obesity, South Asian

ancestry or impaired glucose tolerance. (Weak recommendation, low quality evidence) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 37 2012 CCS Dyslipidemia Guidelines Update Optional Biomarkers for Further Risk Assessment Biomarker Indications for testing Frequency of testing Normal Range Lp(a) Further risk assessment

particularly in individuals with a family history of premature CVD Genetically determined risk factor Repeat testing not required < 30 mg/dl (< 300 mg/L) hsCRP Men > 50y and women > 60y who are not candidates for statin Rx based on conventional risk factors q 3 y from age 50 y (M) 60 y (F) If > 2.0 mg/L, repeat in 2-4 wk, use lower value for risk assessment < 1.0 lowest risk > 2.0 increased risk > 3.0 high risk

A1C Further risk assessment in selected subjects with FPG >5.6 mmol/L q1-5y more frequently if weight gain or incr FBG < 5.5% low risk 5.5-6.0 % mid risk 6.0-6.5 % high risk > 6.5 % diabetes Urinary Alb/Cr T2DM poorly controlled HTN Selected patients who are not candidates for statin Rx based on conventional risk factors q 1 y for patients with T2DM or

poorly controlled HTN < 3 mg/mmol Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 38 2012 CCS Dyslipidemia Guidelines Update Choose a test appropriate for the individual patient (not multiple tests) Lp(a):30-70 mg/dl confers ~ 1.3X increased risk; mg/dl ~ 1.5X increased CVD risk > 80 hsCRP > 2 mg/dl is associated with ~ 1.5 to 2.0 X increased CVD risk HbA1c 6.0 6.5 % is associated with ~ 1.5 1.8 X increased

CVD risk Microalbuminuria is associated with ~ 1.5 X increased CVD risk Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 39 2012 CCS Dyslipidemia Guidelines Update Optional Noninvasive Tests for Further Risk Assessment Noninvasive test Indications for testing Normal Range Frequency of testing Graded exercise

stress test Selected asymptomatic adults with CVD risk factors especially those who are embarking on a vigorous exercise program Selected adults in the intermediate risk category Duke Scorea Low risk +5 Moderate risk -10 to +4 High risk -11 q 3-10 y or if symptoms develop Carotid imaging Selected asymptomatic adults in

not candidates for statin Rx based on conventional risk factors. Only in centres with expertise CIMT <1.0 mm No visible plaqueb q 5-10 y as indicated for reassessment of risk ABI Selected asymptomatic adults, not candidates for statin Rx based on conventional risk factors (particularly smokers, diabetes) ABI 1.0-1.3c q 5-10 y as indicated for reassessment of risk or if symptoms develop CAC

Selected asymptomatic adults who are not candidates for statin Rx based on conventional risk factors Low risk Increased risk High risk Very high risk CAC 0 0 100 100-300d > 300e CAC = 0 q 10y where clinically indicated CAC = 0 100 q 3-5y if Rx is deferred Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 40 2012 CCS Dyslipidemia Guidelines Update Choice & Interpretation of Noninvasive Tests GXT: May be indicated for sedentary patient wishing to start exercise program; note that CAD risk is also increased in subjects with low exercise capacity (< 6 METS) ABI: Consider for patient with suspected PAD. ABI < 0.90 is an indication for intensive statin therapy Carotid IMT: Each 0.1 mm increase in CIMT is associated with a 10% increased risk for MI and a 13% increased risk for stroke. Visible arterial wall plaques defined as a CIMT > 1.5 mm or CIMT values > 75% for age and sex are considered as evidence of subclinical atherosclerosis and an indication for statin therapy Coronary artery calcium: Highest incremental value but radiation exposure and not yet generally available. CAC > 100 is generally an indication for statin Rx. CAC > 300 places patient in very high risk category (10 y risk of MI/CV death = 28%) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 41 2012 CCS Dyslipidemia Guidelines Update Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 Eva Lonn 20-02-22 Copyright 2013, Canadian Cardiovascular Society 42 2012 CCS Dyslipidemia Guidelines Update Novel markers of atherosclerotic risk Met-analysis of 37197 subjects 8 studies, 12 pubs of IMT Anderson TJ, Gregoire et Circ al., Can

