Introduction module

Supported by an educational grant from MSD Pharmaceuticals Pvt. Ltd.

Faculty
PROGRAM DIRECTORS
Jeffrey A. Brinker, MD Professor of Medicine, Cardiology Professor of Medicine, Radiology Johns Hopkins University School of Medicine Baltimore, Maryland Gary Gerstenblith, MD Professor of Medicine, Division of Cardiology Director of Clinical Trials Director, Clinical Translation Unit Johns Hopkins University School of Medicine Baltimore, Maryland

PRESENTING FACULTY

PROGRAM ADVISOR
Soneil Guptha, MD FESC FCCP Dip Pharm Med Consulting Physician-Scientist Chairman: 4H-CARE LLC (USA); Founder Director: I-SAVE (India)

Disclosure
Dr. Brinker has indicated that he has no financial relationships to disclose Dr. Gerstenblith has indicated that he has no financial relationships to disclose Dr. Mala has indicated that she has no financial relationships to disclose Dr. Iyengar has indicated that he has no financial relationships to disclose

Accreditation & Credit Designation Statements

ACCREDITATION STATEMENT This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Johns Hopkins University School of Medicine and CME Universe. The Johns Hopkins University School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation Statement The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 4.75 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity.

Educational Grant

Johns Hopkins would like to acknowledge educational grants from MSD Pharmaceuticals Pvt. Ltd. which helped to make this program possible

Learning Objectives:
Describe strategies to modify risk factors for coronary heart disease (CHD) in Indian patients Implement evidence-based treatment and monitoring practices in patients at risk for CHD Apply lipid-lowering therapy in specific clinical scenarios, such as acute coronary syndrome (ACS), diabetic dyslipidemia and mixed dyslipidemia Identify the low- to moderate-risk patients likely to benefit from management of dyslipidemia

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

Agenda
INTRODUCTION FROM PROGRAM DIRECTOR IMPROVING LIPID MANAGEMENT OUTCOMES IN INDIA AN INTRODUCTION CHD A Leading Cause of Mortality and Morbidity Dyslipidemia as a Major Risk Factor Prevalence of Dyslipidemia Concept of Residual Risk of CHD after Statin Treatment

Module 1 CHD Lipid-lowering Interventional Trials in Management of ACS Management of Patients with CHD Comprehensive Lipid Management in CHD

BREAK Module 2 DIABETES

Recognize Diabetes Carries a Similar Risk as CHD

Lipid Management in Diabetes Trials and Guidelines in Practice

Module 3 DYSLIPIDEMIA WITH LOW/INTERMEDIATE CHD RISK Identification of Low- to Moderate- risk Patient Choice of Appropriate Management Options

DISCUSSION AND CLOSING REMARKS/PROGRAM EVALUATION

Introduction from program director

At the end of the Module, participants should be able to:

Explain the burden of dyslipidemia in the Indian subcontinent Identify and discuss the significance of different lipid parameters in health and disease Describe the residual risk factors in patients with CHD and other associated diseases Discuss the importance of comprehensive dyslipidemia management

Presentation Outline
Coronary heart disease (CHD) is a leading cause of cardiovascular morbidity and mortality

Dyslipidemia is a modifiable risk factor present in more than half of the CHDs in Indians
Dyslipidemia is highly prevalent in India and characterised by low HDL-C with elevated triglycerides & LDL-C Despite guidelines, dyslipidemia is not being treated adequately in many patients. Despite significant progress in the management of dyslipidemia in patients with CHD, residual risk of CHD still persists even after optimal statin treatment and thus may lessened by additional lipid strategies.

