presentación de powerpoint - european society of cardiology affairs... · esc cp guidelines 2016...

ESC Clinical Practice Guidelines 2016

Highlights: Dyslipidaemias

Martine Gilard and Alberto Cordero Brest University Alicante University

France Spain

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias

• Maintain global CV risk assessment by the SCORE

• Moderate renal dysfunction re-classification

• Keep treatment targets

• Proposal of a treatment scheme

• New recommendation for non-statin treatments and drug combinations

• Recommendations for PCSK-9 inhibitors

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Lipid determinations and treatment targets

2016 ESC Dyslipidaemias guidelines 2011 ESC Dyslipidaemias guidelines

Recommendation Class Level

LDL-C is the primary target for treatment

I A

TC should be considered as a treatment target if other are not available

IIa A

Non-HDL-C should be considered as a secondary treatment target

IIa B

ApoB should be considered as a secondary treatment target only if available

IIa B

HDL-C is not recommended as a target for treatment

III A

ApoB/ApoAI or non-HDL-C/HDL-C ratios are not recommended treatment targets

III B


LDL-C is the primary target for treatment

I A

TC should be considered as a treatment target if other are not available

IIa A

Non-HDL-C should be considered as a secondary treatment target in combined DLP, DM, MS and CKD

IIa B

ApoB should be considered as a secondary treatment target

IIa B

HDL-C is not recommended as a target for treatment

III A

ApoB/ApoAI or non-HDL-C/HDL-C ratios are not recommended treatment targets

III B

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Lipoprotein (a)


Recommendations:

- Not recommended for risk screening in the general population - Lp(a) measurement should be considered in:

1. People with high CVD risk 2. Strong family history of premature

atherothrombotic disease

Recommendations:

- Not recommended for risk screening in the general population - Individuals considered for screening:

1. Premature CVD 2. Familial hypercholesterolaemia 3. Family history of premature CVD

and/or elevated Lp(a) 4. Recurrent CVD despite optimal lipid

lowering treatment 5. ≥5% 10-year risk of fatal CVD according

to SCORE

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias CV risk categories


Recommendation

VERY-HIGH CV risk: - Documented CVD - DM or type-1 DM with TOG - GFR <60 mg/ml/1.72 m2

- 10 year risk SCORE ≥10%

HIGH CV risk: - Markedly elevated single risk factor - 10 year risk SCORE ≥5% and <10%

MODERATE CV risk: - 10 year risk SCORE ≥1% and <5%

LOW CV risk: - 10 year risk SCORE <1%

Recommendation

VERY-HIGH CV risk: - Documented CVD - DM or type-1 DM with TOG - Severe RD: GFR <30 mg/ml/1.73 m2

- 10 year risk SCORE ≥10%

HIGH CV risk: - Markedly elevated single risk factor - 10 year risk SCORE ≥5% and <10% - Moderate RD: GFR 30-59 mg/ml/1.73 m2

MODERATE CV risk: - 10 year risk SCORE ≥1% and <5%

LOW CV risk: - 10 year risk SCORE <1%

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Treatment targets

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Treatment targets



VERY-HIGH CV risk: LDL-c goal <70 mg/dl (1.8 mmol/L) and/or 50% reduction when target cannot be reached

I A

HIGH CV risk: LDL-c goal <100 mg/l (2.5 mmol/L)

IIa A

MODERATE CV risk: LDL-c goal <115 mg/dl (3.0 mmol/L)

IIa C


VERY-HIGH CV risk: LDL-c goal <70 mg/dl (1.8 mmol/L) and/or 50% reduction if baseline is 70-135 mg/dl (1.8-3.5 mmol/L)

I B

HIGH CV risk: LDL-c goal <100 mg/l (2.6 mmol/L) or 50% reduction if baseline is 100-200 mg/dl (2.6-5.1 mmol/L)

I B

MODERATE CV risk: LDL-c goal <115 mg/dl (3.0 mmol/L)

IIa C

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Treatment scheme

1. Evaluate the total CV risk of the subject

2. Involve the patient with decisions on CV risk management

3. Identify the LDL-C goal for that risk level

4. Calculate the % of LDL-C reduction required to achieve that goal

5. Choose a statin and a dose that could provide this reduction

6. Response to statin treatment is variable, therefore up-titration

of the dose may be required

7. If the highest tolerated statin dose does not reach the goal,

consider drug combinations

8. In addition, a reduction ≥ 50% in LDL-C should be achieved in

very high and high risk patients

2016 ESC Dyslipidaemias guidelines

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Drug combinations


Recommendation: Class Level

Prescribe statin up to the highest recommended dose or highest tolerable dose to reach the goal

