وصف
Hyperlipidemia is a major risk factor for cardiovascular disease, which can lead to heart attack, stroke, and other serious health problems. There are two main types which include primary hyperlipidemia, which is caused by genetic factors, and secondary hyperlipidemia, which is caused by underlying health conditions such as diabetes, hypothyroidism, or kidney disease. Symptoms of hyperlipidemia are generally not noticeable, but it can be detected through a blood test called a lipid panel. Treatment typically involves lifestyle changes such as diet and exercise, and medications such as statins or fibrates may be prescribed to lower lipid levels.
ملخص
- **Risk Factors and Purpose of the Talk:**
- The talk will cover treatment strategies for hypolipidemia, focusing on two major guidelines: American Heart Association/American College of Cardiology (AHA/ACC) and European Society of Cardiology (ESC). The presentation is limited in scope, excluding detailed discussions of influencing trials, management of non-HDL cholesterol, triglycerides, ApoB, and familial hypolipidemia.
- **Guideline Focus and Primary vs. Secondary Prevention:**
- The discussion will primarily focus on the AHA guidelines (2018) and ESC guidelines (2019). Both primary (prevention before an event) and secondary (prevention after an event like a heart attack or stroke) prevention strategies will be addressed, along with relevant guidelines.
- **Screening and Assessment Questions for Primary Prevention:**
- Key questions to be addressed in primary prevention include who should be screened, at what age, how to assess risk, how to decide on treatment needs, treatment targets (LDL levels), and follow-up investigations.
- **Levels of Evidence and Recommendations:**
- Guideline recommendations are based on varying levels of evidence, ranging from case reports and expert opinions to meta-analyses and randomized controlled trials. Recommendations are classified as Class 1 (beneficial), Class 2 (uncertain benefit, subdivided into 2A and 2B), and Class 3 (not recommended).
- **American Heart Association (AHA) Guidelines: Screening and Assessment:**
- AHA guidelines recommend assessing atherosclerotic cardiovascular risk in all age groups. Screening is advised between ages 7-11 and 17-20, even without risk factors. Earlier screening (as young as age 2) is recommended with strong family history of early coronary artery disease or familial hypercholesterolemia.
- **AHA Guidelines: Treatment Initiation:**
- For individuals aged 20-39, statins should be considered if LDL levels exceed 160 mg/dL and there is a family history of premature atherosclerotic vascular disease. If LDL levels are over 190 mg/dL at any age, high-intensity statins are immediately recommended (Class 1).
- **AHA Guidelines: Risk Assessment for 40-75 Year Olds without Diabetes:**
- For individuals aged 40-75 without diabetes, LDL levels between 70 and 190 mg/dL require a 10-year atherosclerotic cardiovascular risk assessment. Low-risk individuals (less than 5% risk) should focus on lifestyle changes. High-risk individuals (greater than 20% risk) should start statins to reduce LDL levels by over 50% (Class 1).
- **AHA Guidelines: Borderline and Intermediate Risk:**
- Borderline risk (5-7.5% risk) necessitates evaluating additional risk enhancers and discussing moderate-intensity statins (Class 2B). Intermediate risk (7.5-20% risk) also necessitates evaluating additional risk enhancers. The LDL target should be a reduction of 30-49% compared to the original value.
- **Risk Enhancers for Atherosclerotic Cardiovascular Disease:**
- Risk enhancers include a family history of premature atherosclerotic vascular disease, primary hypercholesterolemia (LDL 160-189 mg/dL, non-HDL 190-219 mg/dL), high-risk ethnicities, metabolic syndrome, chronic kidney disease, and chronic inflammatory conditions. Elevated high-sensitivity C-reactive protein, lipoprotein(a), apolipoprotein B, and ankle-brachial index < 0.9 are also risk enhancers.
- **AHA Guidelines: 40-75 Year Olds with Diabetes:**
- AHA guidelines recommend moderate-intensity statins for all diabetic patients aged 40-75 (Class 1). High-intensity statins are considered for patients with additional diabetes-specific risk enhancers like long-standing diabetes, retinopathy, neuropathy, albuminuria, or ankle-brachial index < 0.9.
- **AHA Guidelines: Management Strategies Based on Risk:**
- High-intensity statins are generally recommended for very high-risk individuals under 75, aiming for >50% LDL reduction. Those over 75 can start with moderate-intensity or continue high-intensity statins if already on them. If LDL targets are not met with maximum statin doses, ezetimibe or PCSK9 inhibitors may be added. Individualized treatment plans are necessary.
- **Categorization of Patients for Atherosclerotic Cardiovascular Disease**
- There are three different groups of patients with very high risk, high risk and borderline risk of atherosclerotic cardiovascular disease. Those at high risk had events such as stroke, or acute MI. Those that are borderline are LDL levels between 70 and 189 and they need to assess the risk factor and then decide if medication is required. Those with more than 190, they are very high risk and should immediately start high intensity statins.
- **High vs. Moderate Intensity Statins:**
- High-intensity statins include atorvastatin 40-80 mg and rosuvastatin 20-40 mg. Moderate-intensity statins include atorvastatin 10 mg, rosuvastatin 5-10 mg, and simvastatin 20-40 mg. Low-intensity statins are generally not recommended.
- **Guideline Comparison: AHA vs. ESC Screening:**
- AHA guidelines recommend lipid profile screening for anyone with a family history of early coronary artery disease or between the ages of 7-11 and 17-21, even without risk factors. ESC guidelines recommend screening only for men over 40 and women over 50, or children with suspected familial hypercholesterolemia.
- **Guideline Comparison: Risk Assessment and LDL Targets:**
- AHA guidelines divide risk into low, intermediate, and high categories with defined percentage ranges. ESC guidelines have lower percentage thresholds for risk categories. ESC guidelines also provide specific LDL target numbers for each risk category (e.g., LDL < 116 mg/dL for low risk), whereas AHA guidelines focus solely on percentage reduction.
- **Practical Considerations: Monitoring and Follow-up:**
- Baseline ALT levels are not generally recommended. After starting statins, repeat ALT after three months, then annually if normal. Baseline CK can be done, but repeated only if the patient develops myalgia. Fasting lipid profiles are no longer mandatory for LDL targeting, but are still needed for triglyceride assessment.
- **Practical Considerations: When to Stop Statin:**
- Stop statins if myositis develops, or if creatinine kinase levels increase to more than 3-4 times normal. Repeat lipid profiles 4-12 weeks after starting statins and then every 3-12 months as needed.
- **Take-Home Messages:**
- Some recommendations are clear and universally accepted (e.g., high-intensity statins for LDL > 190 mg/dL). In areas with less clear guidelines, benefits, risks (e.g., liver injury, hyperglycemia), patient compliance, and individual circumstances should be considered. Hypolipidemia is just one of many risk factors; a holistic approach addressing other factors (diabetes, smoking, etc.) is crucial.
نموذج شهادة
حول المتحدثين
دكتور رامكومار سوندارابيرومال
رئيس قسم الطب الباطني وأخصائي الطب الباطني، مستشفى زليخة، دبي
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