Dyslipidemia: Managing a Key Cardiovascular Risk Factor AIMGP Clinic Seminar Updated by R. Cavalcanti Sep 2007

Dyslipidemia: Managing a Key Dyslipidemia: Managing a Key Cardiovascular Risk FactorCardiovascular Risk Factor

AIMGP Clinic SeminarAIMGP Clinic Seminar

Updated by R. CavalcantiUpdated by R. Cavalcanti

Sep 2007Sep 2007

OutlineOutline

Current Practice GuidelinesCurrent Practice Guidelines CasesCases Global Risk AssessmentGlobal Risk Assessment Whom to Screen for Dyslipidemia?Whom to Screen for Dyslipidemia? Risk Categories & Lipid TargetsRisk Categories & Lipid Targets Factors Influencing Risk AssessmentFactors Influencing Risk Assessment Selected StudiesSelected Studies ManagementManagement Cases RevisitedCases Revisited

Current Practice GuidelinesCurrent Practice Guidelines

Canadian GuidelinesCanadian Guidelines– ““Recommendations for the management of Recommendations for the management of

dyslipidemia and the prevention of cardiovascular dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update” CMAJ disease: summary of the 2003 update” CMAJ 169(9):921-4, 28 Oct 2003169(9):921-4, 28 Oct 2003

– www.cmaj.ca/cgi/content/full/169/9/921/DC1www.cmaj.ca/cgi/content/full/169/9/921/DC1– CCS Position Statement on Dx and Rx CCS Position Statement on Dx and Rx

dyslipidemia. Canadian Journal of Cardiology dyslipidemia. Canadian Journal of Cardiology 2006;22(11):913-9272006;22(11):913-927

Current Practice GuidelinesCurrent Practice Guidelines

American GuidelinesAmerican Guidelines– ““Implications of Recent Clinical Trials for the National Implications of Recent Clinical Trials for the National

Cholesterol Education Program Adult Treatment Panel Cholesterol Education Program Adult Treatment Panel III Guidelines” III Guidelines”

» Circulation 110:227-39, 13 July 2004Circulation 110:227-39, 13 July 2004

– ““Third Report of the National Cholesterol Education Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)” in Adults (Adult Treatment Panel III)”

» JAMA 285(19):2486-97, 16 May 2001JAMA 285(19):2486-97, 16 May 2001

Case 1Case 1

56 M56 M– Acute MI 4 months agoAcute MI 4 months ago– No current cardiovascular symptomsNo current cardiovascular symptoms– Tested for DM post-MITested for DM post-MI

» NegativeNegative

– Non-smoker, no HTNNon-smoker, no HTN Lipids measured while in hospital post-MI:Lipids measured while in hospital post-MI:

– TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2)TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2) What is his estimated risk of a cardiovascular event What is his estimated risk of a cardiovascular event

in the next 10 years?in the next 10 years? How should you manage his lipids?How should you manage his lipids?

Case 2Case 2

45 F45 F– ‘‘Healthy’, BP 125/80Healthy’, BP 125/80

– Non-smoker, EtOH: 3 standard drinks/weekNon-smoker, EtOH: 3 standard drinks/week

– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)

What is her estimated risk of a cardiovascular What is her estimated risk of a cardiovascular event in the next 10 years?event in the next 10 years?

How should you manage her lipids?How should you manage her lipids?

Case 3Case 3

55 F55 F– DM Type 2 x 10 years (HbA1c 9.7%), HTNDM Type 2 x 10 years (HbA1c 9.7%), HTN– post menopausal, BMI 33post menopausal, BMI 33– Non-smoker, EtOH: 4 standard drinks/dayNon-smoker, EtOH: 4 standard drinks/day– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)

What is her estimated risk of a cardiovascular What is her estimated risk of a cardiovascular event in the next 10 years?event in the next 10 years?


Current Challenges in Current Challenges in Cardiovascular Risk ReductionCardiovascular Risk Reduction

Aging PopulationAging Population– >20% Canadians will be >65 years old by 2011>20% Canadians will be >65 years old by 2011– 1,900,000 Canadians >80 years old by 20261,900,000 Canadians >80 years old by 2026

ObesityObesity– 31% of Canadians are obese31% of Canadians are obese– Especially if abdominal adiposity, associated with increased Especially if abdominal adiposity, associated with increased

prevalence of metabolic syndrome features (DM, HTN, prevalence of metabolic syndrome features (DM, HTN, ↑TGs, ↓HDL, insulin resistance)↑TGs, ↓HDL, insulin resistance)

– Associated with Associated with ↑inflammatory markers (CRP, IL-6)↑inflammatory markers (CRP, IL-6) DiabetesDiabetes

– 60,000 new cases per year in Canada60,000 new cases per year in Canada– 3,000,000 Canadians with DM by 20103,000,000 Canadians with DM by 2010

Global Risk AssessmentGlobal Risk Assessment

Hyperlipidemia is an important risk factor, Hyperlipidemia is an important risk factor, and should be used to assess overall cardio-and should be used to assess overall cardio-vascular riskvascular risk

Global CV risk should be used to assess Global CV risk should be used to assess treatment goals and modalitiestreatment goals and modalities

Cardiac endpoints:Cardiac endpoints:– non-fatal MInon-fatal MI– death due to CADdeath due to CAD


Risk assessment model adapted from the Risk assessment model adapted from the Framingham Heart StudyFramingham Heart Study

This model only applies in:This model only applies in:– Patients without diabetesPatients without diabetes– Patients without clinically evident Patients without clinically evident

cardiovascular disease (prior CAD, ischemic cardiovascular disease (prior CAD, ischemic stroke, PAD) or CRFstroke, PAD) or CRF


Which patients are automatically considered Which patients are automatically considered high risk (>20% 10-year risk)? high risk (>20% 10-year risk)?

All adult patients with:All adult patients with:– DMDM– History of CADHistory of CAD– Ischemic strokeIschemic stroke– Peripheral arterial diseasePeripheral arterial disease– CRF ( < 60 ml/min of GFR)CRF ( < 60 ml/min of GFR)


What are the risk factors in Framingham What are the risk factors in Framingham risk calculator?risk calculator?

– AgeAge– GenderGender– Smoking historySmoking history– Lipid profile (TC, HDL)Lipid profile (TC, HDL)– Systolic BPSystolic BP

If the calculated 10-year risk is:

≥20% - ‘High Risk’

11-19% - ‘Moderate Risk’

≤10% - ‘Low Risk’

Whom to Screen for Whom to Screen for Dyslipidemia?Dyslipidemia?

Influenced by cardiac risk factors:Influenced by cardiac risk factors: By age alone (Canadian Guidelines):By age alone (Canadian Guidelines):

– Men over age 40Men over age 40– Women over age 50 (or post-menopausal)Women over age 50 (or post-menopausal)

Adults at any age if:Adults at any age if:– At least 2 risk factors At least 2 risk factors

» DM, HTN, Smoking, Abdominal ObesityDM, HTN, Smoking, Abdominal Obesity» Family history of early cardiovascular diseaseFamily history of early cardiovascular disease

– Physical signs of hyperlipidemia Physical signs of hyperlipidemia » Xanthomata, xanthelasmas, arcus corneae, etcXanthomata, xanthelasmas, arcus corneae, etc

– Evidence of existing atherosclerosisEvidence of existing atherosclerosis

Manifestations of DyslipidemiaManifestations of Dyslipidemia

Eruptive xanthomata on the forearm of a patient with severe ↑TGs↑TGs

Xanthelasmas and tendon xanthomata in patients with severe ↑LDL ↑LDL (the patient at (the patient at the bottom the bottom has has heterozygous heterozygous familial familial hyperchol-hyperchol-esterolemia)esterolemia)

Diagnosis of Asymptomatic Diagnosis of Asymptomatic AtherosclerosisAtherosclerosis

To aid in risk stratificationTo aid in risk stratification Recommended:Recommended:

– Physical examinationPhysical examination– Ankle-Brachial IndexAnkle-Brachial Index

Possibly useful in patients already known to be at Possibly useful in patients already known to be at ‘moderate risk’:‘moderate risk’:– Carotid ultrasonographyCarotid ultrasonography– EKGEKG– Exercise stress testing in men >40 years old with Exercise stress testing in men >40 years old with

established cardiovascular risk factorsestablished cardiovascular risk factors

Risk Categories & Lipid TargetsRisk Categories & Lipid Targets

More about LDL targets to come later – for high-risk patients, these are minimum targets – they should be lower if at all possible

Lipid Targets: TriglyceridesLipid Targets: Triglycerides

No discrete triglyceride goal in each No discrete triglyceride goal in each category, but the optimal level is TG <1.7category, but the optimal level is TG <1.7

TG >10 requires targeted treatment to TG >10 requires targeted treatment to prevent pancreatitis independent of prevent pancreatitis independent of cardiovascular risk cardiovascular risk – diet & lifestyle changesdiet & lifestyle changes– fibrate or niacin, fish oil fibrate or niacin, fish oil

Factors Influencing Risk AssessmentFactors Influencing Risk Assessment

Metabolic SyndromeMetabolic Syndrome Abdominal ObesityAbdominal Obesity Apolipoprotein B (apoB)Apolipoprotein B (apoB) Lipoprotein(a)Lipoprotein(a) HomocysteineHomocysteine C-Reactive Protein (CRP)C-Reactive Protein (CRP) Genetic RiskGenetic Risk

Factors Influencing Risk Factors Influencing Risk AssessmentAssessment

Presence of the Metabolic Syndrome: Presence of the Metabolic Syndrome: ↑ Risk↑ Risk– A clustering of cardiovascular risk factors, including A clustering of cardiovascular risk factors, including

abdominal obesity, insulin resistance, and hypertension, abdominal obesity, insulin resistance, and hypertension, as well as lipid abnormalities (as well as lipid abnormalities (↑TGs and ↓HDL↑TGs and ↓HDL))

Presence of Abdominal Obesity: Presence of Abdominal Obesity: ↑ Risk↑ Risk– with waist circumference as a useful estimatewith waist circumference as a useful estimate


Apolipoprotein B (apoB)Apolipoprotein B (apoB)– ↑↑AApoB (for the same lipid levels) = smaller, poB (for the same lipid levels) = smaller,

denser, denser, more atherogenicmore atherogenic LDL particles LDL particles

– ApoB levels ApoB levels correlate bettercorrelate better than LDL than LDL levels levels to clinical outcomesto clinical outcomes in statin trials in statin trials

– For ‘high risk’ patients, For ‘high risk’ patients, target apoB <0.9g/Ltarget apoB <0.9g/L Lipoprotein(a) (lp(a))Lipoprotein(a) (lp(a))

– Appears to be an independent risk factor for Appears to be an independent risk factor for premature atherosclerosis and CADpremature atherosclerosis and CAD


HomocysteineHomocysteine– ↑↑homocysteine levels predict adverse outcomes homocysteine levels predict adverse outcomes

in patients with CADin patients with CAD– Fixed-dose folate & B12 supplementation trials Fixed-dose folate & B12 supplementation trials

so far have been negativeso far have been negative– No evidence yet to screen for homocysteineNo evidence yet to screen for homocysteine


C-Reactive Protein (CRP)C-Reactive Protein (CRP)

– ↑↑CRP may add prognostic information to CRP may add prognostic information to FraminghamFramingham

– ↑↑CRP associated with abdominal obesity and CRP associated with abdominal obesity and the metabolic syndromethe metabolic syndrome

– May be useful in persons with a May be useful in persons with a calculated 10-calculated 10-year risk of 11-19% (year risk of 11-19% (‘moderate risk’)‘moderate risk’)

» More aggressive Rx?More aggressive Rx?


C-Reactive Protein (CRP)C-Reactive Protein (CRP)– Do not measure during acute illness or in Do not measure during acute illness or in

patients with chronic inflammatory diseasepatients with chronic inflammatory disease– Measure 2x, two weeks apart, use the Measure 2x, two weeks apart, use the lowerlower

valuevalue– Low risk <1 mg/ml & high risk 3-10mg/mlLow risk <1 mg/ml & high risk 3-10mg/ml– If >10mg/ml, look for infection/inflammationIf >10mg/ml, look for infection/inflammation


Genetic RiskGenetic Risk– A confirmed, unambiguous family history of early A confirmed, unambiguous family history of early

onset CAD increases the risk for first-degree relatives onset CAD increases the risk for first-degree relatives (parents, siblings, children)(parents, siblings, children)

» RRI 1.7-2.0RRI 1.7-2.0

– Early onset is defined as <55 years old for men and <65 Early onset is defined as <55 years old for men and <65 years old for women (this is the age of the index years old for women (this is the age of the index relative who had the cardiac event)relative who had the cardiac event)

Selected Major StudiesSelected Major Studies

There are many, many, many trials of There are many, many, many trials of statinsstatins

We will discuss:We will discuss:– MRC/HPS- largest trial of 2a. prevention (+ 1a. MRC/HPS- largest trial of 2a. prevention (+ 1a.

prevention in high risk pt)prevention in high risk pt)– ASCOT-LLA- largest trial of 1a. PreventionASCOT-LLA- largest trial of 1a. Prevention– INTERHEART: largest study of risk factorsINTERHEART: largest study of risk factors

Selected Major TrialsSelected Major Trials

MRC/BHF Heart Protection Study:MRC/BHF Heart Protection Study:– 20,556 men & women aged 40-80 with TC >3.520,556 men & women aged 40-80 with TC >3.5

– All at ‘high risk’ of CADAll at ‘high risk’ of CAD» Known CAD/MI/PVD/CVSKnown CAD/MI/PVD/CVS

» DM, HTN, or bothDM, HTN, or both

– RCT: Simvastatin 40mg vs. placebo RCT: Simvastatin 40mg vs. placebo

– Decreased Decreased death rate by 13% at 5 yearsdeath rate by 13% at 5 years» Decreased combined Decreased combined cardiovascular end points by 24%cardiovascular end points by 24%

» Benefits in all subgroups, including baseline LDL <2.6Benefits in all subgroups, including baseline LDL <2.6

– Very compelling, well done trialVery compelling, well done trial

Lancet 360(9326):7-22, 6 July 2002Lancet 360(9326):7-22, 6 July 2002

Selected Major TrialsSelected Major Trials

Anglo-Scandinavian Cardiac Outcomes TrialAnglo-Scandinavian Cardiac Outcomes Trial– 9000 patients aged 40-79 with baseline TC <6.59000 patients aged 40-79 with baseline TC <6.5– All hypertensiveAll hypertensive

» Had at least 3 risk factors for CADHad at least 3 risk factors for CAD» No pre-existing coronary diseaseNo pre-existing coronary disease

– RCT: Atorvastatin 10mg vs. placebo for 5 yearsRCT: Atorvastatin 10mg vs. placebo for 5 years» ↓↓ MI by 36%MI by 36%» ↓↓ stroke rate by 27%stroke rate by 27%» ↓↓ all cardiovascular events and procedures by 21%all cardiovascular events and procedures by 21%» ↓↓ total coronary events by 29%total coronary events by 29%

– Study was stopped after 3 years because of significant Study was stopped after 3 years because of significant benefit in the treatment groupbenefit in the treatment group

Lancet 361(9364):1149-58, 5 April 2003Lancet 361(9364):1149-58, 5 April 2003

Selected Major StudiesSelected Major Studies

The INTERHEART studyThe INTERHEART study– Potentially modifiable risk factors associated Potentially modifiable risk factors associated

with MI in 52 countries: with MI in 52 countries: – Case Control: 15,152 cases & 14,820 controls Case Control: 15,152 cases & 14,820 controls

in 52 countries on every inhabited continentin 52 countries on every inhabited continent– Findings consistent between old/young, Findings consistent between old/young,

male/female, different countriesmale/female, different countries– 9 risk factors 9 risk factors accounted for accounted for

» >90% of the risk (in men) >90% of the risk (in men) » >94% of the risk (in women)>94% of the risk (in women)

Lancet 364(9437):4999-5014, 4 Sept 2004Lancet 364(9437):4999-5014, 4 Sept 2004

The INTERHEART studyThe INTERHEART study Increase riskIncrease risk

– ↑↑ApoB/ApoA1 ratioApoB/ApoA1 ratio » OR 3.25 OR 3.25

– SmokingSmoking (current vs. never) (current vs. never) » OR 2.87OR 2.87

– Psychosocial factorsPsychosocial factors » OR 2.67OR 2.67

– DMDM » OR 2.37OR 2.37

– History of History of HTNHTN » OR 1.91OR 1.91

– Abdominal ObesityAbdominal Obesity » OR 1.12 1OR 1.12 1stst vs. 3 vs. 3ndnd tertile tertile » OR 1.62 2OR 1.62 2ndnd vs. 3 vs. 3rdrd tertile tertile

Protective:Protective:– eating fruits & eating fruits &

vegetables dailyvegetables daily» OR 0.70OR 0.70

– ≥≥3 units/week of 3 units/week of alcoholalcohol

» OR 0.91OR 0.91

– moderate/strenuous moderate/strenuous physical activityphysical activity

» OR 0.86OR 0.86

TreatmentTreatment

TreatmentTreatment

TreatmentTreatment

In low or moderate risk patientsIn low or moderate risk patients– Start with lifestyle, progress to Rx based on targetsStart with lifestyle, progress to Rx based on targets

In ‘high risk’ patients:In ‘high risk’ patients:– Start drug treatment immediately (statin), concurrently Start drug treatment immediately (statin), concurrently

with diet and lifestyle modificationwith diet and lifestyle modification– Priority is to get LDL <2.5 and TC/HDL <4Priority is to get LDL <2.5 and TC/HDL <4– If can’t reach LDL <2.5:If can’t reach LDL <2.5:

» Cholesterol absorption inhibitors (ezetimibe) better tolerated Cholesterol absorption inhibitors (ezetimibe) better tolerated » Bile acid sequestrants (cholestyramine, colestipol)Bile acid sequestrants (cholestyramine, colestipol)» Either can decrease LDL by another 10-20% compared with Either can decrease LDL by another 10-20% compared with

statin alonestatin alone» Limited evidence for CV benefitLimited evidence for CV benefit

2004 ATP III Update2004 ATP III Update

Lower LDL TargetsLower LDL Targets

In high risk patients mounting evidence In high risk patients mounting evidence supports lower LDL-C targetssupports lower LDL-C targets

Latest CCS guidelines (CJC 2006):Latest CCS guidelines (CJC 2006):– High risk patients: LDL-C < 2.0; TC:HDL <4.0High risk patients: LDL-C < 2.0; TC:HDL <4.0

Revision NCEP (Circulation 2004):Revision NCEP (Circulation 2004):– Suggested targets for high risk patientsSuggested targets for high risk patients

– LDL-C <1.8LDL-C <1.8

TreatmentTreatment

If TC/HDL ratio is still high:If TC/HDL ratio is still high:– Lifestyle modificationLifestyle modification– Increasing Statin Dose (with LDL at target)Increasing Statin Dose (with LDL at target)– Combination Drug TherapyCombination Drug Therapy

TreatmentTreatment

Lifestyle modification:Lifestyle modification:– For For ↑TGs: ↑TGs:

» weight lossweight loss» restriction of refined carbohydratesrestriction of refined carbohydrates» no alcohol, increased exerciseno alcohol, increased exercise

– For ↓HDL: For ↓HDL: » weight lossweight loss» increased monounsaturated fatsincreased monounsaturated fats» moderate alcohol (if TGs normal) moderate alcohol (if TGs normal) » increased aerobic exerciseincreased aerobic exercise

TreatmentTreatment

Increasing Statin Dose (with LDL at target):Increasing Statin Dose (with LDL at target):– For ↓HDL and/or mild ↑TGs (TGs <5), may For ↓HDL and/or mild ↑TGs (TGs <5), may

achieve target TC/HDL ratio by increasing the achieve target TC/HDL ratio by increasing the statin dose even if the target LDL has been statin dose even if the target LDL has been reachedreached

TreatmentTreatment

Combination Drug Therapy Combination Drug Therapy (Limited if any evidence)(Limited if any evidence)::– Moderate ↑TGs -> add salmon oil (1-3g tid) to statinModerate ↑TGs -> add salmon oil (1-3g tid) to statin– ↓↓HDL -> combine statin with niacin. HDL -> combine statin with niacin. – Caution: Caution:

» 1) niacin can cause increased insulin resistance1) niacin can cause increased insulin resistance» 2) niacin-statin combination increases risk of hepatotoxicity2) niacin-statin combination increases risk of hepatotoxicity

– If intolerant to niacin:If intolerant to niacin:» consider statin-fibrate combination consider statin-fibrate combination

(simvastatin or pravastatin with fenofibrate, NOT gemfibrozil)(simvastatin or pravastatin with fenofibrate, NOT gemfibrozil)

» lowest possible doses of eachlowest possible doses of each» very close follow-up watching for hepatotoxicity and myositisvery close follow-up watching for hepatotoxicity and myositis» if no CRFif no CRF

TreatmentTreatment

If If ↑↑TGs:TGs:– Ideal target <1.7Ideal target <1.7

» 11stst line: lifestyle modification line: lifestyle modification» Treatments aimed at lowering the TC/HDL ratio usually also Treatments aimed at lowering the TC/HDL ratio usually also

help lower TGshelp lower TGs

– If TGs >6 despite lifestyle changes, need drug If TGs >6 despite lifestyle changes, need drug treatment even if the TC/HDL ratio is acceptabletreatment even if the TC/HDL ratio is acceptable

» Treatment is needed to avoid pancreatitisTreatment is needed to avoid pancreatitis» Options:Options:

FibrateFibrate NiacinNiacin Salmon oilSalmon oil

Follow-UpFollow-Up

Which blood work should be ordered Which blood work should be ordered in follow-up? How frequently?in follow-up? How frequently?

Follow-UpFollow-Up

Lipids:Lipids:– 6 weeks after start / change of dose (levels reach steady 6 weeks after start / change of dose (levels reach steady

state state within 6 weekswithin 6 weeks of start/change of medication) of start/change of medication)– Long-term follow-up every 6-12 monthsLong-term follow-up every 6-12 months

AST / ALT (0.5 –3% incidence):AST / ALT (0.5 –3% incidence):– Get baselineGet baseline– Use with caution if AST/ALT > 3 x normalUse with caution if AST/ALT > 3 x normal– At 12 weeks after initiation or change in dose (FDA)At 12 weeks after initiation or change in dose (FDA)

CK (< 0.5% incidence):CK (< 0.5% incidence):– Get baselineGet baseline– Check only if symptomatic with myalgias (ATP III Check only if symptomatic with myalgias (ATP III

guideline)guideline)

Case 1 RevisitedCase 1 Revisited

56 M56 M– Acute MI 4 months agoAcute MI 4 months ago– No current cardiovascular symptomsNo current cardiovascular symptoms– Tested for DM post-MITested for DM post-MI

» NegativeNegative

– Non-smoker, no HTNNon-smoker, no HTN Lipids measured while in hospital post-MI:Lipids measured while in hospital post-MI:

– TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2)TC 4.2, LDL 2.5, HDL 1.3, TG normal (TC/HDL 3.2) What is his estimated risk of a cardiovascular event in What is his estimated risk of a cardiovascular event in

the next 10 years?the next 10 years?– Assumed to be Assumed to be ≥20%≥20%

How should you manage his lipids?How should you manage his lipids?


45 F45 F– ‘‘Healthy’, BP 125/80Healthy’, BP 125/80– Non-smoker, 3 units EtOH/weekNon-smoker, 3 units EtOH/week– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)TC 6.5, LDL 4.1, HDL 1.4, TG normal (TC/HDL 4.6)

What is her estimated risk of a cardiovascular What is her estimated risk of a cardiovascular event in the next 10 years?event in the next 10 years?– Calculated to be 1%Calculated to be 1%



55 F55 F– DM Type 2 x 10 years (HbA1c 9.7%), HTNDM Type 2 x 10 years (HbA1c 9.7%), HTN– post menopausal, BMI 33post menopausal, BMI 33– Non-smoker, 4 units EtOH/dayNon-smoker, 4 units EtOH/day– No cardiovascular symptomsNo cardiovascular symptoms

Lipids measured at annual visit:Lipids measured at annual visit:– TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)TC 5.9, HDL 0.78, TG 9.8 (TC/HDL 7.6)

What is her estimated risk of a cardiovascular event What is her estimated risk of a cardiovascular event in the next 10 years?in the next 10 years?– Assumed to be Assumed to be ≥20%≥20%


Documents

Dyslipidemia: Managing a Key Cardiovascular Risk Factor AIMGP Clinic Seminar Updated by R. Cavalcanti Sep 2007