esc/eas 2011 guidelines for the management of dyslipidemias

1

ESC/EAS 2011 GuidelinesESC/EAS 2011 Guidelinesfor the management of for the management of dyslipidemias dyslipidemias

2564-12-2011

2

European Heart Journal Advance Access Published June 28, 2011

3

Classes of recommendations

Classes of recommendations Definition Suggested wording to use

Class I‘Everybody agrees’

Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective.

Is recommended/is indicated

Class II‘Not everybody agrees’

Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure.

Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy. Should be considered

Class IIb Usefulness/efficacy is less well established by evidence/opinion. May be considered

Class III‘Everybody agrees’

Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful.

Is not recommended

Classes of recommendations

4

Levels of evidence

Levels of evidence

Level of Evidence AData derived from multiple randomizedclinical trialsor meta-analyses.

Level of Evidence BData derived from single randomizedclinical trialsor large non-randomized studies.

Level of Evidence C Consensus of opinion of the experts and/or small studies, retrospective studies, registries.

5

Risque de maladies cardiovasculaires fatalesRisque à dix ans de maladies cardiovasculaires fatales pour la Belgique en fonction du sexe, de l’âge,

de la pression systolique, du cholestérol et du statut tabagique

Femme Homme

6

This chart may be used to show younger people at low absolute risk that, relative to others in their age group, their risk may be many times higher than necessary. This may help to motivate decisions about avoidance of smoking, healthy nutrition and exercise, as well as flagging those who may become candidates for medication.

Please note that this chart shows RELATIVE not absolute risk. The risks are RELATIVE to 1 in the bottom left. Thus a person in the top right hand box has a risk that is 12 times higher than a person in the bottom left.

Relative Risk Chart < 40y

ESC 2007

8

Recommendations for treatment targets for LDL-C

Recommendations Classa Levelb Refc

In patients at VERY HIGH CV risk (established CVD, type 2 diabetes, type 1 diabetes with target organ damage, moderate to severe CKD or a SCORE level ≥10%) the LDL-C goal is <1.8 mmol/L (less than ~70 mg/dL) and/or ≥ 50% LDL-C reduction when target level cannot be reached.

I A 15,32,33

aClass of recommendation. bLevel of evidence.cReferences.

CKD= chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; LDL-C = low-density lipoprotein-cholesterol

9

Recommendations for treatment targets for LDL-C

Recommendations Classa Levelb Refc

In patients at HIGH CV risk (markedly elevated single risk factors, a SCORE level ≥5 to <10%) an LDL-C goal <2.5 mmol/L (less than ~100 mg/dL) should be considered.

IIa A 15,16,17

In subjects at MODERATE risk (SCORE level >1 to ≤5%) an LDL-C goal < 3.0 mmol/L (less than ~115 mg/dL) should be considered.

IIa C -

aClass of recommendation. bLevel of evidence.cReferences.

CKD= chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; LDL-C = low-density lipoprotein-cholesterol

10

*In patients with MI, statin therapy should be considered irrespective of LDL-C levels.aClass of recommendation.bLevel of evidence.

Intervention strategies as a function of total CV risk and LDL-C level

CV = cardiovascular; LDL-C = low-density lipoprotein-cholesterol; MI = myocardial infarction.

TOTAL CV risk (SCORE) %

LDL-C levels<70 mg/dL

<1.8 mmol/L70 to <100 mg/dL

1.8 to <2.5 mmol/L100 to <155 mg/dL2.5 to < 4.0 mmol/L

155 to < 190 mg/dL4.0 to < 4.9 mmol/L

>190 mg/dL>4.9 mmol/L

<1 No lipid intervention

No lipid intervention

Lifestyle intervention


Lifestyle intervention, consider drug if uncontrolled

Classa/Levelb I/C I/C I/C I/C IIa/A

≥ 1 to < 5 Lifestyle intervention





Classa/Levelb I/C I/C IIa/A IIa/A I/A

>5 to <10, or high risk

Lifestyle intervention, consider drug*


Lifestyle intervention, and immediate drug intervention



Classa/Levelb IIa/A IIa/A IIa/A I/A I/A

≥10 or very high risk






Classa/Levelb IIa/A IIa/A I/A I/A I/A

11

Addendum II. Practical approach to reach LDL-C goal

Percentage reduction of LDL-C requested to achieve goals as a function of the starting value

