1. Goals & Guidelines A summary of international guidelines for CHD

2. 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
CHD or CHD risk equivalents (10-year risk >20%)
100mg/dl (2.6mmol/l)
115mg/dl (3.0mmol/l)
2+ risk factors (10-year risk 20%)
<130mg/dl (3.4mmol/l)
Reference: National Cholesterol Education Program. JAMA 2001; 285: ; Wood D et al. EHJ 1998; 19:

3. NCEP guidelines LDL-C Goals and Cutpoints for Therapeutic
Lifestyle Changes (TLC) and Drug Therapy
Risk Category
LDL-C Goal (mg/dL)
LDL-C Level at which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)
LDL-C Level at which to Consider Drug Therapy (mg/dL)
CHD or CHD Risk Equivalents (10-year risk >20%)
<100
³100
³130 (100–129: drug optional)
2+ Risk Factors (10-year risk £20%)
<130
³130
10-year risk 10–20%: ³130
10-year risk <10%: ³160
0–1 Risk Factor
<160
³160
³190 (160–189: LDL-C lowering drug optional)

4. NCEP guidelines LDL-C Lowering Therapy in Patients with CHD
and CHD Risk Equivalents
Baseline LDL-C ³130 mg/dL
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/dL
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
Baseline LDL-C: <100 mg/dL
Further LDL-C lowering not required
Therapeutic Lifestyle Changes (TLC) recommended
Consider treatment of other lipid risk factors (raised TG, low HDL-C)

5. 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/dL
Aim: reduce both short-term and long-term risk
Immediate initiation of Therapeutic Lifestyle Changes (TLC) if LDL-C is ³130 mg/dL
Consider drug therapy if LDL-C is ³130 mg/dL after 3 months of lifestyle therapies
10-Year Risk <10%
LDL-C goal: <130 mg/dL
Therapeutic aim: reduce long-term risk
Initiate therapeutic lifestyle changes if LDL-C is ³130 mg/dL
Consider drug therapy if LDL-C is ³160 mg/dL after 3 months of lifestyle therapies

6. 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/dL
Initiate therapeutic lifestyle changes if LDL-C is ³160 mg/dL
If LDL-C is ³190 mg/dL after 3 months of lifestyle therapies, consider drug therapy
If LDL-C is 160–189 mg/dL after 3 months of lifestyle therapies, drug therapy is optional

7. Level of risk (definition) Triglyceride level mmol/L
Canadian guidelines
Level of risk (definition)
LDL-C level mmol/L
TC:HDL-C ratio
Triglyceride level mmol/L
Very high*
(10-year risk of CAD > 30%, or history of CVD or diabetes)
High*
(10-year risk 20%-30%)
Moderate†
(10-year risk 10%-20%)
Low‡
(10-year risk<10%)
<2.5
<3.0
<4.0
<5.0
<4
<5
<6
<7
<2.0
Target lipid values by level of risk
*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

8. European guidelines Goals for primary and secondary prevention of CHD:
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 <140/90mmHg
TC <5.0mmol/L (190mg/dL)
LDL-C <3.0mmol/L (115mg/dL)
Good glucose control in diabetes
To be achieved with changes in lifestyle and, if needed, by drug treatment
Most guidelines focus on 10 year risk of between 5 and 40% of the adult population.
Treatment recommendations are common throughout.
However, doctors may interpret the guidelines differently, they do not cover specific population groups and there is often a balance between specificity and sensitivity. A recent paper (Jones et al, Heart 2001; 85: 37-43) demonstrates that the revised Joint British Recommendations has the best combination of sensitivity and specificity.

9. 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 (<1.0mmol/L), raised triglycerides (>2.0mmol/L) or approaching next age category

10. European guidelines

11. Absolute coronary risk <20%
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 > 5.0mmol/L (190mg/dL)
Lifestyle advice with the goal of reducing
TC<5.0mmol/L (190mg/dL) and LDL-C <3.0mmol/L (115mg/dL)
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 <5.0mmol/L (190mg/dL) and LDL-C <3.0mmol/L (115mg/dL)
Maintain lifestyle advice with annual follow-up
TC >5.0mmol/L (190mg/dL) and LDL-C >3.0mmol/L (115mg/dL)
Maintain dietary advice with drug therapy
* High CHD risk >20% over 10 years or will exceed 20% if projected age 60 years

12. 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)

13. 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
For lower risk population
TC  < 6.0 mmol/l
LDL-C  < 4.0 mmol/l
TG  < 4.0 mmol/l

14. 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].
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.
For high risk  highest risk patients:
Monitor diet fortnightly for 6/52, then retest at 6-8/52 until satisfactory and stable response.
Ongoing follow-up for diet and possible drug intervention at 3-6/12.
General population: Lipids at least every 5 years – including risk factor assessment.

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

16. 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: ; Hoerger TJ et al. Am J Cardiol; 82: 61-5; EUROASPIRE. EHJ 2001; 22:
*relates to NCEP II ATP goals