1. Management of Dyslipidemia
Dr Ahmed Waheed
MSc in Diabetes, Glamorgan University – UK
PGDD, Cardiff University - UK

2. Dyslipidemia
Dyslipidemia is elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein level that contributes to the development of atherosclerosis.
Causes may be primary (genetic) or secondary.
Diagnosis is by measuring plasma levels of total cholesterol, TGs, and individual lipoproteins.
Treatment involves dietary changes, exercise, and lipid-lowering drugs.

3. Vascular tissue mainly coronary
Diet
Intestine
Chylomicron
Periperal tissue [adipose and muscle
VLDL
LIVER
ILDL
LDL
Vascular tissue mainly coronary

4. The Lipid Profile
How to interpret ?
Dr Ahmed Waheed

5. Lipoproteins HDL LDL VLDL CM C C A I, A II B 100 TG TG C B 100 + E +C5
Dr Ahmed Waheed

6. Atherogenic Particles
Non-HDL-C
Measurements
Apolipoprotein B
VLDL
VLDLR
IDL
LDL
SDL
TG rich particles
Cholesterol rich 6
Dr Ahmed Waheed

7. Overview
Goal: treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults, currently one of leading cause of death and disability
The goal was To guide clinicians in treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults, currently the leading cause of death and disability
The RCTs identified, demonstrated consistent reduction in ASCVD events from statins therapy in secondary and primary prevention populations (with the exception of those with NYHA class II-IV heart failure or receiving maintenance hemodialysis)

8. Treatment Recommendations
address associated metabolic abnormalities and modifiable risk factors such as hypertension, diabetes, obesity, and cigarette smoking.
The first-line approach to primary prevention in patients with lipid disorders involves the implementation of lifestyle changes, including physical activity and medical nutrition therapy.
pharmacotherapy,
as well as patient education programs to promote further risk reduction through smoking cessation and weight loss.

9. Problems with our attitude to food
No time to eat – fast foods
Eating in front of the telly
Eating more later at night
Portion size

12. lipid management recommend diets rich in
fruits (≥2 servings/day),
vegetables (≥3 servings/day, ≥1 of these servings/day of dark green or orange vegetables),
grains (≥6 servings/day, one-third of those as whole grains),
legumes,
high-fiber cereals,
low-fat dairy products,
fish, lean meats, and skinless poultry
Additional recommendations, such as those provided in the therapeutic lifestyle changes diet, specify limits for the intake of saturated fat (<7% of total calories), trans fats (<1% of total calories), and cholesterol (<200 mg/day).
polyunsaturated and monounsaturated fatty acids may comprise up to 10% and 20% of caloric intake, respectively, and that
total dietary fat should constitute 25% to 35% of calories consumed (10 [EL 4]).
Further recommendations include a reduction in both salt intake and total calories consumed

13. soluble fiber (10-25 g daily) total cholesterol reductions of 5% to 19% and LDL-C reductions of 8% to 24%
Foods high in soluble fiber include oat bran, oatmeal, beans, peas, rice bran, barley, citrus fruits, strawberries, and apple pulp.
Plant stanol esters (~2 g daily) can reduce LDL-C levels by approximately 15% to 20% Stanols/sterols have been incorporated into a variety of foods, including spreads and dressings, breads and cereals, low-fat milk and yogurt, orange juice
The Food and Drug Administration permits food labels to indicate that daily use of plant stanol esters will help reduce LDL levels. These esters are produced by the esterification of the plant steroid stanol with canola oil, and they act by blocking the intestinal absorption of cholesterol.
This reduces the serum LDL but not serum HDL.