Starting LDL-C % Reduction to reach LDL-C

mmol/L ~mg/mL <1.8 mmol/L(~70mg/dL)

<2.5 mmol/L(~100mg/dL)

<3 mmol/L(~115mg/dL)

>6.2 >240 >70 >60 >55

5.2-6.2 200-240 65-70 50-60 40-55

4.4-5.2 170-200 60-65 40-50 30-45

3.9-4.4 150-170 55-60 35-40 25-30

3.4-3.9 130-150 45-55 25-35 10-25

2.9-3.4 110-130 35-45 10-25 <10

2.3-2.9 90-110 22-35 <10 -

1.8-2.3 70-90 <22 - -

12

LDL-

C

13

LDL-C: Percentage Change from Baseline at Week 6 (n=2240)

LS m

ean

% c

hang

e fr

om b

asel

ine

-60

-50

-40

-30

-20

-10

010 20 40 80

Dose (mg)

Log scale

rosuvastatin atorvastatin simvastatin pravastatin

Jones et al. Am J Cardiol 2003: 93: 152-160

14

SCORE2011

WomenHighRisk

15

0

2

4

6

8

10

12

10 20 40 80Dose (mg)

LS m

ean

% c

hang

e fr

om b

asel

ine

Log scale

HDL-C: Percentage Change from Baseline at Week 6 (n= 2240)

Jones et al. Am J Cardiol 2003: 93: 152-160

rosuvastatin atorvastatin simvastatin pravastatin

16

TauxHDL-C, mg/dl 30 38 46 54 62 70Femme x 1,8 x 1,5 x 1,2 x 1 x 0,8 x 0,7Homme x 1,3 x 1,1 x 1 x 0,9 x 0,8 x 0,7

l’effet du cholestérol associé aux lipoprotéinesde haute densité (HDL-C) sur le risque CV global

17

Statins are among the most studied drugs in CV prevention, and dealing with single studies is beyond the scope of the present guidelines.

A number of large-scale clinical trials have demonstrated that statins substantially reduce CV morbidity and mortality in both primary and secondary prevention. Statins have also been shown to slow the progression or even promote regression of coronary atherosclerosis.

StatinsEfficacy in clinical studies

18

Current available evidence suggests that the clinical benefit is largely independent of the type of statin but depends on the extent of LDL-C lowering; therefore, the type of statin used should reflect the degree of LDL-C reduction that is required to reach the target LDL-C in a given patient. More details on this are provided in Addendum II to these guidelines.

Statins Meta-analyses

19

The recent finding that the incidence of diabetes may increase with statins should not discourage institution of treatment; the absolute reduction in the risk of CVD in high risk patients outweighs the possible adverse effects of a very small increase in the incidenceof diabetes.

StatinsMeta-analyses - Type 2 Diabetes

20

Cholesterol absorption inhibitorsEfficacy in clinical studies

Ezetimibe can be used as second-line therapy in association with statins when the therapeutic target is not achieved at maximal tolerated statin dose or in patients intolerant of statins or with contraindications to these drugs.

21

Management of hypertriglyceridaemiaPharmacological therapy

As statins have significant effects on mortality as well as most CVD outcome parameters, these drugs are the first choice to reduce both total CVD risk and moderately elevated TG levels. More potent statins (atorvastatin, rosuvastatin, and pitavastatin) demonstrate a robust lowering of TG levels, especially at high doses and in patients with elevated TG.

