Aggressive Therapy for Aggressive Therapy for Hypercholesterolemia: Hypercholesterolemia: Data, Strategy and Data, Strategy and Outcomes Outcomes Timothy A. Denton, M.D. Timothy A. Denton, M.D. High Desert Heart Institute High Desert Heart Institute Victorville, CA Victorville, CA
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Aggressive Therapy for Hypercholesterolemia: Data, Strategy and Outcomes Timothy A. Denton, M.D. High Desert Heart Institute Victorville, CA.
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Aggressive Therapy for Aggressive Therapy for Hypercholesterolemia:Hypercholesterolemia:
Data, Strategy and Outcomes Data, Strategy and Outcomes
Aggressive Therapy for Aggressive Therapy for Hypercholesterolemia:Hypercholesterolemia:
Data, Strategy and Outcomes Data, Strategy and Outcomes
Timothy A. Denton, M.D.Timothy A. Denton, M.D.
High Desert Heart InstituteHigh Desert Heart Institute
12/1/2000 -- FDA approves 0.8 mg3/30/2001 -- FDA warning about metabolism8/1/01 -- 31 US deaths, 19 lone drug, 12 in combination8/8/2001 -- Bayer removes Baycol from US Market
• UCLA• Observational / Interventional• AHA Guidelines• Standard orders, education, DC planning• Phone follow-up
CHAMPCHAMP
Fonarow, AJC 2001;87:819
CHAMPCHAMP
Fonarow, AJC 2001;87:819
When should weWhen should we
STARTSTART
therapy?therapy?
When should weWhen should we
STARTSTART
therapy?therapy?
AS SOON AS POSSIBLE!!!!
But my hospitalized But my hospitalized
patient’s LDL is at goal.patient’s LDL is at goal.
But my hospitalized But my hospitalized
patient’s LDL is at goal.patient’s LDL is at goal.
Change in LDL over time
0
20
40
60
80
100
120
140
160
180
200
PreProc Proc 3-6 mos 6-9 mos
Time
LD
L m
g%
All MIMI no ThrMI w ThrPTCACABG
Brugada, Cardiology 1996;87:194Original paper reports total cholesterolOriginal paper reports total cholesterolConverted to LDL by assuming LDL = 0.67 * total cholesterolConverted to LDL by assuming LDL = 0.67 * total cholesterol
But my hospitalized But my hospitalized
patient’s LDL is at goal.patient’s LDL is at goal.
But my hospitalized But my hospitalized
patient’s LDL is at goal.patient’s LDL is at goal.
Not for long…Not for long…Not for long…Not for long…
Aggressive Approachto LDL Management
Event
Drug therapy
Diet
Exercise
X
The GuidelinesThe Guidelines
Therapy GWTG Goal A Antiplatelet/warfarin Start the Rx B Beta blockers Start the Rx C Cholesterol Start the Rx C ACE Start the Rx D DM Start the Rx C Smoking Counseling E Exercise Counseling W Weight control Counseling H BP control 130-140/80-90
How often do we provide these therapies?How often do we provide these therapies?
Therapy Rate ReferenceSmoking 48% Doescher J Fam Prac 2000;49;543
BP control 25% Berlowitz, NEJM 1998;339:1957Cholesterol 31.7% Fonarow Circ 2001;103:38
Exercise 19.1% MMWR 1998;47:91
Weight control 10.4% MMWR 1998;47:91DM 45% UKPDS AHJ 1999;138:353
Antiplatelet/warfarin 84% Rogers Circ 1994;90:2103ACE 75% (chf) J Gen Int Med 1997;12:563