Cardiol 2013 Feb;29(2): 151-167 Lorenz etJal. 2007J 115:459 20-02-22 Copyright 2013, Canadian Cardiovascular Society 43 2012 CCS Dyslipidemia Guidelines Update IMT and Discrimination, Reclassification USE-IMT meta-analysis 15 large cohort studies 45,000 subjects 4007 first MI or stroke C-statistic 0.757 and not changed with IMT NRI significant but 0.8% given sample size NCRI for intermediate risk 3.6% Den Ruijiter JAMA 2012; 308:796Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 44 2012 CCS Dyslipidemia Guidelines Update Coronary Artery Calcium Due to atherosclerosis Related to age and risk factors Not related to stenosis but is related to plaque volume Can be detected by EBCT or MDCT Radiation dose is moderate (0.5-1.5 mSev and acquisition very quick Variance about 40% for Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 repeated measures 20-02-22 Copyright 2013, Canadian Cardiovascular Society

45 2012 CCS Dyslipidemia Guidelines Update Coronary calcium score Prevalence aSx group 44,052 CAC related to all cause mortality across age range Tota-Maharaj EHJ 2012;33:2955 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 46 2012 CCS Dyslipidemia Guidelines Update Coronary calcium score - Prognosis MESA 6722 subjects 162 events

HR 7.08 for major Coronary event With CAC >100 Detrano NEJM 2008;356:1336 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 47 2012 CCS Dyslipidemia Guidelines Update Comparison of novel risk markers MESA 1330 IR subjects CAC, IMT, CRP, FH and ABI 123 CVD events Carotid IMT not associated with events while

others were CAC was best Yeboah JAMA 2012;308:788 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 48 2012 UPDATE Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult Health Behaviours Gillian M. Yates, MN NP Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society

49 2012 CCS Dyslipidemia Guidelines Update Search Strategy Update on international and US dietary guidelines for the treatment of dyslipidemias and cardiovascular diseases since 2007 Update on physical activity guidelines for the treatment of dyslipidemias and cardiovascular diseases since 2007 Three primary questions to be addressed: 1. Effect of diets and macronutrient composition in interventions 8 weeks in duration 2. Effect of physical activity in interventions 8 weeks 3. Effect of health behaviour changes (i.e., lifestyle modification with combined dietary and exercise, with or without weight loss) in interventions 8 weeks Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 50

2012 CCS Dyslipidemia Guidelines Update Lifestyle Modification Health behaviour interventions are the cornerstone of cardiovascular disease management and prevention Diet Exercise Alcohol intake Cigarette smoking Stress and mental health issues Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 51

2012 CCS Dyslipidemia Guidelines Update Table 7. Expected Benefit of Health Behaviour Changes Intervention (minimal dose for effect) Dietary cholesterol intake98 < 300 mg/day (NCEP step I diet) < 200 mg/day (NCEP step II diet) Expected Outcome LDL-C 10-12% 12-16% Saturated fats < 7% of daily caloric intake107 LDL-C 5-10%; CVD mortality 14% Phytosterols 1-2 g/day100 LDL-C 5-8% Soy proteins with isoflavones 25g/day101

LDL-C 3-5% Viscous fibre 10 g/day102 LDL-C 3-5% Nuts 30-67 g/day103 LDL-C 5-7%, TG 5-10% Portfolio type diet104 LDL-C 8-14% Mediterranean type diet105 LDL-C 5-10%; CVD mortality DASH (Dietary Approaches to Stop Hypertension) diet106 CVD mortality in those with hypertension Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 52 2012 CCS Dyslipidemia Guidelines Update Table 7. Expected Benefit of Health Behaviour Changes Intervention (minimal dose effect) Expected Outcome Moderated Alcohol intake 1-2 drinks/day HDL 5-10%, CVD events Weight loss and reduction of abdominal obesity42 5-10% of body weight loss LDL-C, HDL, TG, cardiometabolic risk