I A

Recommendation: Class Level

Prescribe statin up to the highest recommended dose or highest tolerable dose to reach the goal

I A




If statin intolerance, ezetimibe or bile acid sequestrants, or these combined, should be considered

IIa C

If goal is not reached, statin combination with a cholesterol absorption inhibitor should be considered

IIa B

Statin combination with a bile acid sequestrant may be considered

IIb B


If statin intolerance, ezetimibe or bile acid sequestrants, or these combined, should be considered

IIa C

If goal is not reached, statin combination with a cholesterol absorption inhibitor, bile sequetran acid or nicotinic acid should be considered

IIb B




If goal is not reached, statin combination with a cholesterol absorption inhibitor should be considered

IIa B

Statin combination with a bile acid sequestrant may be considered

IIb B


If goal is not reached, statin combination with a cholesterol absorption inhibitor, bile sequetran acid or nicotinic acid should be considered

IIb B




Very high risk patients, with persistent high LDL-C despite treatment with maximal statin dose, in combination with ezetimibe or in patients with statin a PCSK9 inhibitor may be considered

IIb C

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Statin intolerants


ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Treatment of tryglicerides



Treatment considered in high risk patients and TG >2.3 mmol/L (200 mg/dl)

IIa B

Statins considered as the first drug of choice for reducing CVD risk in high risk individuals with hypertriglyceridaemia

I A

In high risk patients with TG >2.3 mmol/L despite treated with statin, fenofibrate considered in combination with statins

IIb C


Fibrates drug of choice I B

Considerd nicotinic acid IIa B

Nicotinic acid +laropiprant IIa C

Statin+Nicotinic acid IIa A

Statin+Fibrate IIa C

N-3 fatty acids IIa B

Fibrate+n-3 fatty acids IIb B

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Treatment of HDL



Statins and fibrates raise HDL-C with similar magnitude and these drugs may be considered

IIb B

The efficacy of fibrates to increase HDL-C may be attenuated in people with type 2 diabetes

IIb B


Nicotinc acid is the most efficent drug to raise HDL-C and should be considered

IIa A

Statins and fibrates raise HDL-C with similar magnitude and these drugs may be considered

IIb B

The efificacy of fibrates to increase HDL-c may be attenuated in people with type 2 diabetes

IIb B

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias Familial hypercholesterolemia


• Clinical diagnosis and screening by the Dutch Lipid Clinic Network diagnostic criteria

• Genetic cascade screening of family members

• Cholesterol lowering treatment should be initiated as soon as possible

PCSK9 antibodies have recently been registered for use in FH patients. • Efficiently lower LDL-C by up to 60% on top of the statin. • There are no randomized controlled studies with clinical endpoints and therefore the use

of the drugs still should be restricted. • May be considered in patients with FH:

1. Very high risk due to the presence of CVD 2. Family history of CAD at very young age 3. LDL-C level far from goal even on maximal other therapy 4. FH patients who cannot tolerate statins 5. FH patients with high Lp(a).

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias The elderly



Treatment with statins is recommended for older adults with established CVD in the same way as for younger patients

I A

Lipid-lowering medication should be started at a lower dose and then titrated to targets

IIa C

Statin therapy should be considered in older adults free from CVD, in the presence of HT, smoking, DM or dyslipidaemia.

IIa B


Treatment with statins is recommended for older adults with established CVD in the same way as for younger patients

I B

Lipid-lowering medication should be started at a lower dose and then titrated to targets

I C

Statin therapy should be considered in older adults free from CVD, in the presence of HT, smoking, DM or dyslipidaemia.

IIb B

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias ACS patients or PCI



Initiate or continue high dose statins early after admission in all ACS patients without contraind. or intolerance, regardless of initial LDL-C values

I A

If LDL-C target is not reached, with the highest tolerable statin dose, ezetimibe should be considered in combination with statins in post-ACS.

IIa B

If LDL target is not reached with the highest tolerable statin dose and/or ezetimibe, PCSK9 inhibitors may be considered on top of lipid-lowering therapy; or alone or in combination with ezetimibe in statin intolerant patients or in whom a statin is contraindicated

IIb C

Lipids should be re-evaluated 4–6 weeks after the ACS to assess LDL-C target (70 mg/dL or a reduction of at least 50% and whether there are any safety issues; the therapy dose should then be adapted accordingly.

IIa C

Routine short pretreatment or loading with high-dose statin before PCI should be considered in elective PCI or in NSTE-ACS.

IIa A

ESC CP Guidelines 2016 – Highlights: Dyslipidaemias

presentación de powerpoint - european society of cardiology affairs... · esc cp guidelines 2016...

Documents