Coronary Heart Disease1,2

Coronary heart disease (CHD): 7.2 million deaths a year globally (2001 estimate)1 The CHD burden2 is proposed to rise from 47 million DALYs* in 1990 to 82 million DALYs in 2020 More than 60% of the CHD burden occurs in developing countries2
Stroke 5.5 m

Global deaths from CVD (2002) Total deaths: 16.7 million Inflammatory heart disease 0.4 m
Hypertensive heart disease 0.9 m

Rheumatic heart disease 0.4 m

Other forms of heart disease 2.4 m

Coronary heart disease 7.2 m

*DALY: Disability-adjusted life year 1. Types of cardiovascular disease. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_01_types.pdf. Accessed September 29, 2009. 2. Global burden of coronary heart disease. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdf. Accessed September 29, 2009.

Clinical Challenge

Indians are at a high risk of developing CHD because:

A. They are genetically predisposed B. Lipid profiles are different from the western population C. There is higher contribution by novel risk factors D. They have smaller coronaries E. Indian diet is very different from western population

Coronary Heart Disease in India1-2

Risk of CHD is higher in Indians compared with other ethnicities

3 to 4 times higher than Americans1 6 times higher than Chinese1 20 times higher than Japanese1 High rate of DALY: 20 to 29 DALYs lost per 1000 population due to CHD2 There is higher propensity toward the young1

Incidence in the young is 12% to 13% as compared with 5% in the western

population

Up to 40% of the patients are below 45 years of age

1. Rissam HS, Kishore S, Trehan N. Coronary artery disease in young Indians - The Missing Link. JIACM. 2001;2(3):128-132. 2. Global burden of coronary heart disease. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atlas_13_coronaryHD.pdf. Accessed September 29, 2009.

Indians Consistently Have a Higher Burden of Mortality from CHD vs. Other Ethnic Groups
Indians 700 600 500 400 300 200 100 0 Whites Chinese 300 250 200 150 100 50
Canada England Singapore S Africa

Blacks

Malays

Men

Women

Canada

England

Singapore S Africa

*Age-standardized per 100,000/year Rates are age-standardized per 100,000/year

1. Enas EA, Senthilkumar A. Coronary Artery Disease In Asian Indians: An Update And Review . The Internet Journal of Cardiology. 2001:1 (http://www.ispub.com/journal/the_internet_journal_of_cardiology/volume_1_number_2_10/article/coronary_artery_disease_in_asian_indians_an_update_and_review.html. Accessed October 21, 2010.

CHD in Urban and Rural Populations1

There is a higher prevalence of CHD in the urban population

16%

% prevalence of CHD

14% 12% 10% 8% 6% 4% 2% 0%

14%

7%

Urban

Rural

1. Rissam HS, Kishore S, Trehan N. Coronary artery disease in young Indians - The Missing Link. JIACM. 2001;2(3):128-132.

CHD in South India and North India1

The CHD prevalence in North India increased from 1% during the 1960s to 10.5% in 1998* The prevalence in South India was 7.4% in 1993, which increased to 14.2% in 2001*

North India

South India

*These studies do not represent the entire region. The North Indian data are obtained from Jammu and Kashmir and the South Indian data are obtained from Kerala.
1. Sharma M, Ganguly NK. Premature coronary artery disease in Indians and its associated risk factors. Vasc Health Risk Manag. 2005;1(3):217-225.

Trends in CHD Mortality in India1

1. Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ. 2004;328(7443):807-810.

No. in thousands

Current Status of Dyslipidemia

Coronary heart disease (CHD) is a leading cause of cardiovascular morbidity and mortality Dyslipidemia is a risk factor contributing to more than half of the CHDs in Indians Dyslipidemia is highly prevalent in India and characterised by low HDL-C with elevated triglycerides & LDL-C Despite guidelines, dyslipidemia is not being treated adequately or appropriately Despite significant progress in the management of dyslipidemia in patients with CHD, residual risk of CHD still persists even after optimal statin treatment

Role of Dyslipidemia in CHD1

WHO estimates that dyslipidemia contributes to more than 50% of the cases of CHD
60%

56% 49% 31% 22%

% contribution to CHD

50% 40% 30% 20% 10% 0%

Systolic BP >115 mmHg

Dyslipidaemia

Dietary factors

Physical inactivity

1. Risk Factors. World Health Organization website. http://www.who.int/cardiovascular_diseases/en/cvd_atla_03_risk_factors.pdf. Accessed September 29, 2009.