23

Le risque sera également plus élevé qu’indiquédans les tableaux pour :

• Les personnes socialement défavorisées ; les privations induisent denombreux autres facteurs de risque.• Les sujets sédentaires et ceux présentant une obésité abdominale ;ces caractéristiques déterminent de nombreux autres aspects desrisques énumérés ci-dessous.• Les personnes diabétiques : une nouvelle analyse de la base de donnéesSCORE indique que les personnes présentant un diabète avéré ont unrisque nettement plus élevé ; cinq fois plus élevé pour les femmes ettrois fois plus élevé pour les hommes.• Les personnes ayant un faible taux d’HDL-C ou d’apolipoprotéine A1(apo A1), des taux élevés de TG, de fibrinogène, d’homocystéine,d’ apolipoprotéine B (apo B) et de lipoprotéine(a) (Lp(a)), une hypercholestérolémie familiale (HF) ou un taux élevé de hs-CRP ;ces facteurs indiquent un niveau de risque accru pour les deux sexes, pour toutes les tranches d’âge et pour tous les niveaux de risque.

24

• Les personnes asymptomatiques présentant des signes précliniques

d’athérosclérose, par exemple la présence de plaques ou un

épaississement de l’intima–média carotidienne détecté lors d’une

échographie carotidienne.

• Les personnes atteintes d’insuffisance rénale.

• Les personnes ayant des antécédents familiaux de MCV précoce dont

on considère qu’ils multiplient le risque par 1,7 chez les femmes et par

2,0 chez les hommes.

• À l’inverse, le risque peut être inférieur à celui indiqué chez les

personnes ayant des taux très élevés d’HDL-C ou des antécédents

familiaux de longévité.

25

Risk factor management in coronary Risk factor management in coronary patients – results from a European patients – results from a European

wide survey wide survey EUROASPIRE IIIEUROASPIRE III

Professor David A Woodon behalf of the EUROASPIRE Investigators

26

0

10

20

30

40

50

60

70

80

90

100

Survey 1 24,9 59,3 47,8 25,6 25,6 25,8 23,0

Survey 2 25,2 59,4 48,1 24,8 27,8 26,1 21,2

Survey 3 23,1 60,9 40,6 28,3 49,8 9,9 12,0

Women Mean ageAge < 60

yrs CABG PTCA AMI ISCHAEMIA

Distribution of Age, Gender and Diagnostic Category

(%) (%) (%) (%) (%) (%)(years)

Gender Age Diagnostic category

27

Prevalence of Smoking*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 22,0% 12,8% 25,0% 16,8% 23,3% 18,6% 31,8% 13,3% 20,3%

Survey 2 19,3% 21,6% 24,2% 16,8% 30,1% 15,1% 28,3% 14,6% 21,2%

Survey 3 22,2% 16,8% 24,8% 18,4% 18,3% 14,0% 15,1% 12,0% 18,2%

Czech Rep.

Finland France Germany Hungary ItalyNether-lands

Slovenia ALL

P=0.64

S2 vs. S1 : P=0.83S3 vs. S2 : P=0.37S3 vs. S1 : P=0.48

* Self-reported smoking or CO in breath > 10 ppm

28

Prevalence of Overweight*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 81,3% 79,3% 75,8% 82,4% 71,0% 81,4% 70,5% 73,8% 76,8%

Survey 2 87,0% 78,4% 79,7% 82,7% 79,2% 71,7% 78,5% 78,7% 79,9%

Survey 3 84,6% 77,2% 77,1% 85,3% 85,6% 81,3% 78,9% 84,4% 82,7%

Czech Rep.


Slovenia ALL

P=0.04


* Body mass index ≥ 25 kg/m²

29

Prevalence of Obesity*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 31,4% 29,6% 33,4% 23,0% 23,3% 22,4% 18,9% 19,2% 25,0%

Survey 2 40,1% 33,6% 37,5% 30,6% 36,8% 23,6% 28,2% 28,0% 32,6%

Survey 3 37,9% 26,4% 36,8% 43,1% 49,3% 29,4% 26,5% 39,1% 38,0%

Czech Rep.