Omega -3 - 2-4 g of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA)/day TG 25-30% in pts. with TG Exercise109,110 30-60 min/day moderate to vigorous intensity HDL 5-10%, CVD events Smoking cessation HDL, CVD events Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 53 2012 CCS Dyslipidemia Guidelines Update

Recommendations We suggest that all individuals be encouraged to adopt healthy eating habits to lower their cardiovascular (CVD) risk: 1.Moderate energy (caloric) intake to achieve and maintain a healthy body weight 2.Emphasize a diet rich in vegetables, fruit, whole-grain cereals, and polyunsaturated and monounsaturated oils, including omega-3 fatty acids particularly from fish 3.Avoid trans fats, limit saturated and total fats to < 7% and < 30% of daily total energy (caloric) intake, respectively 4.Increase daily fibre intake to > 30 g 5.Limit cholesterol intake to 200 mg daily for individuals with dyslipidemia or at increased CVD risk (Conditional Recommendation, Moderate-Quality Evidence) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 54 2012 CCS Dyslipidemia Guidelines Update

Recommendations We recommend the Mediterranean, Portfolio or DASH diets to improve lipid profiles or decrease CVD risk (Strong Recommendation, High-quality Evidence) and for cholesterol lowering consider increasing phytosterols, soluble fibre, soy and nut intake (see Table 7) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 55 2012 CCS Dyslipidemia Guidelines Update Recommendations We recommend that adults should accumulate at least 150 min. of moderate-to-vigorous-intensity aerobic physical activity per week, in bouts of 10 min or more to reduce cardiovascular disease risk. (Strong Recommendation, High-Quality Evidence)

We recommend smoking cessation (Strong Recommendation, Moderate-Quality Evidence) and limiting alcohol intake to 30 g or less per day (1-2 drinks) (Conditional Recommendation, Moderate-Quality Evidence) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 56 2012 UPDATE Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult Statin Intolerance Glen J. Pearson PharmD Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 57 2012 CCS Dyslipidemia Guidelines Update Statin Intolerance Recommendations 1. Because overall risk/benefit favours therapy in patients meeting criteria for lipid lowering therapy and cardiovascular risk reduction, we recommend that: i. despite concerns about a variety of other possible adverse effects, all purported statin-associated symptoms should be evaluated systematically, incorporating observation during cessation, reinitiation (same or different statin, same or lower potency, same or decreased frequency of dosing) to identify a tolerated, statin-based therapy for chronic use; and (Strong Recommendation, Very Low-Quality Evidence) Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 58 2012 CCS Dyslipidemia Guidelines Update Statin Intolerance Recommendations 1. Because overall risk/benefit favours therapy in patients meeting criteria for lipid lowering therapy and cardiovascular risk reduction, we recommend that: (cont) ii. Statins not be withheld on the basis of a potential, small risk of new-onset diabetes mellitus emerging during long-term therapy (Strong Recommendation, Very Low-Quality Evidence) 2. We do not recommend vitamins, minerals, or supplements for symptoms of myalgia perceived to be statin-associated (Strong Recommendation, Very Low-Quality Evidence). Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 59 2012 CCS Dyslipidemia Guidelines Update Statin Intolerance Practical tip Patients should be advised to stop statin therapy and contact the prescribing health care provider if worrisome symptoms develop. The amount of effort spent persevering with statin therapy in subjects with adverse effects should be directly related to the level of risk for an individual patient. In those at highest risk all options should be exercised before changing to alternative lipid-lowering therapy or withdrawing all lipid-lowering treatment. Lower dose combination therapy remains an option for these subjects. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society

60 2012 CCS Dyslipidemia Guidelines Update Statin Intolerance Practical tip Strong emphasis should be put on a more aggressive nonpharmacologic approach such as diet modulation and exercise. For subjects at lower risk who do not tolerate statin therapy, a reevaluation of the need for lipid lowering therapy should precede a change to alternative therapy because outcomes studies are not as robust. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 61 2012 CCS Dyslipidemia Guidelines Update Management Algorithm for Statin-Induced Muscle Symptoms