Clinical Challenge
Which of the following are risk factors that contribute to the development of coronary artery disease?
A. LDL-C B. LDL-C and HDL-C C. LDL-C and TGs D. LDL-C, HDL-C, and TGs

Clinical Challenge
According to the ATP III guidelines, which one of the following is the most important risk factor that contributes to development of coronary artery disease? A. LDL-C B. HDL-C C. NonHDL-C D. ApoB

E. Triglycerides

Association of Various Risk Factors with CHD1

2

1.8
1.6
1.59 1.43 1.31 1.05 1.08 1.11

Hazard ratio

1.4 1.2 1 0.8 0.6 0.4 0.2 0

Age Female Sex 0.56

Smoking, current

Diabetes

SBP 160-199 Or DBP 95-99

SBP 200 Or DBP 100+

LDL cholesterol

ADL: Activities of daily living

1. Adapted from Simons LA, Simons J, Friedlander Y, McCallum J. A comparison of risk factors for coronary heart disease and ischaemic stroke: the Dubbo study of Australian elderly. Heart Lung Circ. 2009;18(5):330-333.

Low HDL-C, High LDL-C and TGAll Contribute to CHD Risk1

* *

*P<.001. From a large (n=4849) prospective study of men aged 40 to 65 years without a history of myocardial infarction (MI) or stroke. Data reflect relative risk of major coronary events for individual lipid parameters at 8 years. Relative risk factors are not cumulative.
1. Assmann G, Schulte H, von EA. Hypertriglyceridemia and elevated lipoprotein(a) are risk factors for major coronary events in middle-aged men. Am J Cardiol. 1996;77(14):11791184.

Role of Triglycerides in CVD Risk: PROVE IT-TIMI* Trial1

Elevated triglyceride level 200 mg/dL increases the risk of death, myocardial infarction or acute coronary syndrome significantly

30-day risk death, MI, or recurrent ASC (%)

LDL-C <70 mg/dL, on statins

On Treatment (mg/dL)
*PROVE IT-TIMI: Pravastatin or Atorvastatin Evaluation and Infection TherapyThrombolysis In Myocardial Infarction 22 trial 1. Fruchart JC, Sacks F, Hermans MP, et al. The Residual Risk Reduction Initiative: a call to action to reduce residual vascular risk in patients with dyslipidemia. Am J Cardiol. 2008;102(10 Suppl):1K-34K.

Role of HDL-C in CVD Risk: The TNT* Study1

LDL-C <70 mg/dL, on statins
5year risk of major cardiovascular events (%) 39% relative increase risk (Q1 vs Q5)

Hazard ratio (95% CI) vs Q1 Q2 0.85(0.571.25) Q3 0.57(0.360.88) Q4 0.55(0.350.86)

Quintile of HDL cholesterol level (mg/dL)

* TNT: Treating to New Targets study

Q5 0.61(0.380.97)

1. Fruchart JC, Sacks F, Hermans MP, et al. The Residual Risk Reduction Initiative: a call to action to reduce residual vascular risk in patients with dyslipidemia. Am J Cardiol. 2008;102(10 Suppl):1K-34K.

CHD Risk Increases as Plasma Cholesterol Increases

MRFIT (n=356,222) 1
150

Framingham Study (n=5,209)2

16 14 CHD Mortality 12 Rate 10 per 1,000 8 6 4 2 0 100

125

CHD 100 Incidence per 1,000 75

50 25 0

150

200

250

300

<204

205234 235264 265294

>295

Serum Cholesterol, mg/dL

Serum Cholesterol, mg/dL

MRFIT=Multiple Risk Factor Intervention Trial.