Slovenia ALL

P=0.0006


* Body mass index ≥ 30 kg/m²

30

Prevalence of Raised Blood Pressure (1)*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 60,1% 56,1% 48,4% 58,4% 50,6% 55,3% 54,0% 55,1% 54,6%

Survey 2 46,9% 52,0% 55,5% 67,0% 40,4% 50,8% 54,4% 62,8% 54,0%

Survey 3 62,5% 67,1% 48,1% 50,9% 46,3% 60,5% 59,6% 55,1% 55,2%

Czech Rep.

Finland France Germany Hungary ItalyNether lands

Slovenia ALL

P=0.79


* SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg

31

Therapeutic Control of Blood Pressure*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 34,4% 39,1% 47,9% 39,7% 44,0% 41,0% 43,3% 37,7% 41,0%

Survey 2 47,2% 43,4% 36,7% 29,1% 55,0% 45,7% 43,5% 31,1% 41,2%

Survey 3 30,1% 29,1% 44,1% 45,2% 44,1% 34,8% 35,3% 41,4% 38,7%

Czech Rep. Finland France Germany Hungary Italy Netherlands Slovenia ALL

P=0.57


* SBP/DBP < 140/90 mmHg for non-diabetics or < 130/80 mmHg for diabetics

32

Prevalence of Raised Total Cholesterol*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 94,2% 93,7% 91,5% 94,3% 97,4% 96,9% 97,1% 95,5% 94,5%

Survey 2 86,1% 63,8% 79,3% 83,4% 54,5% 72,5% 66,7% 82,2% 76,7%

Survey 3 47,1% 28,2% 40,8% 49,4% 57,0% 48,8% 33,1% 41,8% 46,2%

Czech Rep.


Slovenia ALL

P<0.0001S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001

* Total cholesterol ≥ 4.5 mmol/L

33

Therapeutic Control of Total Cholesterol*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 4,6% 6,8% 14,2% 9,6% 4,8% 0,0% 7,9% 8,1% 8,4%

Survey 2 17,3% 46,2% 23,4% 20,5% 31,4% 31,1% 40,0% 22,0% 28,7%

Survey 3 55,8% 72,6% 62,4% 54,0% 48,7% 53,2% 68,9% 60,3% 57,3%

Czech Rep.


Slovenia ALL


* Total cholesterol < 4.5 mmol/L

34

Prevalence of Diabetes*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 21,8% 15,4% 16,7% 13,5% 26,6% 17,2% 10,3% 17,4% 17,4%

Survey 2 21,5% 18,7% 27,5% 13,5% 21,1% 21,8% 13,2% 23,8% 20,1%

Survey 3 30,8% 19,1% 34,2% 22,6% 44,8% 21,7% 20,6% 18,8% 28,0%

Czech Rep.


Slovenia ALL

P=0.004


* Self-reported history of diagnosed diabetes

35

Therapeutic Control of Diabetes*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 38,7% 34,4% 15,1% 71,4% 48,6% 39,1%

Survey 2 29,9% 30,8% 20,4% 26,9% 42,3% 53,2% 70,7% 72,7% 42,1%

Survey 3 17,2% 40,0% 27,8% 18,7% 25,4% 10,2% 33,3% 20,0% 21,5%

Czech Rep.


Slovenia ALL

P=0.04


* Fasting glucose < 7 mmol/L in patients with history of diabetes

36

Medication Use: Antiplatelets

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 85,2% 82,2% 82,1% 82,9% 72,0% 86,1% 77,5% 79,4% 80,8%

Survey 2 87,6% 81,9% 85,7% 86,3% 75,1% 91,5% 81,0% 82,3% 83,6%

Survey 3 92,5% 96,4% 98,1% 91,8% 86,1% 98,0% 95,7% 92,4% 93,2%

Czech Rep.


Slovenia ALL

P<0.0001

S2 vs. S1 : P=0.29S3 vs. S2 : P=0.0002S3 vs. S1 : P<0.0001

37

Medication Use: Beta-Blockers

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 65,3% 77,8% 56,3% 43,6% 57,7% 49,2% 46,8% 51,8% 56,0%

Survey 2 73,7% 87,9% 60,4% 68,1% 84,3% 61,2% 48,2% 65,7% 69,0%

Survey 3 91,3% 95,8% 74,4% 85,0% 85,9% 87,6% 74,6% 87,0% 85,5%

Czech Rep.