Anderson TJ, Baker Gregoire J et al., Can J Cardiol Feb;29(2): 151-167 Mancini GBJ, S, Bergeron J, et al. Can2013 J Card 2011; 27:635662 20-02-22 Copyright 2013, Canadian Cardiovascular Society 62 2012 CCS Dyslipidemia Guidelines Update Canadian Lipid Guidelines: Summary FRS doubled with positive family history

Primary target: - absolute LDL-C 2 mmol/L - relative decrease in LDL-C 50% Alternates: - non-HDL-C 2.6 mmol/L - apo B 0.8 g/L 5-9% risk: - monitor yearly Secondary markers: - biochemical: Lp(a), hsCRP, HbA1c, ACR - non-invasive: GXT, IMT, ABI, CAC Lifestyle recommendations Statin intolerance recommendations Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 63 Case Discussions Jean Grgoire MD

Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 64 2012 CCS Dyslipidemia Guidelines Update Case # 1 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 65 2012 CCS Dyslipidemia Guidelines Update Case # 1

54 year old woman Treated hypertension x 12 years, otherwise healthy Non-smoker, non-diabetic, no relevant family history BP 132/90, TC 5.4, HDL 1.3, LDL 3.3 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 66 2012 CCS Dyslipidemia Guidelines Update What is her FRS? 1. < 5 % 2. 5-9%

3. 10-19% 4. >20% FRS is 10% LDL is 3.3 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 67 2012 CCS Dyslipidemia Guidelines Update Should she receive a statin? 1. Yes 2. No 3. I need more information in order to decide Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 68 2012 CCS Dyslipidemia Guidelines Update High risk hypertension (ASCOT) HT plus any 3 of these risk factors equates to high risk: Male gender Age >55 Smoking LVH

TC:HDL > 6 Family history premature CHD Abnormal ECG Microalbuminuria Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 69 ASCOT Primary Endpoint: Non-fatal MI and Fatal CHD Cumulative Incidence (%) 44 Atorvastatin 10 mg Number of events 100

Placebo Number of events 154 36% reduction 33 22 11 HR = 0.64 (0.50-0.83) 00 0.0 0.0 0.5 0.5

1.0 1.0 1.5 1.5 2.0 2.0 2.5 2.5 3.0 3.0 3.5 3.5 Years Years Sever PS, Dahlf B, Poulter N, Wedel H, et al, for the ASCOT Investigators. Lancet 2003;361:1149-58 p=0.0005

2012 CCS Dyslipidemia Guidelines Update Case # 1 Additional information Weight 66 kg, BMI 25.8, waist circumference 85 cm FPG 5.3, A1c 0.058 hsCRP 1.2 Creatinine 168, eGFR 40 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 71 2012 CCS Dyslipidemia Guidelines Update

Case # 1 She has chronic kidney disease (eGFR < 45) This is considered a high risk equivalent She should therefore be considered for statin therapy to a target LDL < 2.0 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 72 2012 CCS Dyslipidemia Guidelines Update Alberta Kidney Disease Network Tonelli et al. Lancet 2012 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society

73 2012 CCS Dyslipidemia Guidelines Update SHARP: Major Atherosclerotic Events in Patients with CKD Proportion suffering event (%) 25 20 Risk ratio 0.83 (0.74-0.94) Logrank 2P=0.0021 15 Placebo Simv/Eze 10 5

0 0 1 2 3 Years of follow-up 4 5 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 74 2012 CCS Dyslipidemia Guidelines Update

Case # 1 She is started on atorvastatin 20 mg daily LDL falls to 2.4 and the drug is well-tolerated The dose is titrated to 40 mg daily but she develops bothersome muscle aches with a CK of 450 Renal function remains stable Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 75 2012 CCS Dyslipidemia Guidelines Update Muscle aches on atorvastatin 40 mg, suboptimal LDL What next? 1. 2. 3. 4.