1. Stamler J et al. JAMA. 1986;256:28232828. 2. Reprinted from Am J Med. Castelli WP. Epidemiology of coronary heart disease: the Framingham Study. 1984:4 12, with permission from Excerpta Medica Inc.

Seven Countries Study

CHD Mortality is linearly related to serum cholesterol levels Absolute differences exist from culture to culture
CHD Mortality Rates, %

175-200

200-225

225-250

250-275

275-300

25 20 15 10 5 0
USA South Europe North Europe

JAMA. 1995;274:131-136.

Serum Total cholesterol

Lipid Research Clinics Prevalence Study

LDL-cholesterol was strongly associated with CAD death

Deaths/1000 Person-Years

HDL- cholesterol inversely associated with CAD death NEJM. 1990;322:1700-1707.

20 18 16

14 12 10 8 6 4 2 0

<130 LDL

>159

<35

>44 HDL

Johns Hopkins Precursor Study

NEJM. 1993;328:313-318.

40 Year Events

Serum Cholesterol level measured early in adult life correlated with cardiovascular disease in midlife

MI 40 35 30 25 20 15 10 5 0
118-172

CAD

CVD

190-208

Cholesterol

Effect of Reduction of LDL-C on CHD Event Rate

Opie et al. Lancet 2006; 367: 69-78

Current Status of Dyslipidemia

Coronary heart disease (CHD) is a leading cause of CV morbidity and mortality Dyslipidemia is a risk factor responsible for more than half of the CHDs in Indians Dyslipidemia is highly prevalent in India and characterised by low HDL-C with elevated triglycerides & LDL-C Despite guidelines, dyslipidemia is not being treated adequately or appropriately Despite significant progress in the management of dyslipidemia in patients with CHD, residual risk of CHD still persists even after optimal statin treatment

Prevalence of Dyslipidemia1
China, Hongkong Southeast Asia Japan
59.9 56.3 81 90 Prevalence among controls (%) 80 70

Asia

Non-Asian region

South Asia

53.8

45.6

46.2

47.3

44.3

34.8

33.9

35.4

50 32.3 25.3 40 30 20 10 0

33.7

37

29.5

31.2

34

18.2

27.6

28

40.1

43.7

100

9.5

>100, 130
LDL-C (mg/dL)

>130
Low HDL-C* Normal or high HDL-C*

Low HDL-C; HDL-C<40 mg/dL (men) and <50 mg/dL (women); normal or high HDL-C: 40 mg/dL (men) and 50 mg/dL (women). P<.001 for both between-case and between-control comparisons. For conversions of LDL-C and HDL-C levels into mmol/L, multiply by 0.0259, and for triglycerides, multiply by 0.0113. South Asia: India, Pakistan, Bangladesh, Nepal, Sri Lanka 1. Karthikeyan G, Teo KK, Islam S, et al. Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: an analysis from the INTERHEART study. J Am Coll Cardiol. 2009;53(3):244-253.

11.9

19

45.3

60

52.7

54.7

88.1

100

Prevalence of Dyslipidemia in Indian Population

Authors No. of patients with TG >200 mg/dL (%) 338 (37)* (n=913) 52 (21) 89 (19.4)* 68 (1.52) 331 (30.3)* (n=1091) 751 (23) 69 (13.7) (n=503) 77 (30) 26 (13.2)* (n=197) -- (22) 396 (22)* 33 (8.2) -No of patients with HDL< 40 mg/dL (M) & < 50 mg/dL (F) (%) 662 (72.5) (n=913) 43 (18)# 324 (70.7)# 1013 (22.68)# 796 (73) (n=1091) 764 (23)# 80 (16.4) (n=488) -86 (43.9) (n=197)# -- (18.5) 170 (9)# 96 (23.9)# 89 (29.7)# Patients with >2 RF or CVD or DM and LDL>100 mg/dL (%) 213 (23.3) (n=913) -------96 (48.7) (n=197) -- (28) ---Patients with >2 RF and LDL>130 mg/dL (%) --167 (36.5) --845 (26) 119 (25.6) (n=465) 82 (31.9) --- (48) -55 (13.7) 45 (15) Patients with <2 RF and LDL of >160 mg/dL (%) -----239 (07) -----33 (8.3) 20 (6.7)

