Society guidelines2012 Update of the Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult
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.