5. 6. Reduce atorvastatin to 20 mg daily, accept LDL 2.4 Change to rosuvastatin 10 mg and titrate as tolerated Change to simvastatin 20 mg and add ezetimibe 10 mg Reduce to atorvastatin 20 mg and add ezetimibe 10 mg Leave atorvastatin at 40 mg and add coenzyme Q10 Other While the correct answer is 4, 2 and 3 could be used as second choices. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 76 2012 CCS Dyslipidemia Guidelines Update Canadian Journal of Cardiology 2011; 27:635-662

Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 77 2012 CCS Dyslipidemia Guidelines Update Non-Statin Lipid Lowering Strategies Fibrates Ezetimibe Lowers LDL 15-20% Well tolerated May be added to low dose statin Bile acid sequestrants Lowers LDL 15% May prevent diabetes

Colesevalam better tolerated TG LDL little change ? Benefit when HDL low Niacin Flushing/pruritus may limit tolerance Lowers LDL 20% TG40%, HDL30% Ezetimibe + Bile acid sequestrant 40-45% LDL reduction Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 78 2012 CCS Dyslipidemia Guidelines Update

What if she was already on hemodialysis? Should she receive lipid-lowering therapy? 1. Yes 2. No 3. Uncertain Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 79 2012 CCS Dyslipidemia Guidelines Update SHARP: Major Atherosclerotic Events by renal status Simv/Eze (n=4650) Placebo (n=4620)

Non-dialysis (n=6247) 296 (9.5%) 373 (11.9%) Dialysis (n=3023) 230 (15.0%) 246 (16.5%) Major Atherosclerotic Event 526 (11.3%) 619 (13.4%) No significant heterogeneity between non-dialysis and dialysis patients (p=0.25) Risk ratio & 95% CI

16.6% SE 5.4 reduction (p=0.0021) 0.6 0.8 Simv/Eze better 1.0 1.2 1.4 Placebo better The treatment of dyslipidemia in subjects on hemodialysis remains controversial and individual judgment is required. Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 80 2012 CCS Dyslipidemia Guidelines Update Case # 2 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 81 2012 CCS Dyslipidemia Guidelines Update Case # 2

36 year old South Asian man Non-smoker, non-diabetic, normotensive Father had MI at age 46 BP 128/84, TC 5.8, HDL 1.0, LDL 4.1 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 82 2012 CCS Dyslipidemia Guidelines Update What is his FRS? 1. < 5 % 2. 5-9% 3. 10-19% 4. >20% FRS is 3.9% Family history FRS 7.8% LDL is 4.1

Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 83 2012 CCS Dyslipidemia Guidelines Update Ten-Year vs. Lifetime Risk Men (n = 3564) 70 Women 69 60 (n = 4362) 70

60 50 46 50 Adjusted cumulative 40 incidence 30 of CVD (%) 20 36 50 50 40 39 30

27 20 10 5 10 8 0 0 50 60 70 80 90

50 Attained age (years) 60 2 Major RFs 1 Elevated RF 1 Major RFTJ, Gregoire J et al., Can 1 JNot optimal RF 151-167 Anderson Cardiol 2013 Feb;29(2): 70 80 90 All optimal RFs

Lloyd-Jones DM et al. Circulation. 2006;113:791-8. 20-02-22 Copyright 2013, Canadian Cardiovascular Society 84 2012 CCS Dyslipidemia Guidelines Update Lifestyle Recommendations Mediterranean, Portfolio or Dash diets: including foods high in plant sterols, soy protein, high viscous fiber, omega 3 fatty acids and nuts Moderate alcohol intake 1-2 drinks/day 150 min of moderate to vigorous aerobic activity per week Healthy body weight with BMI 20-25 kg/m(2) 0-5-30 approach to counselling: 0 cigarettes 5 servings of fruits/vegetables/day 30 min of exercise per day Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 85 2012 CCS Dyslipidemia Guidelines Update Should he receive a statin? 1. Yes 2. No 3. I need more information in order to decide Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 86 2012 CCS Dyslipidemia Guidelines Update

