New Lipid Guidelines Focus on LDL Targets

Dr. Milan Gupta interviewed for The Medical Post at the Canadian Cardiovascular Congress-2009. Written by Andrew Skelly on Dec. 1, 2009 for THE MEDICAL POST. From the Canadian Cardiology Congress held in October 2009.

EDMONTON | New Canadian dyslipidemia guidelines shine the spotlight on LDL cholesterol targets, while relegating most other lipid measures to the sidelines.

The 2009 update of the Canadian Cardiovascular Society (CCS) guidelines for the diagnosis and treatment of dyslipidemia also recommend an equally aggressive LDL target for both high- and moderate-risk patients (<2 mmol/l or at least a 50% reduction).

Meanwhile, other targets involving the total to HDL cholesterol ratio and triglycerides are considered secondary, optional goals to consider once the desired LDL cholesterol level is achieved.

However, apolipoprotein B—a measure of the total number of atherogenic particles—is now considered a valid alternative to LDL cholesterol, with a goal of <0.80 g/l, even though the test isn’t funded by every province.

And the role of high-sensitivity C-reactive protein (hs-CRP) has now been clearly defined, based on last year’s JUPITER (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin) study of statin therapy in people with normal cholesterol. Measurement of hs-CRP is recommended for men older than 50 years and women older than 60 years who are at moderate risk for cardiovascular disease and whose level of LDL cholesterol is less than 3.5 mmol/l.

More intensive lipid-lowering

Dr. Jacques Genest, the lead author of the guidelines and professor and head of cardiology at McGill University in Montreal, told the Medical Post a more intensive lipid-lowering strategy makes sense in moderate-risk patients because they still have a high lifetime risk for cardiovascular disease. And “the data on statins are so strong, robust, compelling and cohesive, that we put priority on treatment of LDL cholesterol,” he said in an interview at the congress, where he and several co-authors discussed the new guidelines in a well-attended workshop.

In another major change since the previous guidelines in 2006, risk stratification now uses a modified Framingham risk score that estimates 10-year risk of all cardiovascular diseases, rather than just cardiovascular death and nonfatal myocardial infarction. A family history of premature coronary artery disease is considered to increase the risk by 1.7-fold in women and 2.0-fold in men.

Dr. Ruth McPherson, a guideline co-author and director of the lipid clinic at the University of Ottawa Heart Institute, told the Medical Post the updated risk calculation is just one of several new features that may prove challenging for physicians to integrate into their practices. For example, “there’s been a lot of confusion out there” about the use of hs-CRP, and using a 50%-reduction target for LDL cholesterol may not be helpful in a patient who is already on a statin and has an unknown baseline level. “Not everybody (on the guideline team) thought the 50% reduction was going to be that useful.”

Reluctance to use higher doses

Indeed, poster presentations by other guideline co-authors suggested there’s plenty of opportunity to improve Canadian patients’ cardiovascular care.

Dr. Lawrence Leiter, head of the division of endocrinology and metabolism at St. Michael’s Hospital and professor of medicine and nutritional sciences at the University of Toronto, reported that 40% to 50% of the 2,436 statin-treated patients enrolled in the Canadian portion of an international epidemiological study, and who visited their health-care provider between April 2008 and February 2009, did not have their LDL cholesterol level at target, especially those at highest risk for cardiovascular events.

“Most of these patients were on low to medium doses of statin,” Dr. Leiter said in an interview. “It is a major challenge that both among patients and physicians, there’s still a reluctance to use higher doses of statins.”

In another study, a team led by Dr. Milan Gupta, staff cardiologist with the William Osler Health Centre in Brampton, Ont., invited 2,225 primary-care physicians across Canada to answer a survey about cardiovascular risk assessment, treatment thresholds and novel biomarkers of vascular risk.

Biomarker

Almost all of the 846 respondents had heard of hs-CRP (the survey was done in the months just after JUPITER was published in November 2008) but only about 31% correctly responded that the biomarker is most useful in the intermediate-risk patient.

“Simply publishing the guidelines is not going to be enough. We really need to help physicians understand the nuances in applying the guidelines, because they’re not completely straightforward,” Dr. Gupta told the Medical Post.

He said the CCS, as a specialist organization, isn’t able to address the educational needs of primary-care physicians, and that task will fall to the pharmaceutical industry through sponsored symposia, printed supplements and other strategies.

No financial backing

However, the guidelines themselves had no financial backing. Dr. Genest said he and his colleagues volunteered their own time to work on them, without any funding, but individual members of the team have relationships with the pharmaceutical industry. “In Canada, it’s tough to find a nationally or internationally known expert who is not also sought by industry for advice. Is that good, or is that bad? I think physicians will have to decide for themselves.”

He added that the CCS worked with other groups, including the Canadian Diabetes Association and the Canadian Hypertension Society, to ensure that overlapping guideline recommendations were harmonized.

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