International Guidelines for Dyslipidemia Management
Cathleen E. Maki,
Introduction The Canadian Guidelines The European Guidelines Conclusion References


Cardiovascular disease (CVD) is a leading cause of global mortality and is responsible for approximately 17 million deaths annually (1). In an effort to reduce this number, the World Heart and Stroke Forum (WHSF) Guidelines Task Force of the World Heart Federation (WHF) recommended that every country develop its own policy on CVD prevention. Although the causes of CVD are common to all parts of the world, the approaches to its prevention will differ between countries for cultural, social, medical, and economic reasons. As stated in a World Health Organization (WHO) report from 2002, “Epidemiological theory indicates that, compared with intensive individual treatment of high-risk patients, small improvements in the overall distribution of risk in a population will yield larger gains in disease reduction when the underlying conditions that confer risk are widespread in the population”; therefore, national policy should be developed combining the expertise of governmental, public health, and professional clinical groups. A number of tools for estimating the risk of coronary heart disease (CHD) have been created including risk-score charts, risk-assessment algorithms, and computer software programs. Many were based on Framingham Heart Study data and others, such as the European Guidelines Systematic Coronary Risk Evaluation (SCORE) system were modified based on results from the second European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE II) (2). The guidelines that describe these tools are widely available from medical societies such as the American Heart Association (AHA), European Society of Cardiology (ESC), the Canadian

From: Contemporary Cardiology: Therapeutic Lipidology Edited by: M. H. Davidson, P. P. Toth, and K. C. Maki © Humana Press Inc., Totowa, NJ


Published guidelines from these sites focus on three strategies (3): 1. When the most recent guidelines were published. the US National Cholesterol Education Panel. and diabetes along with primary care physicians (5). In 1988. For example. Also.5 million in 1998 to 3 million in 2010. In 1998. (4) demonstrated how widely several guidelines differ in the identification and quantification of coronary risk as well as when to initiate lipid-lowering drug therapy. and the United Kingdom. more than 20% of Canadians were predicted to be aged over 65 years by 2011 with the fastest growing age group consisting of those aged over 80 years (5). abdominal obesity. the Working Group on Hypercholesterolemia and other Dyslipidemias formed to analyze data and update these Canadian Guidelines. The guidelines agree that risk factors for CHD are multiplicative and that drug therapy must be initiated once a risk threshold is met. In 2001. Canada. as in all industrialized nations. manifestations of hyperlipidemia. the Canadian Working Group reconvened and published an update in 2003. The committee issued updated management recommendations for dyslipidemia in 2000. The new guidelines attempted to . Based on these findings. hypertension. anyone with diabetes.38 Maki Medical Society (CMS). the Canadian Consensus Conference of Cholesterol (CCCC) published national guidelines for patient screening and the treatment of dyslipidemia (6). Broedl et al. and the Joint British Societies (JBS). 3. lipid metabolism. This chapter will review and compare guidelines for the management of dyslipidemia and prevention of CVD from Europe. The First Nations population. which comprises about 3% of the total Canadian population. THE CANADIAN GUIDELINES Introduction Challenges in the treatment of CVD in Canada. include aging of the population and increasing prevalence of obesity and diabetes mellitus. A secondary prevention strategy for those with established coronary artery disease (CAD). the guidelines differ on how to measure CV risk and what threshold is best before initiating treatment for dyslipidemia (4). 2. in a study of 100 German men and women. The guidelines were reviewed by two expert panels that included recognized specialists in the areas of CVD prevention. smoking history. strong family history of premature CVD. and 31% of Canadian adults were obese BMI >27 kg/m2 . however. Adult Treatment Panel III (NCEP ATP III) Guidelines were published followed by findings from several large clinical trials on dyslipidemia.000 per year with the prevalence increasing from 1. Risk Assessment The 2003 Canadian Update recommend routine screening for all men over age 40 and all women who are postmenopausal or are over age 50. The authors predicted the incidence of new cases of diabetes to be 60. is felt to be at particular risk in the development of diabetes at 3–5 times higher than the general Canadian population (5). A high-risk strategy first to identify those at high risk and then to treat this population. A population strategy for altering lifestyle and environmental risk factors as well as social and economic contributions to CHD. or evidence of symptomatic or asymptomatic atherosclerosis should be routinely screened (5).