14. SKIN LESS CHECKEN
PEAS

15. NUTS
OAT

16. B

19. Dietary Cholesterol
There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C.

20. sugar-sweetened beverages

21. Exercise
Exercise is associated with significant reduction in coronary mortality and total mortality1,2
Exercise has most impact as part of a multifactorial intervention2
1Oldridge et al. JAMA 1988; 260: 945–50
2O’Connor et al. Circulation 1989; 80: 234–44

23. Regular physical activity helps to increase strength and flexibility, maintain bone density, and improve insulin sensitivity
fitness therapy as a cornerstone of dyslipidemia treatment. Patients who are nonadherent to fitness therapy should be repeatedly encouraged, and practitioners should apply a variety of strategies as necessary to improve adherence.
Strategies may include patient-tailored advice, identification of adherence barriers, referral to instructor-led exercise classes, and routine patient follow-up and consultation

24. pharmacotherapy
statin therapy

25. What has changed compared to ATP-III guideline?
initiate either moderate-intensity or high-intensity statin therapy for patients who fall into the four categories
Unlike ATP-III, Do not titrate to a specific LDL cholesterol target
Measure lipids during follow-ups to assess adherence to treatment, not to achieve a specific LDL target
current guidelines direct clinicians to initiate either moderate-intensity or high-intensity statin therapy for patients who fall into the four categories, without titration to a specific LDL cholesterol target
Measuring lipids during follow-ups is done to assess adherence to treatment and not to see whether a specific LDL cholesterol target has been achieved
Rather than use a "lowest is best" approach that combines a low dose of a statin drug along with several other cholesterol-lowering drugs, new guidelines focuses on a healthy lifestyle along with a higher dose of statins, eliminating the need for additional medications.

26. Four Major Statin Benefit Groups
Individuals with clinical ASCVD
Individuals with LDL >190
Individuals with DM, yrs with LDL and without clinical ASCVD
Individuals without clinical ASCVD or dm with LDL and estimated 10-year ASCVD risk >7.5%
-Based on extensive review of the evidence, the expert panel identified 4 groups that would benefit from statin therapy:
Individuals with clinical ASCVD
Individuals with LDL >190
Individuals with dm, yo with LDL and without clinical ASCVD
Individuals without clinical ASCVD or dm with LDL and estimated 10-year ASCVD risk >7.5%
Note that Clinical ASCVD is defined by the inclusion criteria for the secondary prevention statin RCTs (acute coronary syndromes, or a history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin).

27. This algorithim summarizes the major guidelines in one page
You see the 4 statin benefit groups in the middle: on top, you see the patient’s group with clinical ASCVD, below that you see the group with LDL >190, below that you see the patient’s with history of DM years old, and in the bottom, you see patients who don’t have the characteristics of the first 3 groups but their 10 year ASCD risk is greater than 7.5%
For the first group: based on the guidline, if you have clinical ASCD, are younger than 75 and don’t have any history of intolerance to statin, you should be started on high intensity statin. On the other hand, if you are older than 75, or not a candidate for high intensity statin due to lets say intolerance to statins, you are a candidate for moderate-intensity statin
For the second group, if your LDL is greater than 190, you need to be started on high-intensity statin, unless you have contra-indication to high dose start on moderate dose
For the third group, individuals with diabetes with above mentioned group age, you need to calculate the 10 year ASCVD risk using a new equation/calculater called “pooled Cohort Equations” if the 10 year risk is greater than 7.5%, start them on high-intensity, otherwise, you can start them on moderate-intensity statin
For the last group, you need to calculate patient’s risk factor and start them on moderate-to-high intensity statin if their estimated 10-y ASCVD risk is greater than 7.5%
Keep that in mind that what we mean by “high intensity” statin, is the daily dose of statin that lowers the LDL by appox greater than 50%, and what we mean by moderate intensity statin, is the daily dose of statin that lowers the LDL by appox 30-50%.

28. This is the new equation, the pooled cohort risk assessment equation
As you can see, there are different parameters that you need to plug in to the equation to calculate the risk: gender, age, race, total cholesterol, HDL, systolic BP, whether or not you are on any anti-HTN meds, any history of DM or being a smoker

29. Intensity of Statin Therapy in primary and secondary prevention
This is just a chart you can use as a reference to choose the specific statin and its dose that is recommended to be used as high, moderate or low intensity statin

30. STATIN Safety recommendations
Select the appropriate dose
Keep potential Side effects and drug-drug interaction In mind (grade A)
If high or moderate intensity statin not tolerated, use the maximum tolerated dose instead
The next few slides tells you the new guidelines on the safety recommendations for statins

