Society guidelines
2012 Update of the Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult

https://doi.org/10.1016/j.cjca.2012.11.032Get rights and content

Abstract

Many developments have occurred since the publication of the widely-used 2009 Canadian Cardiovascular Society (CCS) Dyslipidemia guidelines. Here, we present an updated version of the guidelines, incorporating new recommendations based on recent findings and harmonizing CCS guidelines with those from other Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used, per present standards of the CCS. The total cardiovascular disease Framingham Risk Score (FRS), modified for a family history of premature coronary disease, is recommended for risk assessment. Low-density lipoprotein cholesterol remains the primary target of therapy. However, non-high density lipoprotein cholesterol has been added to apolipoprotein B as an alternate target. There is an increased emphasis on treatment of higher risk patients, including those with chronic kidney disease and high risk hypertension. The primary panel has recommended a judicious use of secondary testing for subjects in whom the need for statin therapy is unclear. Expanded information on health behaviours is presented and is the backbone of risk reduction in all subjects. Finally, a systematic approach to statin intolerance is advocated to maximize appropriate use of lipid-lowering therapy. This document presents the recommendations and principal conclusions of this process. Along with associated Supplementary Material that can be accessed online, this document will be part of a program of knowledge translation. The goal is to increase the appropriate use of evidence-based cardiovascular disease event risk assessment in the management of dyslipidemia as a fundamental means of reducing global risk in the Canadian population.

Résumé

De nombreux développements sont survenus depuis la publication communément utilisée des Lignes directrices 2009 de la Société canadienne de cardiologie (SCC) sur la dyslipidémie. Nous présentons ici une version mise à jour des lignes directrices, qui inclut des nouvelles recommandations fondées sur des résultats récents qui harmonisent les lignes directrices de la SCC à celles d'autres sociétés. La méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) a été utilisée selon les normes actuelles de la SCC. Le score de risque cardiovasculaire global de Framingham (SRF) total sur les maladies cardiovasculaires modifié pour tenir compte des antécédents familiaux de coronaropathie prématurée est recommandé pour l'évaluation du risque. Le cholestérol à lipoprotéines de faible densité demeure la cible principale du traitement. Cependant, le cholestérol non à lipoprotéines de haute densité a été ajouté à l'apolipoprotéine B comme autre cible. L'accent est davantage mis sur le traitement des patients exposés à un risque élevé, incluant ceux ayant une maladie rénale chronique et une hypertension à risque élevé. Le panel principal a recommandé une utilisation judicieuse d'examens secondaires des sujets chez qui la nécessité d'un traitement par des statines est incertaine. De plus en plus de renseignements sur les comportements en matière de santé sont présentés et sont les bases de la réduction du risque chez tous les sujets. Finalement, une approche systématique sur l'intolérance aux statines est recommandée pour optimiser l'utilisation de traitements hypolipidémiants. Ce document présente les recommandations et les conclusions principales de ce processus. Par les contenus complémentaires associés qui peuvent être consultés en ligne, ce document fera partie d'un programme d'application des connaissances. Le but est d'accroître l'utilisation appropriée de l'évaluation des risques d'événements cardiovasculaires fondée sur les preuves dans la prise en charge de la dyslipidémie en tant que moyen fondamental pour réduire le risque global dans la population canadienne.

Section snippets

Whom to Screen for Lipids

Screening of plasma lipids is recommended in adult men ≥ 40 and women ≥ 50 years of age or postmenopausal (Fig. 1). The presence of modifiable CVD risk factors (smoking, diabetes, arterial hypertension, obesity) is taken into account in the decision to screen for lipids at any age. Adults with the following risk factors should also be screened at any age: rheumatoid arthritis,10, 11 systemic lupus erythematosus,12, 13, 14 psoriatic arthritis,12, 15 ankylosing spondylitis,12 inflammatory bowel