and moderate alcohol intake [only with normal triglycerides (TGs)] combined with weight loss are recommended. Clinical trials have demonstrated that patients with low HDL-C have a significantly higher residual risk of events on statin therapy. the management of patients who have combined dyslipidemia and low HDL-C levels. To achieve a TC: HDL-C target of <4 0. moderate (11–19%). the 10-year absolute risk is calculated. and the NCEP ATP III Guidelines (6) adapted the equations based on the estimated 10-year risk of “hard cardiac endpoints” including death from CAD and non-fatal myocardial infarction (MI).Chapter 3 / International Guidelines for Dyslipidemia Management 39 standardize CV risk assessment across North America using the Framingham Heart Study model for estimating the 10-year risk of CVD in men and women without diabetes mellitus or clinical evidence of CVD (Fig. Metabolic Syndrome The Working Group defined metabolic syndrome in qualitative terms that included abdominal obesity. the addition of fish oil in combination with a statin may be beneficial in patients with moderate hypertriglyceridemia. For patients with low HDL-C levels. low HDL-C levels. Lifestyle Therapy For patients with hypertriglyceridemia. If a patient is not a candidate for niacin therapy. One advantage of this approach is for patients with low HDL levels where more aggressive LDL-C lowering and/or HDL-C raising may be necessary to achieve both targets. Specific topics addressed in the 2003 Guidelines include the management of patients that are at high risk of CAD and are already at target for LDL-C (100 mg/dL). or low ≤10% risk have established target goals to guide lipid-lowering drug therapy (Table 1). homocysteine. increased intake of monounsaturated fats. and both targets must be met. increased activity (aerobic exercise). the combination of a statin with niacin is recommended. Combination Therapy In patients with combined dyslipidemia and low HDL-C levels. The Framingham CV risk equations were first published by Grundy and colleagues in 1999. Patients at high (≥20% or a history of diabetes mellitus or other atherosclerotic disease). the LDL-C must often be lowered to <75 mg/dL in those patients with low HDL-C (7). 1). The Working Group has published the following recommendations to achieve the TC: HDL-C of <4 0. the group recommends substituting a fibrate. The ratio has also been shown to be a better epidemiologic predictor of CV events than LDL-C and also appears to significantly improve event prediction on statin therapy (14). Also. dietary therapy and exercise regimens are intensified with the focus on weight loss and the restriction of refined carbohydrates and alcohol. The Canadian Guidelines were further simplified by using two treatment targets [low-density lipoprotein cholesterol (LDL-C) and the total cholesterol to highdensity lipoprotein cholesterol ratio (TC: HDL-C)]. Using the revised Framingham risk-stratification algorithm as described in the NCEP ATP III Guidelines (6). Factors such as metabolic syndrome. and C-reactive protein are discussed as they relate to their influence on risk assessment. lipoprotein (a). elevated plasma TG levels. and high blood pressure (Table 2). and the patient is placed into one of three risk categories. insulin resistance. apolipoprotein B. The Working Group used waist circumference . and the non-invasive assessment of CVD and other risk factors.

. 1.40 Age (years) Points Men –9 –4 0 3 6 8 10 11 12 13 Maki Women –7 –3 0 3 6 8 10 12 14 16 20–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 Total Cholestral Points Age 20–39 Men Women Age 40–49 Men Women 0 3 5 6 8 0 3 6 8 10 Age 50–59 Men Women 0 2 3 4 5 0 2 4 5 7 Age 60–69 Men Women 0 1 1 2 3 0 1 2 3 4 Age 70–79 Men Women 0 0 0 1 1 0 1 1 2 2 >160 160–199 200–239 240–279 ≥280 0 4 7 9 11 0 4 8 11 13 Smoking Status Points Age 20–39 Men Women 0 8 0 9 Age 40–49 Men Women 0 5 0 7 Age 50–59 Men Women 0 3 0 4 Age 60–69 Men Women 0 1 0 2 Age 70–79 Men Women 0 1 0 1 Non-Smoker Smoker HDL (mg/dL) ≥60 50–59 40–49 <40 Points Men –1 0 1 2 Women –1 0 1 2 Fig. (Continued).