Slovenia ALL

P<0.0001S2 vs. S1 : P=0.001S3 vs. S2 : P=0.0002S3 vs. S1 : P<0.0001

38

Medication Use: ACE Inhibitors & Angiotensin II RA

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 28,1% 17,3% 33,8% 31,4% 46,3% 31,8% 27,4% 31,2% 31,0%

Survey 2 47,1% 31,0% 43,7% 50,6% 58,6% 53,5% 42,9% 63,0% 49,2%

Survey 3 76,1% 59,3% 78,9% 72,8% 80,6% 70,9% 66,5% 83,0% 74,6%

Czech Rep. Finland France Germany Hungary ItalyNether-

landsSlovenia ALL

P<0.0001

S2 vs. S1 : P<0.0001S3 vs. S2 : P<0.0001S3 vs. S1 : P<0.0001

39

Medication Use: Statins

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 6,3% 34,9% 20,2% 31,1% 6,7% 6,8% 14,0% 23,2% 18,1%

Survey 2 38,8% 62,6% 61,0% 65,6% 45,2% 57,0% 75,1% 56,3% 57,3%

Survey 3 88,1% 95,2% 89,1% 85,4% 76,7% 90,0% 91,4% 90,1% 87,0%

Czech Rep. Finland France Germany Hungary ItalyNether-

landsSlovenia ALL


40

Medication Use: Diuretics

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Survey 1 15,7% 12,0% 18,7% 14,5% 15,9% 17,6% 13,7% 14,3% 15,3%

Survey 2 22,7% 12,4% 13,2% 32,7% 23,9% 16,3% 12,6% 14,3% 18,8%

Survey 3 36,3% 10,8% 19,2% 33,8% 52,6% 20,4% 23,2% 29,1% 31,1%

Czech Rep. Finland France Germany Hungary Italy Nether-lands Slovenia ALL

P=0.006


41

No change in blood pressure control despite increased use of anti-hypertensive medications

61% above therapeutic target (BP < 140/90 mmHg)

Continuing improvement in lipid control with increased use of statins

42% above the 2003 therapeutic target (TC < 4.5 mmol/l)

Conclusions

42ESH - ESC Guidelines, J Hypertens 2003ESH - ESC Guidelines, J Hypertens 2003

-BP < 140/90 mmHg in all hypertensive patients

< 130/80 mmHg in hypertensive patients with diabetes or renal disease

-Control of all cardiovascular risk factors

-BP < 140/90 mmHg in all hypertensive patients

< 130/80 mmHg in hypertensive patients with diabetes or renal disease

-Control of all cardiovascular risk factors

Goals of treatmentGoals of treatment

43

Sympathetic nervous systemRenin-angiotensin systemTotal body sodium

Sympathetic nervous systemRenin-angiotensin systemTotal body sodium

Patient 1 Patient 2 Patient 3Patient 1 Patient 2 Patient 3

44

Percentage of patients with normal blood pressure


Drug ADrug A

0 20 40 60 801000 20 40 60 80100

%%Drugs CDrugs C

Drug BDrug B

45

Achieved BP: <140/90 mmHg Achieved BP: <140/90 mmHg

Dickerson et al, Lancet, 1999Dickerson et al, Lancet, 1999

During monotherapy(diuretic, -blocker, ACE inhibitor or Ca antagonist)

During monotherapy(diuretic, -blocker, ACE inhibitor or Ca antagonist)

%% 39 39

00

2020

4040

6060

8080

BP control rate during antihypertensive monotherapy

46



Drug ADrug A

0 20 40 60 801000 20 40 60 80100

%%Drugs A + BDrugs A + B

Drug BDrug B

47

SystolicDiastolicSystolicDiastolic

0

-5

-10

-5

0

-5

-10

-5

Effects of two different drugs on BP separately and in combination

(119 randomized placebo controlled trials)