Risk Assessment

Cardiovascular risk assessment has been shown to help primary health care providers identify patients most likely to benefit from primary prevention therapies such as the treatment of dyslipidemia or hypertension.22 Several studies have also demonstrated that the potential benefits of risk assessment are maximized when the results are directly communicated to the patient to engage them in treatment decisions and increase their adherence with prescribed therapy.23, 24, 25, 26

Despite the

LR

The LR category still applies to individuals with a modified 10-year FRS <10% (Fig. 2). Pharmacologic lipid-lowering treatment is still advised for LR subjects with severe dyslipidemia (LDL-C > 5.0 mmol/L), a level that usually reflects a genetic lipoprotein disorder, especially familial hypercholesterolemia. Clinical judgement should be used concerning the proper timing for the initiation of pharmacological therapy in such patients. The recent meta-analysis of studies of primary prevention in

Secondary Testing in Risk Stratification

In a subset of patients who do not exhibit significant dyslipidemia (LDL-C <3.5 mmol/L, apo B <1.2 g/L, or non-HDL-C <4.3 mmol/L), it might be unclear whether to offer or withhold therapy when the adjusted FRS falls between 5% and 19%. Secondary testing might be considered in such patients, and might help direct decision-making regarding the need for lipid-lowering therapy.67, 68 Secondary testing is optional, and left to the discretion of the clinicians in discussion with the individual

Noninvasive Testing

There is much interest in the use of noninvasive testing and imaging to identify subclinical atherosclerosis and its physiological consequences. Though there is strong support for this approach, this strategy has not been yet tested in a randomized fashion in a large prospective cohort. However, emerging data that demonstrate favourable effects on discrimination and reclassification have been obtained (Supplemental Table S5).

Health Behaviours

Health behaviour interventions remain the cornerstone of chronic disease prevention, including CVD. They should be universally applied for the prevention of chronic diseases such as obesity, type 2 diabetes, atherosclerosis, cancer, and neurodegenerative diseases. Data from the INTERHEART study indicate that, in addition to the traditional risk factors (abnormal lipids, hypertension, and diabetes), abdominal obesity, dietary patterns, alcohol consumption, physical inactivity, psychosocial

Statin Intolerance and Adverse Effects

The main intolerance issues with statins pertain to adverse muscle effects, but there are many other purported effects that are either uncommon or difficult to relate conclusively to statin therapy. Baseline transaminases (alanine aminotransferase; ALT), creatinine, and creatine kinase are useful to monitor potential side effects associated with therapy. There is however no indication for routine repeat measures of ALT and creatine kinase in patients using statin therapy unless symptoms

Nonstatin Pharmacotherapy

No new formal recommendations are presented because this topic was not reviewed in detail (see 2009 Guidelines for detail).1 No studies to date have demonstrated a decrease in CVD event rate with the addition of lipid modulating drugs to statin therapy. The SHARP study did however demonstrate that simvastatin and ezetimibe decreased CVD events in subjects with CKD compared with placebo. A statin-only arm was not tested.4

For subjects who do not tolerate statin therapy or only at low dose,

Practical Approach to the Guidelines

For those wishing a simple approach, one would identify risk based on the phenotype of the patient, use LDL-C as the predominant threshold, and target and forego any secondary testing or use of alternate targets. Patients will separate into those in whom treatment is clearly not indicated (lower end of lower risk) and those in whom treatment is indicated (Fig. 2). For the others, a discussion with the patient would determine the desire for pharmacotherapy most of the time. Emerging evidence

Acknowledgements

Todd J. Anderson and Jean Grégoire are equal contributors to this work.

The authors thank Marinda Fung for expert manuscript preparation support, and research, and the Secondary Review Panel (listed in the Supplementary Material) for thoughtful feedback and comments.

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    A summary of recommendations for this article is available in the Supplementary Material.

    The disclosure information of the authors and reviewers is available from the CCS on the following websites: www.ccs.ca and/or www.ccsguidelineprograms.ca.

    This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.

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