05 g/L the 50th percentile. Advantages also include being able to measure a non-fasting blood sample. Apolipoprotein B The Canadian Guidelines discuss the advantages of measuring apolipoprotein B especially in patients with moderate hypertriglyceridemia and metabolic syndrome. . (5) Canadian population values for apolipoprotein B have been established. 1. Reproduced with permission (6). Modified Framingham Score: estimate of 10-year coronary heart disease (CHD) risk. apolipoprotein B measurement has been standardized. According to Genest. The guidelines also review the role of visceral fat as being the most strongly related to insulin resistance and dyslipidemia (5).Chapter 3 / International Guidelines for Dyslipidemia Management Systolic BP (mm Hg) If Untreated Men 0 0 1 1 2 If Treated Men 0 1 2 2 3 41 Women 0 1 2 3 4 Women 0 3 4 5 6 <120 120–129 130–139 140–159 ≥160 Total Points: ———–. Fig. an apolipoprotein B level of 0. and 1. and most Canadian laboratories have the equipment and expertise to measure it. 1. values as established by the NCEP ATP III Guidelines of 102 cm for men and 88 cm for women as the cut-off values. Check next table to determine 10-year CHD risk.9 g/L is around the 20th percentile.2 g/L the 75th percentile. Men Total Points ≤12 13 14 15 16 ≥17 Women Total Points ≤19 20 21 22 23 24 ≥25 10-year risk (%) ≤10 12 16 20 25 ≥30 10-year risk (%) ≤8 11 14 17 22 27 ≥30 10-year risk:———–% A 10-year CHD risk >20% is a CHD risk equivalent. In the Canadian population.

high-density lipoprotein cholesterol. Reproduced with permission (5). low-density lipoprotein cholesterol. Reproduced with permission (5). LDL-C.0 mmol/L HDL-C. Homocysteine Randomized controlled trials studying the effects of lowering homocysteine levels on CV endpoints are finishing. Table 2 Clinical Identification of the Metabolic Syndrome Risk factor Abdominal obesity Men Women TG level HDL-C level Men Women Blood pressure Fasting glucose level Defining level Waist circumference >102 cm Waist circumference >88 cm 1.2–7.7 mmol/L <1 0 mmol/L <1 3 mmol/L 130/85 mmHg 6. The position of the Working Group.42 Table 1 Risk Categories and Target Lipid Levels Target level Risk category High Moderate Low LDL-C (mmol/L) <2 5 <3 5 <4 5 TC: HDL-C <4 0 <5 0 <6 0 Maki HDL-C. triglyceride. and the Heart and Stroke Foundation of Canada is that there is currently insufficient evidence to warrant homocysteine screening until the results of these trials are known. the Canadian Cardiovascular Society. The group does recommend however that there may be a specific indication for treatment with folic acid and vitamin B12 in patient’s undergoing percutaneous coronary revascularization (8–10). They also suggest the . Lipoprotein (a) The Canadian Guidelines suggest that the measurement of lipoprotein (a) although not a routine measurement may be useful in determining CV risk in patients with moderate risk and a family history of early CVD. A lipoprotein level >30 mg/dL in a patient with a TC: HDL-C >5 5 or other risk factors may indicate the need for earlier and more intensive therapy to lower the LDL-C level (5). TG. total cholesterol. high-density lipoprotein cholesterol. the AHA. TC.