Kasliwal et al,1 2006 (n=1000) Chadha et al,2 2006 (n=245) Gupta et al,3 2004 (n=458) Ashavaid et al,4 2004 (n=4466) Gupta et al,5 2003 (n=1123) Reddy et al,6 2002 (n=3307) Misra et al,7 2001 (n=532)

Gupta et al,8 2001 (n=257) Misra et al,9 2001 (n=227) Udawat et al,10 2001 (n=650) Singh et al,111998 (n=1806) Gupta et al,12 1997 (n=401) Gupta et al,13 1994 (n=300)

Note: It is difficult to compare observations of the above studies due to different sampling procedures, heterogeneity in the population samples, different methodologies used for estimations of lipoproteins and different cut-offs taken to define dyslipidemia. *TG <200 mg/dL. #HDL<35 mg/dL (M) & <45 mg/dL (F) or not defined separately for males & females.

Current Status of Dyslipidemia

Coronary heart disease (CHD) is a leading cause of CV morbidity and mortality Dyslipidemia is a risk factor responsible for more than half of the CHDs in Indians Dyslipidemia is highly prevalent in India and characterised by low HDL-C with elevated triglycerides & LDL-C Despite guidelines, dyslipidemia is not being treated adequately or appropriately Despite significant progress in the management of dyslipidemia in patients with CHD, residual risk of CHD still persists even after optimal statin treatment

Clinical Challenge Do you believe that guidelines by various scientific bodies have provided adequate weightage to all risk factors (LDL-C, HDL-C, TG) ?
A. No
B. Yes C. Not sure

Evolution of the Lipid Treatment Guidelines1-6

ATP I1 1988 ATP II2 1993 ATP III3 2001 ATP III UPDATE4 2004 AHA/ACC Guidelines6 2006

Framingham MRFIT LRC-CPPT Coronary Drug Project Helsinki Heart CLAS

Angiographic trials (FATS, POSCH, SCOR, STARS, Ornish, MARS) Meta-analyses (Holme, Rossouw)

4S WOSCOPS CARE LIPID AFCAPS/ TexCAPS VAHIT Others

HPS PROVE IT ASCOT-LLA PROSPER ALLHAT-LLT CARDS5*

TNT FIELD JELIS IDEAL ASTEROID

*Published after updated NCEP ATP III.

Current Treatment Guidelines: Adult Treatment Panel III1

Current treatment guidelines recommend LDL-C as the primary target of therapy Statins are the cornerstone of drug therapy owing to their impressive LDL-C-lowering effects Non-HDL cholesterol is recognized as the secondary target of therapy
If LDL goal not achieved, intensify LDL-lowering therapy Consider higher dose of statin or add bile acid sequestrant or nicotinic acid If LDL goal is not achieved, intensify drug therapy or refer to a lipid specialist If LDL goal is achieved, treat other lipid risk factors Monitor response and adherence therapy

Initiate LDLlowering drug therapy

6 wk

6 wk

Q-4-6 mo

Start statin or bile acid sequestrant or nicotinic acid

1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143-3421.

Current Treatment Guidelines: European Society of Cardiology1

Established CVD

Diabetes as above

Markedly raised lipid levels

SCORE risk >5%

SCORE risk <5%

Dietary and exercise advice, together with attention to all risk factors, comes first. Aim to reduce total cholesterol to <4.5 mmol/L (~175 mg/dL) or <4 mmol/L (~155 mg/dL) if possible. This will often require statin treatment. Some recommend statins for all CVD and most diabetic patients regardless of baseline levels.

