1	Nurses Lipid Network: Current Canadian Lipid Therapy Guidelines Dr. Greg Searles Cardiologist, Saint John Regional Hospital May 26, 2007
2	Disclosure: Paid Talks For…
3	Greatest Lifetime Probability of Death is Due to Heart Disease
4	Leading causes of death: Canada
5	Evolution of Lipid Guidelines
6	Guidelines for the Management and Treatment of Dyslipidemia in Canada
7	Percentage of patients achieving NCEP LDL-C targets by risk group
8	LOWER IS BETTER in Secondary and Primary Prevention
9	What is “normal” Cholesterol
10	New Studies In Lipid Lowering
11	Aggressive Lipid-lowering Trials
12	More Effective LDL-C Lowering Improves Patient Outcomes (Prove-It) All-cause death or major cardiovascular events
13	TNT (Treating-to-New Targets) First Major Cardiovascular Event
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15	ASCOT Rationale
16	Study design
17	Reductions in Total and LDL Cholesterol
18	Primary End Point: Nonfatal MI and Fatal CHD
19	Number of Patients Needed to be Treated to Prevent Primary Outcome Primary Prevention WOSCOPS 45 AFCAPS/TexCAPS 50 ASCOT-LLA 90 Secondary Prevention 4S 30 CARE 33 LIPID 53 HPS 18
20	IVUS Studies
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22	The IVUS technique can detect angiographically ‘invisible’ atheroma
23	Prior Coronary IVUS Progression Trials
24	ASTEROID Study Atherosclerosis is usually viewed as a chronic progressive disease characterized by continuous accumulation of atheroma within the arterial wall. Intravascular ultrasound (IVUS) has emerged as the most sensitive and reliable measure of the progression of coronary disease. Prior angiographic and IVUS trials have shown reduced progression of coronary atherosclerosis with statin therapy, but not regression.
25	ASTEROID: Hypothesis and Objective Objective: To evaluate whether 24 months treatment with rosuvastatin 40 mg will result in regression of coronary atherosclerosis as measured by IVUS. Primary hypothesis: Very Intensive lipid lowering with 40 mg rosuvastatin will reduce coronary atheroma burden using two separate IVUS measures. Null hypothesis: Treatment will result in either progression or no change in disease burden.
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28	Lipid Values and Percent Change (n=349)
29	Adverse Events: Safety Population (n=507)
30	Dual Primary IVUS Efficacy Parameters
31	Relationship between LDL-C levels and change in percent atheroma volume for several IVUS trials
32	2006 Canadian Lipid Guidelines
33	2006 Canadian Lipid Guidelines Presented Spring 2006, published shortly after Available on-line at www.ccs. Copies available in room today Similar in past as to risk assessment, with revision of levels at which to treat and targets for some groups Also specific recommendations re. suggested intensity of pharmacologic therapy
34	Estimate 10-Year Risk for Women
35	Estimate 10-Year Risk for Women
36	Determine 10-Year Risk for Women
37	2006 Canadian Dyslipidemia Guidelines
38	2006 Canadian Dyslipidemia Guidelines
39	Lifestyle Modifications
40	Lifestyle Modifications
41	Drugs and Cholesterol
42	Pharmacologic therapy Drugs are more efficacious, better tolerated and safer than ever before Statins are the mainstay of therapy for most patients (some role for fibrates, niacin and cholesterol absorption inhibitors) There are well-known adverse effects with statin therapy, but with patient reporting of symptoms and routine monitoring of CK, ALT and AST, severe reactions should never occur
43	Statins HMG-CoA Reductase Inhibitors 85% of LDL is produced in the liver, only 15% or so comes from diet Work in liver to reduce production of cholesterol
44	Efficacy of statins: LDL-C response
45	HDL-C response
46	Ezetrol (Ezetimibe) Cholesterol absorption inhibitor
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48	Metabolic Syndrome: An Emerging Healthcare Epidemic
49	Metabolic Syndrome – Recognized as a Major Health Issue Metabolic syndrome: Is a clustering of risk factors for CVD Increases the risk of heart disease, stroke, diabetes and other CV diseases Increases the risk of death from CVD twofold and CV events (heart attack and stroke) threefold Increases risk of death from all causes even for people without diabetes Prevalence estimated at approximately 24% Expected to increase with aging population and increasing incidence of obesity
50	Metabolic Syndrome Defined Presence of 3 or more of the following risk determinants:
51	Metabolic Syndrome – Manage the Underlying Cause and Cluster of Risk Factors Metabolic syndrome: Underlying cause is unknown, but is closely related to insulin resistance Obesity, physical inactivity and genetic factors promote the development of insulin resistance Studies have shown the effectiveness of treating individual components of metabolic syndrome such as dyslipidemia and hypertension Management has 2 objectives: Reduce underlying cause Treat associated lipid and non-lipid risk factors Aggressive early management may have a significant impact on the prevention of type 2 diabetes and CVD
52	Conclusions Current lipid guidelines are up to date (for now) and are well regarded All patients should be be counselled re. lifestyle modifications where room exists for improvement For patients at high risk or well above target values, pharmacologic therapy is necessary Patients on lipid-lowering therapy need regular monitoring for adverse effects