central. particularly recent clinical trials. Europe has the oldest population in the world. . 1 in 8 men and 1 in 17 women die from CVD before the age of 65 (3). High-Sensitivity C-Reactive Protein The Canadian Guidelines do not currently recommend the use of C-reactive protein in risk-assessment screening. and eastern European countries. the European Atherosclerosis Society. and the European Society of Hypertension collaborated and published a set of guidelines in 1994 on the prevention of CHD in clinical practice. they recognize that the measurement may be useful in identifying people at higher CV risk than that predicted by the global riskassessment score. In Europe. ischemic stroke. and peripheral artery disease. and therapeutic goals for the prevention of CHD. Two European surveys (EUROASPIRE I and EUROASPIRE II) were done in 1995 and again in 1999–2000. formed to represent eight societies across Europe. most Canadians would pay out of pocket for the test. the European Heart Network. CVD accounts of 49% of all deaths in Europe and 30% of all deaths before the age of 65 (3). The first guideline revision was published in 1998 by the Second Joint Task Force. (iii) elaboration on explicit clinical priorities. There was little improvement seen between the two surveys (3). Historically. At this time. Both surveys revealed an unacceptable gap between coronary disease prevention recommendations and what was achieved in the European population. the Third Joint Task Force of European and other Societies on CVD Prevention in Clinical Practice. The studies described how secondary prevention was being achieved in clinical practice. the ESC. CVD accounted for 22% of all disability-adjusted life years lost in Europe (3). with the highest rates found in the east. The objective of the revised guidelines was to reduce the incidence of first or recurrent clinical events because of CHD. and the International Society of Behavioral Medicine joined the original three societies. The Third Joint Task Force provided the second revision in 2003 which differed from the previous guidelines in four major areas: (i) a shift of focus from CHD prevention to CVD prevention.Chapter 3 / International Guidelines for Dyslipidemia Management 43 treatment of patients with homocysteine levels >10 mol/L using folic acid and vitamins B12 and B6 may be warranted in high-risk patients with renal or CVD (5). the prevalence of CVD is on the rise. This revision set lifestyle. The Third Joint Task Force was joined by the European Association for the Study of Diabetes and the International Diabetes Federation of Europe. In the Second Joint Task Force. and (iv) the inclusion of newly published data in preventive cardiology. however. and projections determine that one in three Europeans will be older than age 65 by the year 2050 (3). risk factor. (ii) the development of the SCORE method of estimating CVD risk. The ESC Committee for Practice Guidelines (CPS) supervises and coordinates the development and subsequent publication of new or updated guidelines produced by expert groups or consensus panels (Task Forces) within the European community. In 2000. One such Task Force. There are also large differences between CVD mortality in western. Even though mortality rates are declining. the European Society of General Practice/Family Medicine. THE EUROPEAN GUIDELINES Introduction Cardiovascular disease is the leading cause of death in European adults in their middle and older years.

and 4.g. and the ability to estimate relative risk by comparing one risk cell against that of a non-smoking healthy person of the same age/gender (3). Risk Assessment As in the Canadian and NCEP ATP III Guidelines. Luxembourg. systolic blood pressure. Spain. Italy. markedly raised levels of a single risk factor. b. the SCORECARD system software program provides information on how total risk can be reduced by specific interventions such as lifestyle modification and drug therapy. liver/kidney disease. other individuals encountered in routine clinical practice (3). and either TC or HDL-C ratio. therefore. The high-risk chart is used in all other European countries. Greece. Management of CVD Risk Factors Behavioral Risk Factors Behavioral risk factors including diet. TC and LDL-C goals are used to guide the decision process and. Advantages of the SCORE system include the ability to produce risk charts tailored to specific European countries where reliable national mortality data are available. The low-risk chart is used in Belgium. the Task Force recognized that these interventions are targeted at populations of highest risk. these will not be reviewed. Two risk-stratification charts are available.44 Maki In the preparation of these guidelines. Total risk is estimated using the SCORE system for patients without known vascular disease. Systematic Coronary Risk Evaluation integrated several modifiable and nonmodifiable risk factors including gender. Lipid Management Prior to the initiation of any therapies. age. smoking. 3. Therefore. and c. the ability to project estimated CVD risk to age 60. SCORE is derived from a large data set of European subjects (EUROASPIRE II) and was designed to predict fatal atherosclerotic endpoints (e. which also suggest that recent surveys identified a significant gap between the recommendations provided and the advice given out by physicians in routine clinical practice (3). type 2 diabetes mellitus. 2). activity. In addition to SCORE. diabetes. should be kept <190 . one for high-risk European countries and one for low-risk European countries. and smoking are addressed in the new guidelines. 2. close relatives of patients with early onset CVD and asymptomatic individuals at particularly high risk. France. Switzerland. the Third Task Force uses a CVD risk-stratification method to guide therapeutic intervention in the European community (Fig. secondary causes of dyslipidemia are ruled out including alcohol. multiple risk factors. in general. Using the recommendations from the SCORE chart. PVD. and Portugal. asymptomatic patients with a. patients with established CHD. fatal CVD events) over a 10-year period (3). and concurrent drug therapy. Patients who score ≥5% are candidates for intensive risk-factor intervention. hypothyroidism. ESC guideline recommendations in these areas closely follow evidence-based practice guidelines as outlined in all guidelines referenced in this chapter. and cerebrovascular atherosclerotic disease.. the guidelines suggest the following priorities for CVD prevention in clinical practice: 1.

. 2. CVD risk-stratification method to guide therapeutic intervention in the European Community. Reproduced with permission (3).Chapter 3 / International Guidelines for Dyslipidemia Management 45 Fig. the SCORE chart.