31. STATIN Safety recommendations
conditions that could predispose pts to statin side effect:
Impaired renal or hepatic function
History of previous statin intolerance or muscle disorder
Age >75
Unexplained ALT elevation > 3x ULN
History of hemorrhagic stroke
Asian ancestry

32. STATIN Safety recommendations
Check baseline ALT prior initiating the statin (Grade B)
Check LFTs if patient develops Symptoms of hepatic dysfunction (Grade E)
If 2 consecutive LDL <40, Consider decreasing the statin dose (Grade C, weak recommendation)
It may be harmful to initiate simvastatin 80mg, or increase the dose of simvastatin to 80mg (Grade B)
Symptoms of hepatic dysfunction: unusual fatigue or weakness, loss of appetite, abdominal pain, dark colored urine, Jaundice

33. Case 1 62 year old AA male Total cholesterol: 140 Low HDL: 35
SBP: 130 mmHg
Not taking anti-hypertensive medications
Non-diabetic
Non-smoker
Calculated 10 yr risk of ASCVD : 9.1%

34. Mention that patient belongs to the fourth group meeting the criteria for moderate to high intensity statin given the 10 year risk of ASCVD is greater than 7.5%

35. Case 2 50 year old white female Total cholesterol 180 HDL: 50 SBP: 130
taking anti-hTN meds
+diabetic
+smoker
Calculated 10 yr ASCVD: 9.8%

36. Mention that patient is a diabetic with 10 yr risk is greater than 7
Mention that patient is a diabetic with 10 yr risk is greater than 7.5% so he or she is candidate for high intensity statin

37. Case 3 48 yo white female Total cholesterol 180 HDL: 55 SBP: 130
Not taking anti-hTN meds
+diabetic
Non-smoker
Calculated 10 yr risk ASCVD : 1.8%

38. Mention that patient is a diabetic but since his or her ASCVD is less than 7.5%, he or she is a candidate for moderate intensity statin

39. Case 4 22 yo white male LDL: 195 SBP: 120 Not taking anti-hTN meds
Non-diabetic
Non-smoker
Ask the learner whether or not you need to calculate the 10 yr risk for developing the ASCVD in a patient with LDL>195. The answer is NO. This patient belongs to the second statin benefit group and is a candidate for high intesntity Statin regardless of 10 year risk

41. Case 5 66 yo white female High Total cholesterol: 230 HDL: 55 SBP: 150
taking anti-hTN meds
Non-diabetic
Non-smoker
Calculated 10 yr risk of ASCVD : 2.0 %

42. Mention that despite the fact that the total cholesterol is high, since the LDL is less than 195, and patient doesn’t meet any other statin benefit group, there is no indication for statin therapy

43. Take Home Message
Rather than LDL–C or non-HDL– C targets, new guideline uses the intensity of statin therapy as the goal of treatment.
Know the 4 Statin Benefit Groups:
Individuals with clinical ASCVD
Individuals with primary elevations of LDL–C ≥190 mg/dL
Individuals 40 to 75 years of age with diabetes and LDL–C 70 to189 mg/dL without clinical ASCVD
Individuals without clinical ASCVD or diabetes who are 40 to 75 years of age with LDL–C 70 to 189 mg/dL and have an estimated 10-year ASCVD risk of 7.5% or higher. (using the Pooled Cohort Equations for ASCVD risk prediction)

44. Re-emphasize the importance of learning how to use the new pooled cohort equation in daily practice

45. References:
Stone Nj, Robinson J, Lichtenstein Ah, Bairey Merz Cn, Lioyd-jones Dm, Blum Cb, Mcbride P, eckel Rh, Schwartz Js, Goldberg Ac, Shero St, Gordon D, Smith Sc Jr, Levy D, Watson K, Wilson Pw ACC/AHA Guideline On The Treatment Of Blood Cholesterol To Reduce Atherosclerotic Cardiovascular Risk In Adults: A Report Of The American College Of Cardiology/American Heart Association Task Force On Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. Pii: S
John F. Keaney, Jr., M.D., Gregory D. Curfman, M.D., And John A. Jarcho, M.D. A Pragmatic View Of The New Cholesterol Treatment Guidelines. N Engl J Med 2014; 370: