Management%20of%20Hyperlipidemia%20Clinical%20Management%20Course%201/30/06 - PowerPoint PPT Presentation

View by Category
About This Presentation
Title:

Management%20of%20Hyperlipidemia%20Clinical%20Management%20Course%201/30/06

Description:

Diabetes: CHD risk equivalent. Framingham projections of ... Stress: HDL, diabetes, & diet/exercise. AHA step II is standard diet. Statins as primary therapy ... – PowerPoint PPT presentation

Number of Views:404
Avg rating:3.0/5.0
Slides: 20
Provided by: desktoppu79
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Management%20of%20Hyperlipidemia%20Clinical%20Management%20Course%201/30/06


1
Management of HyperlipidemiaClinical Management
Course1/30/06

James M. May, M.D. Department of
Medicine Vanderbilt University School of Medicine
2
GOALS
  • Rationale for treatment
  • NCEP guidelines
  • Diet therapy
  • Drug therapy

3
Summary of Effects of Lipid Lowering on Coronary
Events in Recent Statin Trials
Nonfatal MI/CHD death
CHD death
All-cause mortality
LDL-C
TC
HDL-C

1o prevention
2o prevention
2o prevention
N number enrolled.
4
Risk of increased LDL and CHD 30 change in
30 change in CHD
Grundy, SM et al. . Circulation. 110227-239,
2004.
5
Event Reduction and LDL At What LDL Level Does
Risk Go to Zero?
Primary Prevention
Secondary Prevention
OKeefe, JH, et al. Am. J. Cardiol. 432142-2146,
2004.
6
Relation Between CHD Events and LDL-C in Recent
Statin Trials
4S-PI
30
2 Prevention
25
4S-Rx
20
with
LIPID-Rx
15
LIPID-PI
1 Prevention
CHD event
CARE-Rx
CARE-PI
WOSCOPS-PI
10
AFCAPS/TexCAPS-PI
5
WOSCOPS-Rx
AFCAPS/TexCAPS-Rx
0
90
110
130
150
170
190
210
Mean LDL-C level at follow-up (mg/dL)
PIplacebo Rxtreatment Shepherd J et al. N
Engl J Med. 19953331301-1307. 4S Study Group.
Lancet. 19953451274-1275. Sacks FM et al. N
Engl J Med. 19963351001-1009. Downs JR et al.
JAMA. 19982791615-1622. Tonkin A. Presented at
AHA Scientific Sessions, 1997.
7
New Features of NCEP Guidelines ATP III
  • LDL remains primary treatment goal
  • Diabetes CHD risk equivalent
  • Framingham projections of 10-year CHD risk
  • Identify certain patients with multiple risk
    factors for more intensive treatment
  • HDL cholesterol lt40 mg/dL
  • Raised from lt35 mg/dL
  • Multiple metabolic risk factors (metabolic
    syndrome)

8
The Insulin Resistance Syndrome
Clinical Manifestations
Central obesity Glucose intolerance Atherosclerosi
s Hypertension Polycystic ovary syndrome
Biochemical Abnormalities
Lipid
Carbohydrate
Fibrinolysis
Insulin resistance Hyperinsulinemia
High TG Low HDL-C Small, dense LDL particles
Increased PAI-1
9
Laboratory Fasting Lipid Profile
  • 12-h fast
  • Draw total cholesterol, HDL and triglycerides
  • Calculate LDL TC HDL TG/5
  • (accurate up to TG of 400 mg/dl)
  • If TG gt 400, measure LDL directly following
    ultracentrifugation.

10
(No Transcript)
11
Causes of Secondary Dyslipidemia
  • Diabetes
  • Hypothyroidism
  • Obstructive liver disease
  • Chronic renal failure
  • Drugs Raise TG, LDL and lower HDL
    progestins anabolic steroids thiazides beta-b
    lockers corticosteroids

12
LDL Cholesterol Goals and Levels for Therapeutic
Lifestyle Changes (TLC) and Drug Therapy
Risk Category LDL Level for TLC (mg/dL) LDL Level for Drug Therapy (mg/dL) LDL Goal (mg/dL)
01 Risk Factor ?160 ?190 (160189 drug optional) lt160
2 Risk Factors (10-year risk ?20) ?130 ?130 (10-year risk 1020) ?160 (10-year risk lt10) lt130
CHD or CHD Risk Equivalents(10-year risk gt20) ?100 ?130 (100129 drug optional) lt100 (lt70 if very high risk patient)
13
Major CHD Risk Factors NCEP-ATP III
  • Positive risk factors
  • Age
  • Male ³45
  • Female ³55
  • Family Hx of premature CHD in 1st-degree
    relative
  • Male relative ltage 55
  • Female relative ltage 65
  • Cigarette smoking
  • Hypertension BP ³140/90 mm Hg or on
    antihypertensive
  • Low HDL-C lt40 mg/dL
  • Negative risk factor
  • HDL-C gt60 mg/dL

or having premature menopause without
ERT. Expert Panel on Detection, Evaluation, and
Treatment ofHigh Blood Cholesterol in Adults.
JAMA. 2852486-2496, 2001.
14
Therapeutic Lifestyle Changes
  • TLC Diet
  • Previous Step II Diet)
  • Saturated fats lt7 of total calories
  • Dietary cholesterol lt200 mg per day
  • LDL-lowering therapeutic options
  • Plant stanols/sterols (2 g/day)
  • Viscous (soluble) fiber (1025 g/day)
  • Weight reduction
  • Increased physical activity