Diabetes In general. The European Guidelines also suggest the following in the prevention of CHD in clinical practice: Aspirin or other platelet-modifying drug therapy in virtually all patients with diagnosed CVD. In those asymptomatic patients with high multifactorial risk as defined in the SCORE chart. these values are used as risk markers of increased CVD risk. In asymptomatic patients with a risk score of <5%. total cholesterol. the guidelines recommend a further reduction of TC to <175 mg/dL and LDL-C to <100 mg/dL using lipid-lowering drug therapy. the total risk remains ≥5%. respectively. drug therapy is begun.46 Maki and 115 mg/dL. Although no treatment goals are defined for TGs and HDL-C.0 mmol / L 79–90 mg / dL 4. The patient is then monitored at yearly intervals. treatment goals for patients with diabetes are more extensive and are represented in Table 3. If. Beta-blockers following MI or in patients with left ventricular dysfunction related to CHD.0–5. low-density lipoprotein cholesterol. The goals in this population are TC <175 mg/dL and LDL-C <100 mg/dL. Reproduced with permission (11). the full lipid panel analysis is completed and interventions are prescribed (including intensive dietary changes exclusive of drug therapies) until the value for LDL-C falls <190 mg/dL and TC falls <155 mg/dL and the total CVD risk falls <5%. no specific guidelines exist beyond those described by the SCORE assessment guidelines. An HDL-C of <40 mg/dL in men and <46 mg/dL in women along with TG of >150 mg/dL increase the patients’ risk score. Although the guidelines suggest that patients with metabolic syndrome are usually at high risk of CVD. . TC. Table 3 Diabetic Treatment Goals Goal HbA1C Venous plasma glucose Fasting/pre-prandial Self-monitored blood glucose Fasting/pre-prandial Postprandial Blood pressure TC LDL-C ≤6 1% ≤6 0 mmol/L <110 mg/dL 4. Metabolic Syndrome The European Guidelines use the definition of metabolic syndrome as defined in the NCEP ATP III Guidelines. If the risk score is ≥5%. however.5 mmol / L 70–135 mg/dL <130/80 mmHg <4 5 175 mmol/L mg/dL <2 5 100 mmol/L mg/dL LDL-C. the risk assessment is repeated at 5-year intervals.0–7.

In the United Kingdom. women with premature menopause. those at highest risk for the development of CVD (≥20% over the next 10 years). the guidelines suggest that an absolute risk of ≥20% . This includes those patients with any known form of CVD. smoking status is defined as lifetime exposure to tobacco. and those who are not yet diabetic but demonstrate impaired glucose tolerance. All representatives of the committee contributed to the text and those from the specialist societies of hypertension. All sections of the document represent an evidence-based consensus by all professional societies involved. Lipid Management The decision to initiate lipid-lowering drug therapy is determined by the absolute risk of developing CVD. The JBS2 guidelines focus on those individuals considered at highest risk from CVD. In the year 2000. The National Health Service estimated that costs related to CHD are £1 6 billion per year with only 1% spent on primary prevention of CVD. those with elevated TGs >1 7 mmol/L . In situations where patients are being treated for one or more of these risk factors. 3). and those with diabetes mellitus (13). the charts may then only be used as a guide (13). Behavioral Management All patients are encouraged to stop smoking. In general. and glucose management. Of note. and maintain a BMI of <25 kg/m2 with no central obesity (waist circumference <102 cm in men and <88 cm in women). The use of these charts is not appropriate for patients with existing CVD or those at higher risk ≥20% from other medical conditions such as diabetes.Chapter 3 / International Guidelines for Dyslipidemia Management 47 Angiotensin-converting enzyme (ACE) inhibitors in patient with symptoms or signs of Left ventricular Dysfunction LVD related to CHD and/or arterial hypertension. HEART UK. CHD was responsible for one in four male deaths and one in six female deaths totaling around 125. The JBS2 guidelines consider a patient at ≥20% risk of developing CVD is approximately equivalent to a >15% risk of developing CHD over the next 10 years. familial dyslipidemias. Joint British Society Guidelines Data collected from 1988 to 1991 by the WHO revealed that the death rate from CVD in the United Kingdom was the highest in the world at that time. The overall cost to the UK economy is estimated at £10 billion each year (12). CHD is the most common cause of premature death (12). and The Stroke Association. The absolute risk for developing CVD can be estimated from the JBS2 CV risk prediction chart (Fig. and diabetes were specifically responsible for developing the sections on blood pressure.000 deaths. make healthier food choices. and HDL values. Primary Care Cardiovascular Society. increase aerobic activity. TC. limit alcohol intake to <21 units/week for men and <14 units/week for women. British Hypertension Society. The most recent JBS’ guidelines on CVD prevention (JBS2) published in 2005 were developed by nominated representatives from six professional societies including the British Cardiac Society. The charts are also based on groups of patients with untreated blood pressure. Diabetes UK. lipids. and Anti-coagulants in those patients with CHD who are at increased risk of developing a thromboembolic event. lipids. The authors also state that absolute CVD risk is higher than indicated in the charts for those patients with a family history of premature CVD. not only tobacco use only at the time of assessment. or renal dysfunction.

(Continued). . In patients with existing CVD. Angiotensin-converting enzyme inhibitors for patients with symptoms of heart failure at the time of MI or those with persistent LVD (ejection fraction <40%). Fig.48 Maki of developing CVD over the next 10 years is sufficient to consider drug therapy. Blood pressure-lowering therapy as outlined by the British Hypertension Society. the target range for TC is <4 0 mmol/L or a 25% reduction (whichever is lower) and for LDL-C <2 0 mmol/L or a 30% reduction (whichever is lower). Beta-blockers following MI. 3. all patients with existing CVD should be considered for cardioprotective therapies that include Aspirin 75 mg daily. Cardioprotective Therapy In addition to the lipid-lowering target ranges.

Use angiotensin II receptor blockers if ACE inhibitor intolerant. lipid-lowering drug therapies. 3. Guidelines for Asymptomatic Patients at High Risk The JBS2 guidelines also discuss management of asymptomatic patients at high risk for developing CVD according to blood pressure management. Consider ACE inhibitor for those with normal LV function if blood pressure targets not achieved. and screening of first-degree relatives (Table 4). and Anticoagulant therapy for those with CVD patients at high risk for systemic embolization. Calcium channel inhibitors in patients with coronary disease when blood pressure targets have not been achieved. Reproduced with permission (12). . JBS2 CV risk prediction chart.Chapter 3 / International Guidelines for Dyslipidemia Management 49 Fig. cardioprotective drug therapy.

LDL-C. Reproduced with permission (12). total cholesterol. .50 Table 4 Guidelines for Asymptomatic People at High Risk of Developing Cardiovascular Disease (CVD) Category BP Parameters Healthy subjects SBP ≥160 mmHg DBP ≥100 mmHg Healthy subjects SBP = 140–159 mmHg DBP = 90–99 mmHg Sub-parameters Treatment Maki Lifestyle advice drug therapy if sustained CVD risk ≥20% or target organ damage or diabetes CVD risk <20% and no target organ damage and no diabetes Healthy subjects BP = 140/85 mmHg Cholesterol Healthy subjects with familial hypercholesterolemia or other inherited dyslipidemias Healthy subjects with CVD risk ≥20% Lifestyle advice and drug therapy Lifestyle advice. low-density lipoprotein cholesterol. monitor BP. and reassess annually Lifestyle advice. reassess in 5 years Lifestyle advice and drug therapy TC >4 0 mmol/L and LDL-C >2 0 mmol/L TC >4 0 mmol/L and LDL-C >2 0 mmol/L Cardioprotective drug therapy Screening of first-degree relatives Healthy subjects with CVD risk <20% and no CV complications and no diabetes Adults aged >50 years Lifestyle advice and drug therapy Lifestyle advice and reassess annually Lifestyle advice. TC. blood pressure. reassess in 5 years Aspirin 75 mg daily Screen close relatives if familial hypercholesterolemia or other inherited dyslipidemia is suspected Controlled BP <150/90 mmHg BP.