Lifestyle advice for 3 months, then reassess SCORE and fasting lipids

SCORE risk still >5%

TC<5 mmol/L and LDL-C <3 mmol/L and SCORE now <5%

Lifestyle advice to reduce total cholesterol <5 mmol/L (<190 mg/dL) and LDL-C <3 mmol/L (115 mg/dL) Regular follow-up

1. Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: full text. Fourth Joint Task Force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Eur J Cardiovasc Prev Rehabil. 2007;14 Suppl 2:S1-113.

Current Treatment Guidelines: American Diabetes Association1

The American Diabetes Association guidelines also consider LDL cholesterol as the primary target of therapy
Diabetes

Lifestyle modification
Age >40 with 1 other CVD risk factor(s)

Without overt CVD

With overt CVD

Age <40

LDL-C >100 mg/dL

>1 other CVD risk factors

Statin

1. Standards of Medical Care in Diabetes-2009. Diabetes Care. 2009;32(Supplement 1):S13-S61.

Guidelines for Management of Low HDL-C/High Triglycerides

European guidelines (2003)1 Emphasis on lifestyle changes (eg, reduce body weight, increase physical activity) Drug therapy may be needed for hypertension, dyslipidemia, diabetes International Diabetes Federation (2006)3 Reduce triglycerides/increase HDL-C and reduce LDL-C Definition of metabolic syndrome includes HDL-C <1.03 mmol/L (men)/<1.29 mmol/L (women) and TG >1.7 mmol/L

US ATP III guidelines (2005)2 Modify risk factors (eg, obesity, physical inactivity, atherogenic diet, smoking) Drug therapy may be needed for elevations in LDL-C, blood pressure and glucose

Consider adding fibrates or nicotinic acid for low HDL-C/high nonHDL-C after LDL-C lowering therapy

American Diabetes Association (2006)4 Raise HDL-C to >1.15 mmol/L (men) or >1.3 mmol/L (women); lower triglycerides to <1.7 mmol/L

1. 2. 3. 4.

De BG, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J. 2003;24(17):1601-1610. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112(17):2735-2752. IDF Consensus Worldwide Definition of the Metabolic Syndrome. International Diabetes Federation website. http://www.idf.org/webdata/docs/IDF_Meta_def_final.pdf. Accessed December 29, 2009. Standards of medical care in diabetes 2006. Diabetes Care. 2006;29 Suppl 1:S4-42.

Clinical Challenge
In your practice are you able to implement these guidelines ? A. In all cases B. In acute cases only

C. In patients with diabetes only

D. In patients with high risk or multiple risk factors E. No, I do not believe in guidelines

Dyslipidemia Management in ACS Patients in India1

Only 50% of ACS patients receive any kind of lipid-lowering therapy
CREATE Registry

N=20,468 Percentage
CREATE: Treatment and outcomes of acute coronary syndromes in India 1. Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. 2008;371(9622):1435-1442.

Dyslipidemia Management in ACS Patients in India1

Underutilization of lipid-lowering drug therapy is significant in India irrespective of the socioeconomic status
CREATE Registry
N=20,468

1. Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. 2008;371(9622):1435-1442.

Percentage

Suboptimal Use of Statins for Secondary Prevention of CHD and CVD Patients in India1
WHO-PREMISE Study Percentage of patients on statin treatment
N=1013

WHO-PREMISE: WHO study on Prevention of Recurrences of Myocardial Infarction and Stroke 1. Mendis S, Abegunde D, Yusuf S, et al. WHO study on Prevention of Recurrences of Myocardial Infarction and Stroke (WHO-PREMISE). Bull World Health Organ. 2005;83(11):820-829.