Case # 2 Additional information Weight 65 kg, BMI 22.5, waist circumference 80 cm FPG 6.2, A1c 0.062 Creatinine 78, eGFR 120 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 87 2012 CCS Dyslipidemia Guidelines Update Should he receive a statin? 1. Yes 2. No 3. I need more information in order to decide Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22

Copyright 2013, Canadian Cardiovascular Society 88 2012 CCS Dyslipidemia Guidelines Update Case # 2 36 year old South Asian man Non-smoker, non-diabetic, normotensive Father had MI at age 46 BP 128/84, TC 5.8, HDL 1.0, LDL 4.1 Weight 65 kg, BMI 22.5, waist circumference 80 cm FBS 6.2, A1c 0.062 Creatinine 78, eGFR 120

Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 89 2012 CCS Dyslipidemia Guidelines Update Statins and low risk individuals CTT Lancet 2012;379 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 90 2012 CCS Dyslipidemia Guidelines Update Case # 2

He is at low to intermediate risk (7.8%) He is South Asian, indicating higher risk than suggested by FRS LDL is fairly high at 4.1, though not > 5.0 Secondary testing is reasonable to further risk stratify He has dysglycemia, with an abnormal A1c, which increases his risk by 1.5 -2 fold He can therefore be considered for statin therapy to a target LDL < 2.0 or a 50% reduction from baseline Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 91 2012 CCS Dyslipidemia Guidelines Update

Case # 3 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 92 2012 CCS Dyslipidemia Guidelines Update Case # 3 56 year old white man Non-smoker, non-diabetic, normotensive No relevant family history BP 124/78, TC 5.6, HDL 1.1, TG 3.2, LDL 3.0 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 93 2012 CCS Dyslipidemia Guidelines Update What is his FRS? 1. < 5 % 2. 5-9% 3. 10-19% 4. >20% FRS is 15.6% LDL is 3.0 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society

94 2012 CCS Dyslipidemia Guidelines Update Should he receive a statin? 1. Yes 2. No 3. I need more information in order to decide Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 95 2012 CCS Dyslipidemia Guidelines Update Case # 3 Additional information Weight 86 kg, BMI 30, waist circumference 104 cm FBS 5.4, Creatinine 85, eGFR 90

Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 96 2012 CCS Dyslipidemia Guidelines Update Should he receive a statin? 1. Yes 2. No 3. I need more information in order to decide Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 97

2012 CCS Dyslipidemia Guidelines Update Is secondary testing necessary? 1. Yes 2. No 3. Uncertain Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 98 2012 CCS Dyslipidemia Guidelines Update If secondary testing is necessary, which test would you consider? 1. 2. 3.

4. 5. 6. 7. 8. hsCRP HbA1c Urinary protein Stress testing Carotid ultrasound Ankle brachial index Coronary calcium score Other Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 99 2012 CCS Dyslipidemia Guidelines Update

Case # 3: Secondary testing is not required 56 year old white man Non-smoker, non-diabetic, normotensive No relevant family history BP 124/78, TC 5.6, HDL 1.1, TG 3.2, LDL 3.0 Weight 86 kg, BMI 30, waist circumference 104 cm FBS 5.4, Creatinine 85, eGFR 90 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 100

2012 CCS Dyslipidemia Guidelines Update Case # 3 Options other than secondary testing The role of non-HDL For patients with FRS 5-19% with LDL<3.5, one can consider assessment of apoB or non-HDL Non-HDL = TC minus HDL No fasting required, no extra cost, immediately calculated from any full lipid profile This patients non-HDL = 5.6 1.1 = 4.5 If non-HDL > 4.3 with LDL < 3.5, can consider statin therapy Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 20-02-22 Copyright 2013, Canadian Cardiovascular Society 101 Thank You and Questions Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167

20-02-22 Copyright 2013, Canadian Cardiovascular Society 102

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