NCEP ATP III. high-density lipoprotein cholesterol. Fasting plasma glucose ≤6 0 mmol/L. Diabetes Mellitus The guidelines discuss optimal targets for the following: HbA1C <6 5%. Blood pressure <130/80.0 mmol/L and LDL-C >2 0 mmol/L and prescribe drug therapy Women >50 or postmenopausal Considered high risk ≥20% over the next 10 years Diabetic patients Considered high risk ≥20% over the next 10 years Included in the same riskstratification chart Cholesterol management (asymptomatic and known CVD) Dependent on LDL-C and number of risk factors High risk ≥5%. TC <4 mmol/L or 25% decrease. drug therapy to decrease TC to <5 0 mmol/L and LDL-C <3 mmol/L Based on risk level—high. and low CVD. cardiovascular disease. LDL-C. National Cholesterol Education Panel. and LDL-C <2 0 mmol/L or 30% decrease. . moderate. Adult Treatment Panel III. TC. total cholesterol.Chapter 3 / International Guidelines for Dyslipidemia Management Table 5 Guideline Comparisons Guideline Database Parameters used to calculate absolute risk NCEP ATP III Framingham Sex Joint European Eurosphere II Sex Joint British Framingham TC: HDL-C Canadian Framingham TC 51 Age ranges applicable to guidelines (years) Age SBP Smoking Diabetes TC HDL-C 20–79 Tobacco SBP TC Age SBP Sex Tobacco Age HDL-C SBP Age Tobacco 40–65 <50 Men >40 50–59 >60 Aged ≥40 years receive statin and 18–29 based on comorbidities Known CVD or asymptomatic/high risk with TC> 4. low-density lipoprotein cholesterol. HDL-C.

Prentice RL. and Family history of premature CVD. Comparison of current guidelines for primary prevention of coronary heart disease. vitamin B(12). Nephropathy. N Engl J Med 2001. Fodor G.10(supplement 1):s1–s78. all describe what the ideal parameters should be and when to consider initiating drug therapy. Effect of homocysteine-lowering therapy with folic acid. et al. 10. Schnyder G. Broedl UC. Principles for national and regional guidelines on cardiovascular disease prevention: a scientific statement from the World Heart and Stroke Forum.htm. Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update. et al. Schnyder G. Pin R. Smith SC. Rossouw JE. The Joint European Guidelines are now unique in their use of EUROASPIRE II data versus Framingham Heart Study data.gov/guidelines/cholesterol/atp3_rpt. 8. The JBS2 guidelines provide specific target goals for diabetic (Type 1 and Type 2) patients regarding cholesterol. Metabolic syndrome. Available at http://www. yet. Davidson. et al. National Cholesterol Education Program Expert Panel. Writing group for women’s health initiative investigators. Circulation 2004. TC >6 mmol/L. Am J Cardiol 2004. Brookes L.109:3112–3121.345(22):1593–1600. 6. and treatment of high cholesterol in adults (Adult Treatment Panel III). REFERENCES 1. Flammer Y. DeBacker G. Anderson GL. Notable differences remain in whether to utilize the TC: HDL-C or continue to use LDL-C as the primary marker for cholesterol management. Jackson R. NIH Publication 02–5125. CMAJ 3004. (2004) Emerging Therapeutic Strategies for the Management of Dyslipidomia in Patients with the Metabolic Syndrome. Frohlich J. Pearson TA. Ambrosioni E. evaluation. Elevated blood pressure requiring therapy. and vitamin B(6) on clinical outcome after percutaneous coronary intervention: the Swiss Heart study: a randomized controlled trial. Some prefer to include patients with diabetes in the same stratification system as non-diabetics. European guidelines on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts).nhlbi. HbA1C >9%. Genest J. 4. 5.288(8):973–979. McPherson R. Medscape Cardiol 2003. . Parhofer KG. Third Report.nih.169(9):921–924. diabetics with at least one of the following conditions are to be prescribed statin therapy: Retinopathy.18:190–195. 9. Decreased rate of coronary restenosis after lowering of plasma homocysteine levels. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial.52 Maki Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers are to be prescribed for patients with renal dysfunction and microalbuminuria. Roffi M. the guidelines and stratification systems will be modified to reflect the changing demographics and will incorporate the latest research data. Eur J Cardiovasc Prev Rehabil 2003. Borch-Johnson K. CONCLUSION Table 5 summarizes the similarities and differences of the guidelines reviewed.288(3):321–333. J Gen Intern Med 2003. All diabetic patients aged ≥40 years are to be prescribed statin therapy. Detection. For those aged 18–39. et al. 2. 3. As the population ages and more countries become industrialized. et al. JAMA 2002. Geiss HC. Roffi M. MH. 7.93(suppl): 3c–11c. JAMA 2002. European guidelines on cardiovascular disease prevention.

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