15
70
60
50
HDL (mg/dl)
40
1 mg/dl increase 450 Calories
30
r 0.987, p lt 0.001
20
0
0
1000
2000
3000
4000
Exercise Calories/Week
16
Effects of Drug Therapy and Diet on Lipids
Plt0.01
TC (mg/dL)


1 Prevention (n40)
2 Prevention (n53)
84 reached NCEP LDL target (lt130 mg/dL) 63
reached NCEP LDL-C target (lt100 mg/dL) Barnard
RJ, et al. Exerpta Medica Brief Reports.
19971112-1114.
17
Mechanism of action of Lipid-Lowering Agents on
Lipoproteins
Agents LDL-C HDL-C
VLDL-C Resins 15-40
(modest ) secretion Niacin
10-15 30-40 30-40 Fibric
acids (small ) 10-15
50 Statins 25-50 5-8
20-50 Ezetimibe 18-20
5-8 15-20
18
The CURVES Trial A Comparison of LDL-C Lowering
Among Statins
0
-10


-20





Mean LDL-C reduction
-30




-40


-50
-60
0
10
20
30
40
50
60
70
80
90
Dose range (mg)
Significantly less than atorvastatin 10 mg
(Plt0.02). Significantly less than atorvastatin
20 mg (Plt0.01). Significantly greater than
mg-equivalent dose of comparative agents
(P?0.01). Jones P et al. Am J Cardiol.
199881582-587.
19
Atorvastatin Dose-Response Relationship in
Primary Hypercholesterolemia
0
-10
-20
Mean in LDL-C
-30
10 mg
-40
20 mg
40 mg
-50
80 mg
-60
-70
Baseline
Week 2
Week 4
Last DB visit
Plt0.05. DBdouble blind.
Nawrocki JW et al. Arterioscler Thromb Vasc Biol.
199515678-682.
20
Drug Therapy in Primary Prevention
21
SUMMARY and CONCLUSIONS
  • LDL Lowering remains primary
  • Stress HDL, diabetes, diet/exercise
  • AHA step II is standard diet
  • Statins as primary therapy
  • Treat triglycerides, low HDL, especially if part
    of the metabolic syndrome

22
1
Patient EL 52 yo White Female
Patient referred for new onset diabetes and
hyper- lipidemia. Diagnosis of diabetes was made
on a routine exam, the patient complained only
of mild fatigue. She denies weight loss, has
nocturia x1, but no visual symptoms. She is on
no special diet and gets no regular
exercise. PMH Hypertension for 5 years, no
smoking ROS post-menopausal, no chest pain or
dyspnea FH for late onset diabetes in her
mother, and a cholesterol problem in a sister
23
2
  • Medications
  • Cholestyramine, 4 g BID
  • Glyburide, 5 mg BID
  • Premarin, 0.625 mg q d
  • Hydrochlorothiazide, 25 mg qd
  • Physical Exam
  • Wt 210 lbs. BP 135/82
  • Exam significant only for obesity with abdominal
  • fat distribution. No xanthomata or acanthosis.
  • Normal circulatory and neurologic exams.

24
3
Initial Fasting Laboratory T. Cholesterol 284
mg/dL Triglyceride 802 mg/dL HDL 35
mg/dL Blood glucose 244 mg/dL Hgb A1C 9.6
25
4
  • Recommendations
  • ADA/AHA Step 1 diet instruction
  • Home glucose monitoring BID
  • Exercise program, 30 min x 3-5 times /wk
  • D/C cholestyramine
  • Continue other meds
  • Return to clinic 3 months

26
5
3 Month Return visit Feels better. Home
glucoses 150-200 mg/dL Wt. 215 lbs.
Laboratory T. Cholesterol 262
mg/dL Triglyceride 594 mg/dL ?-Quant LDL 154
mg/dL HDL 36 mg/dL Hgb A1C 8.4
27
  • Recommendations
  • Stress
  • Diet ADA 1800 Cal. diet
  • Exercise 30 min x 3-5 times /wk
  • Weight loss
  • Rx Metformin, 500 mg BID
  • Return to clinic 3 months

6
28
7
6 Month Return visit Home glucoses 100-140
mg/dL Wt. 205 lbs., BP 132/84
Laboratory T. Cholesterol 255
mg/dL Triglyceride 325 mg/dL Calc. LDL 150
mg/dL HDL 40 mg/dL Hgb A1C 7.2
29
  • Recommendation
  • Rx atorvastatin, 10 mg qd
  • Return to clinic 3 months

8
30
9
9 Month Return visit Home glucoses 110-150
mg/dL Wt. 204 lbs., BP 124/80
Laboratory T. Cholesterol 192
mg/dL Triglyceride 252 mg/dL Calc. LDL 98
mg/dL HDL 44 mg/dL Hgb A1C 7.4
About PowerShow.com