Effects of two different drugs on BP separately and in combination

(119 randomized placebo controlled trials)P

lace

bo-

subt

ract

ed B

P

resp

onse

. m

mH

g

Pla

cebo

-su

btra

cted

BP

re

spon

se.

mm

Hg

Law et al, BMJ 2003

Law et al, BMJ 2003

"First" drug alone

"First" drug alone

"Second" drug alone

"Second" drug alone

Combination

Combination

48

Advantages of fixed versus liberal combinations of two antihypertensive

drugs

Advantages of fixed versus liberal combinations of two antihypertensive

drugsFixed

Liberal

Simplicity of treatment +-

Compliance +-

Efficacy ++

Tolerability +*-

Price +-

Flexibility -+

Risk of administering +-

contraindicated drug

FixedLiberal

Simplicity of treatment +-

Compliance +-

Efficacy ++

Tolerability +*-

Price +-

Flexibility -+

Risk of administering +-

contraindicated drug

* lower doses generally used in fixed-dose combinations* lower doses generally used in fixed-dose combinations

49

Pharmacological treatment of hypertensionPharmacological treatment of hypertension

Consider :Blood pressure level before treatmentAbsence or presence of TOD and risk factors

Consider :Blood pressure level before treatmentAbsence or presence of TOD and risk factors

2003 European Society of Hypertension - European Society of Cardiology Guidelines for the Management of Arterial Hypertension, J Hypertens, 2003

2003 European Society of Hypertension - European Society of Cardiology Guidelines for the Management of Arterial Hypertension, J Hypertens, 2003

Two-drug combination at low dose

Two-drug combination at low dose

Choose between :Choose between :

Single agent at low dose

Single agent at low dose

If goal BP not achieved :If goal BP not achieved :

Previous agent at full dose

Previous agent at full dose

Switch to different agent at low dose

Switch to different agent at low dose

Previous combination at full

dose

Previous combination at full

dose

Add a third drug

at low dose

Add a third drug

at low doseIf goal BP not achieved :If goal BP not achieved :

Two-three drug combination




50

Stage 1 hypertension (SBP 140-159 or DBP 90-99

mmHg)

Thiazide-type diuretics for most, consider ACE inhibitor, ARB, -blocker, CCB, or combination

Stage 1 hypertension (SBP 140-159 or DBP 90-99

mmHg)

Thiazide-type diuretics for most, consider ACE inhibitor, ARB, -blocker, CCB, or combination

Stage 2 hypertension (SBP ≥160 mmHg or DBP ≥100

mmHg)

2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or -blocker or CCB)

Stage 2 hypertension (SBP ≥160 mmHg or DBP ≥100

mmHg)

2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or -blocker or CCB)

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACE inhibitor, ARB, -blocker, CCB) as needed

Not at goal BPNot at goal BP

Lifestyle modificationsLifestyle modifications

Algorithm for treatment of hypertensionAlgorithm for treatment of hypertension

The JNC VII Report, 2003The JNC VII Report, 2003

Not at goal BP (<140/90 mmHg or <130/80 mmHg for those with diabetes or chronic kidney disease)

Not at goal BP (<140/90 mmHg or <130/80 mmHg for those with diabetes or chronic kidney disease)

Initial drug choicesInitial drug choices

Hypertension with compelling indicationsHypertension with compelling indicationsHypertension without compelling indicationsHypertension without compelling indications

Optimize dosages or add additional drugs until goal BP is achievedConsider consultation with hypertension specialist

Optimize dosages or add additional drugs until goal BP is achievedConsider consultation with hypertension specialist

51

SATISFACTIONSATISFACTION

Normalization of BP

Normalization of BP

Goodtolerability

Goodtolerability

Simple drug regimen

Simple drug regimen

Day-to-day compliance Day-to-day compliance Long-term compliance Long-term compliance

esc/eas 2011 guidelines for the management of dyslipidemias

Documents