Current Status of Dyslipidemia

Coronary heart disease (CHD) is a leading cause of CV morbidity and mortality

Dyslipidemia is a risk factor responsible for more than half of the CHDs in Indians
Dyslipidemia is highly prevalent in India and characterised by low HDL-C with elevated triglycerides & LDL-C Despite guidelines, dyslipidemia is not being treated adequately or appropriately Despite significant progress in the management of dyslipidemia in patients with CHD, residual risk of CHD still persists even after optimal statin treatment

Clinical Challenge In your experience, do patients with dyslipidemia achieve the lipid goal?
A. LDL goal is easily achieved B. HDL goal is easily achieved

C. TG goal is easily achieved

D. None of the goals are achieved E. We may achieve individual goals but the residual risk still remains

Failure to Reach Cholesterol Goals with Statins1

Results of the EUROASPIRE II study demonstrated that a significant proportion of patients on statins did not achieve the cholesterol targets`
% Reaching goal Sweden Netherlands UK France Germany Spain Finland Italy Ireland Czechoslovakia Slovenia Hungary Belgium Greece Poland 0
49 41 39 39 41 31 55 49 70 52 41 44 54 66 65

20

40

60

80

Percentage receiving lipid-lowering medication

EUROASPIRE: European Action on Secondary and Primary Prevention through Intervention to Reduce Events 1. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries. Principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J. 2001;22(7):554-572.

Persistent Lipid Abnormalities by Risk Categories1

DYSIS
LDL-C not at goal, %a Non-HDL-C not at goal, %b Low HDL-C, %c Elevated TGs, %d High TC, %e High TC/HDL-C ratio, %f LDL-C at goal with normal HDL-C and normal TG, % CHD or Risk Equivalent n=13,503 (70.3%) 43.4/79.1 71.1 35.9 40.9 67.4 37.3 26.0/8.6 2+ Risk Factors n=3522 (18.3%) 35.7 56.8 33.6 41.5 70.2 20.1 29.2 0-1 Risk Factor n=2171 (11.3%) 16.7 35.8 1.4 20.7 69.5 1.0 67.5

DYSIS: Dyslipidemia International Survey

a100

mg/dL (CHD/CHD equivalent), 130 mg/dL (2+ RF), 160 mg/dL (01 RF). mg/dL (CHD/CHD equivalent), 160 mg/dL (2+ RF), 190 mg/dL (01 RF); % of patients with TGs >200 mg/dL (n=1507). c<40 mg/dL (male); <50 mg/dL (female). d150 mg/dL. e155 mg/dL (CHD/CHD equivalent), 175 mg/dL (2+ RF), 190 mg/dL (01 RF). f4 (CHD/CHD equivalent), 5 (2+ RF), 6 (01 RF).
b130

1. Gitt AK. Poster presented at: 58th Annual Scientific Session of the American College of Cardiology; March 29 31, 2009; Orlando, FL.

Residual Risk in Key Studies1

4S, the Scandinavian Simvastatin Survival Study; CARE, Cholesterol and Recurrent Events trial; LIPID, Long-Term Intervention with Pravastatin in Ischemic Disease trial; HPS, Heart Protection Study; PROSPER, Prospective Study of Pravastatin in the Elderly at Risk; ASCOT-LLA, Lipid-Lowering Arm of the Anglo-Scandinavian Cardiac Outcomes Study Trial; ALLHAT-LLT, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid Lowering Trial; ASPEN, the Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in Non-Insulin-Dependent Diabetes Mellitus; WOSCOPS, West of Scotland Coronary Prevention Study; AFCAPS/TexCAPS, Air Force/Texas Coronary Atherosclerosis Prevention Study; CARDS, the Collaborative Atorvastatin Diabetes Study. 1. Fruchart JC, Sacks F, Hermans MP, et al. The Residual Risk Reduction Initiative: a call to action to reduce residual vascular risk in patients with dyslipidemia. Am J Cardiol. 2008;102(10 Suppl):1K-34K.

CHD risk

SUMMARY Residual Risk & Comprehensive Lipid Management

CHD is highly prevalent in India Dyslipidemia is an important risk factor for CHD Mixed dyslipidemia is underdiagnosed and undertreated

Despite guidelines many patients are inadequately treated.

Despite adequate treatment, residual risk persists