NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx

8/14/2019 NATIONAL CHOLESTEROL EDUCATION PROGRAM.pptx

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In patients without coronary heart disease

(CHD), the NCEP recommends screening

with a complete lipid profile after a 12

hours fast for all adults > 20 years of age

once every 5 years and as indicated


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DETECTION, EVALUATIONand

TREATMENTof High BloodCholesterol in Adults

RISK ASSESSMENT in an effort to

reduce premature death and disabilityfrom CHD


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1stNCEP

outlined a strategy for primary preventionof CHD in persons with high levels of LDL

>160mg/dL or those with borderline high

LDL (130-159 mg/dL) and multiple (2+) risk

factors


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Expand the prior list of cardiovascular

events to include virtually all occlusive

vascular diseases of the heart as well as

the brain and peripheral arteries.

Focus on global risk assessment rather

than just lipid parameters

GRAquantitation of the 10 year risk of

developing CHD


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Major New Feature:

Primary prevention in persons with

multiple risk factors


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DMCHD risk equivalent

Thus, all diabetic px should be treated as

aggressively as px who have survived a

prior occlusive event of the heart, brain or

peripheral arteries


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Modifications of Lipid and Lipoprotein

Classficiation

Identifies LDL


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mg/dL

LDL Cholesterol

190 Very High

Total cholesterol

240 High

HDL Cholesterol

60 High


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Any person with elevated LDL or other

form of hyperlipidemia should undergo

clinical or laboratory assessment to rule

out secondary dyslipidemia before initiationof lipid-lowering therapy.


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Causes of secondary dyslipidemia:

Hypothyroidism

Obstructive Liver Disease

Chronic Renal Failure Drugs that inc LDL and dec HDL (progestins,

anabolic steroids, and corticosteroids

Once secondary causes have been excluded, or,

if appropriately treated, the goals for LDLlowering therapy in primary prevention areestablished according to a persons risk category


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First step in risk management

Basic principle of prevention

1st

step in selection of LDL loweringtherapy to assess a persons risk status


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Risk status in person without clinicallymanifest CHD or other clinical forms ofatherosclerotic disease is determined by a

2-step procedure First, the number of risk factors is counted

Second, for persons with multiple (2+) risk

factors, 10 yr risk assessment is carriedout with Framingham Scoring to identifyindividuals whose short term (10yr) riskwarrants consideration of intensive

treatment


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Estimation of the 10 yr CHD risk adds a

step to risk assessment beyond risk factor

counting, but this step is warranted

because it allows better targeting ofintensive treatment to people who will

benefit from it.


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Risk Category LDL Goal (mg/dL)

CHD and CHD riskequivalents


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Healthcare providersasked to quantitatethe 10 yr risk of all primary prevention pxwith 2 or more risk factors using the

Framingham Risk Assessment System Sex

Age

Cholesterol status

HDL

Systolic BP


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More robust for total cholesterol than LDL

Total cholesterol and HDL values should

be the average of at least 2 measurements

obtained from lipoprotein analysis

BP- obtained at the time of assessment,

regardless of whether the person is on

antihypertensive therapy


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If absolute risk is 20% or greater, primary

prevention px should be treated as

aggressively as a patient who experience a

previous event


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Primary prevention patient at high risk

due to multiple metabolic risk factorsor

metabolic syndrome


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3 out of 5 factors:

Abdominal obesity (waist >101.6cm/40in in

men and >88.9cm/35in in women)

Low HDL levels (130 or diastolic

>85mmHg)


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Large and usually more-than-additive

benefits in terms of risk reduction

Efficacy of drug therapy with statins is

enhanced


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Reduced intake of saturated fats and

cholesterol

Therapeutic options for enhancing LDL

lowering such as plant stanols and sterols

and increased viscous fiber

Weight reduction

Increased physical activity


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Saturated fat less than 7% of total calories

and cholesterol


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3-hydroxy-3-methylglutaryl coenzyme A

reductase inhibitors

STATINS

Recommended by NCEP as the 1stline

drug of choice for virtually all pxs eligible

for lipid modification

Goal -> drug therapy + therapeutic lifestyle

changes


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STATINS

lower TC, LDL, and TG and inc HDL

LDL reduction of approx 35% Meta-analysis

Primary and secondary prevention pxs

assigned at random to statins

22% reduction in cholesterol

30% reduction in LDL


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STATINS

Beneficial changes were associated with

significantly reduced risks of:

MI,

stroke

vascular death total mortality


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STATINS

Reduce LDL levels by at least 30-35%

Usual starting doses of atorvastatin,fluvastatin and simvastatin provide even

larger decreases

Starting dose of atorvastatin yield the

largest reduction

All statins have favorable safe profile


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STATINS

Induced liver dysfunction and myopathy

RARE

Higher doses will provide an even greater

reduction in LDL with proportionately less

increases in HD


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STATINS

Atorvastatin 10mg, 20mg, 4omg, 80mg:

10-80mg tab OD-HS

Simvastatin 10mg, 20mg, 40mg: 5-

40mg/day: start with 10mg OD HS

Rosuvastatin 5mg, 10mg, 20mg: 5-20mg

OD HS

Pravastatin 10mg, 20mg: 10-40mg OD HS


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Fibrates

Gemfibrozil 300-600mg BID

Fenofibrate 100-300mg cap ODNicotinic Acid

Nicotinic acid 50mg, 100mg: 50mg OD then

inc up to 100mg TID


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Combination Therapy

Statin + Niacin of fibratesyield greater

elevations of HDL and decrease in

Triglycerides but increased risk of myopathy


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Progression of Drug Therapy


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No level of HDL protects against HDL

Thus, there needs to be a wider usage of

statins in px with LDL despite the

presence of normal or HDL level

HDL with LDLat sufficient risk to

warrant lipid modification


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Airforce/Texas Coronary Atherosclerosis

Prevention Study

Px with normal LDL but HDL -> statin ->

cardiovascular benefits


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Adherence to the NCEP guidelines by both

patients and providers is a key to

approximating the magnitude of the

benefits demonstrated in clinical trials ofcholesterol lowering.


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These guidelines are intended to inform,

not replace, the physicians clinical

judgment, which must ultimately determine

the appropriate treatment for eachindividual.


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