curriculum vitae - papdi. san pin 2019 (materi...stage 3 or 4 ckd, or hefh –history of premature...
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CURRICULUM VITAE
SALLY AMAN NASUTION, MD, FINASIM, FACP
- Born in Medan, August 8th 1967
- Internist – Cardiologist
- Faculty Member Division of Cardiology, Department of Internal Medicine at Faculty of Medicine University of
Indonesia, Jakarta
- Head of Intensive Coronary Care Unit (ICCU), Integrated Cardiac Services Cipto Mangunkusumo National General
Hospital Jakarta
- President of the Indonesian Society of Internal Medicine
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Updates in Dyslipidemia Guidelines:
How to apply in clinical practice
Dr dr SALLY AMAN NASUTION, SpPD-KKV, FINASIM, FACP
Division of Cardiology Department of Internal Medicine
Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo National General Hospital
Jakarta
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Prevalence of raised lipid levels
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LDL-Cholesterol and Blood Presssure
Sub-analysis DYSIS (Dyslipidemia International Study) II in Indonesia
% Patients at LDL-C goals Recommended by the 2004 updated NCEP ATP III* guidelines
% of Patients at LDL-C goals recommended by 2004 updated NCEP ATP III* guidelines
Indonesia patients had the lowest LDL-C attainment rate (31.3 – 52.7%)
Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.
Management of Hypercholesterolaemia remains Sub-optimal: Pan-Asian CEPHEUS
Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.
Attainment of LDL-C
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https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019
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https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019Cannon B. Nature 2013; 493: S2 – S3
American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 201713
ASCVD Risk Categories and LDL-C Treatment Goals
Risk category Risk factors/10-year riskTreatment goals
LDL-C
(mg/dL)
Non-HDL-C
(mg/dL)
Apo B
(mg/dL)
Extreme risk
– Progressive ASCVD including unstable angina in individuals after achieving an LDL-C <70 mg/dL
– Established clinical cardiovascular disease in individuals with DM, stage 3 or 4 CKD, or HeFH
– History of premature ASCVD (<55 male, <65 female)
<55 <80 <70
Very high risk
– Established or recent hospitalization for ACS, coronary, carotid or peripheral vascular disease, 10-year risk >20%
– DM or stage 3 or 4 CKD with 1 or more risk factor(s)
– HeFH
<70 <100 <80
High risk– ≥2 risk factors and 10-year risk 10%-20% – DM or stage 3 or 4 CKD with no other risk factors
<100 <130 <90
Moderate risk ≤2 risk factors and 10-year risk <10% <100 <130 <90
Low risk 0 risk factors <130 <160 NR
Barter PJ, et al. J Intern Med. 2006;259:247-258; Boekholdt SM, et al. J Am Coll Cardiol. 2014;64(5):485-494; Brunzell JD, et al. Diabetes Care. 2008;31:811-822; Cannon CP, et al. N Engl J Med. 2015;372(25):2387-2397; Grundy SM, et al. Circulation. 2004;110:227-239; Heart Protection Study Collaborative Group. Lancet. 2002;360:7-22; Jellinger P, Handelsman Y, Rosenblit P, et al. Endocr Practice. 2017;23(4):479-497; Lloyd-Jones DM, et al. Am J Cardiol. 2004;94:20-24; McClelland RL, et al. J Am Coll Cardiol. 2015;66(15):1643-1653; NHLBI. NIH Publication No. 02-5215. 2002; Ridker PM, J Am Coll Cardiol. 2005;45:1644-1648; Ridker PM, et al. JAMA. 2007;297(6):611-619; Sever PS, et al. Lancet. 2003;361:1149-1158; Shepherd J, et al. Lancet. 2002;360:1623-1630; Smith SC Jr, et al. Circulation. 2006;113:2363-2372; Stevens RJ, et al. Clin Sci. 2001;101(6):671-679; Stone NJ. Am J Med. 1996;101:4A40S-48S; Weiner DE, et al. J Am Soc Nephrol. 2004;15(5):1307-1315.
Abbreviations: ACS, acute coronary syndrome; apo, apolipoprotein; ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; DM, diabetes mellitus; HeFH, heterozygous familial hypercholesterolemia; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NR, not recommended.
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Heart SCORE (Systematic Coronary Risk Estimation)
1 mmol/L = 38.67 mg/dLEuropean Heart Journal (2019) 00, 178
• Social deprivation and psychosocial stress set the scene for increased risk. For those at moderate risk, other factors—including metabolic factors such as increased ApoB, Lp(a), TGs, or C-reactive protein; the presence of albuminuria; the presence of atherosclerotic plaque in the carotid or femoral arteries; or the coronary artery calcium (CAC) score—may improve risk classification
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Factors modifying heart SCORE
European Heart Journal (2019) 00, 178
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Risk categories
aTarget organ damage is defined as microalbuminuria, retinopathy, or neuropathy
European Heart Journal (2019) 00, 178
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Intervention strategies as a function of total cardiovascular risk & untreated LDL-C levels
European Heart Journal (2019) 00, 178
dThe term ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C-lowering medication.
In people who are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based on the average LDL-C-lowering efficacy of the given medication or combination of medications.
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Recommendations for treatment goals for LDL-C
European Heart Journal (2019) 00, 178
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Treatment goal for LDL-C
European Heart Journal (2019) 00, 178
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Treatment algorithm for pharmacological LDL-C lowering
European Heart Journal (2019) 00, 178
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Recommendations for the treatment of dyslipidaemiasin metabolic syndrome & DM
European Heart Journal (2019) 00, 178
Challenges in dyslipidemia management
American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 2017
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Patients(%) reporting statin non-adherence behaviors in the last 12 months by statin PDC (proportion of days covered) level
Note: Weighted for sampling proportions; p<0.05
Fung V, GraetzI, Reed M, Jaffe MG (2018) Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk. PLoS ONE 13(2): e0191817.
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Doubling statin dose
Statin intolerance• 20% of individuals with a clinical indication for statin therapy are unable to take a daily statin because of some
degree of intolerance, and 40–75% of patients discontinue their statin therapy within 1–2 years after initiation
Toth PP, et al. Management of Statin Intolerance in 2018: Still More Questions than Answers. Am J Cardiovasc Drugs (2018) 18:157–
17326
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Further improvement from what NLA proposed
Rosenson RS, et al. Cardiovasc Drugs Ther (2017) 31:179–186
How to apply in clinical practice
CASE
Patient : M.K.
Profile : 43 years old male
BMI : 29.7 kg/m2
BP : 140/75 mm Hg
HR : 65 bpm
Medical History:
Type 2 Diabetes Mellitus with microalbuminuria
Previous MI last month
Heavy smoker
Lab results:
TC : 210 mg/dl
LDL :135 mg/dl
HDL : 38 mg/dl
TG : 500 mg/dl
Current medication:
Chinese herbal medicine
He comes to your clinic for follow up
How would you manage this patient?
• During anamnesis, what other questions would you like to ask? Why?
• Is there any other lab tests would you order? Why?• Would you change his current medication? Why?