Controversial issues in dyslipidemia management

1
Controversial issues in dyslipidemia management

• By
• Ashraf Reda,MD
• Menoufiya university

2

• ACS
• Regression of plaque
• Aggressive lipid lowering
• Guide lines
• Which statin to which pt.?

3

• ACS
• Regression of plaque
• Aggressive lipid lowering
• Guide lines
• Which statin to which pt.?

4
ACSPROVE-IT TIMI 22
4162 Pts With ACS
80mg Atorvastatin
40mg Pravastatin
Mean follow up24 months
95 mg/dl (2.46 mmol/l)
62 mg/dl (1.6 mmol/l)
LDL
1ry end points
26.3
22.4
16RRR (p0.005)
5
ACS A to Z trial

• 2265 Pts with ACS receiving 40 mg/d of
  simvastatin for 1 month
• followed by 80 mg/d thereafter

• 2232 Pts with ACS patients receiving placebo for
  4 months
• followed by 20 mg/d of simvastatin

--------------------------------------------------
----------------------------
6-24 months follow up
Placebo-Simva (20)gr. Simva
only(40/80) gr.
Median LDL 1 month 8 months
122mg/dl 77mg/dl
68 mg/dl 63mg/dl
--------------------------------------------------
--------------------------------------------------
-----------
HR, 0.89 95 CI 0.76-1.04 P .14).
1ry EPs 343(16.7)
309(14.4)
CVD 109(5.4)
83(4.1)
HR, 0.75 95 CI, 0.57 -1.00 P .05)
Myopathy occurred in 9 patients (0.4) receiving
simvastatin 80 mg/d, in no patients receiving
lower doses of simvastatin , and in 1 patient
receiving placebo (P .02).
6
Is It due to Difference in LDL reduction
or Different in anti inflammatory effect
?
7
Statin effect and baseline CRP
Evidence of an anti-inflammatory effect of
statins
Patients (n 2,924) with 70 stenosis in 1
coronary artery
average of 2.4 years after discharged on a
statin prescription.
.No early statin benefit .Survival curves
separated after gt2 years
.improved survival .Curve separation3months
.Improved survival .Curve separation1week
lt1.2 1.2 to 1.7
gt1.7 mg/dl),
CRP
Joseph B. Muhlestein, a,b, , Jeffrey
L. Anderson, a,b, Benjamin D. Horne, a, John
F. Carlquist, a,b, Tami L. Bair, a,
T.Jared Bunch, a, Robert R. Pearson,
8
Treating to dual targets
Investigators also further stratified patients
based on levels of CRP and LDL cholesterol LDL
cholesterol gt70 mg/dL and CRP gt2.0 mg/L. LDL
cholesterol gt70 mg/dL and CRP lt2.0 mg/L.
II LDL cholesterol
lt70 mg/dL and CRP gt2.0 mg/L. LDL cholesterol
lt70 mg/dL and CRP lt2.0 mg/L.
"Even with the most aggressive statin that we
have used to date, 56 of patients still did not
make it to the dual target,"
9
What can we do to patient with LDL reaching the
goal But wit persistently high CRP?
10

• ACS
• Regression of plaque
• Aggressive lipid lowering
• Guide lines
• Which statin to which pt.?

11

• Decrease the progression
• Prevent progression
• Regression
• 0r is it the plaque stabilization?

12
Main 1ry and 2ry end-point results of REVERSAL
End points Pravastatin, 40 mg (n249) Atorvastatin, 80 mg (n253) p, difference between groups
Median change in atheroma volume (95 CI) 2.7 (0.2-4.7) -0.4 (-2.4-1.5) 0.02
Median change in total atheroma volume (mm3) (95 CI) 4.4 (0.1-6.0) -0.9 (-3.5-1.6) 0.02
Median change in atheroma volume (95 CI) 1.6 (1.2-2.2) 0.2 (-0.3-0.5) 0.0002
---------------------------------------------
--------------------------------------------------
------
-------------------------------------------------
--------------------------------------------------
--
Nissen SE et al. JAMA 2004 2911071-1080.
The effect on clinical out come?
13
REVERSAL Cholesterol levels and percent change
Symptomatic CAD Pts with LDL 125-210mg/dl
LDL level Pravastatin, 40 mg (n249) Atorvastatin, 80 mg (n253)
Final LDL-C, mg/dL 110.4 78.9
change in LDL-C from baseline -25.2 -46.3
--------------------------------------------------
----------------------------------------
--------------------------------------------------
-------------------------------------
Nissen SE et al. JAMA 2004 2911071-1080.
14
Simvastatin and plaque regression after 6 months
of MRI-monitored therapy.
27 patients (treated with simvastatin 20 to 80 mg
daily)
(MRI) for aortic atherosclerotic plaque (AP)
before and after 6 months of therapy
AP volume was reduced from 3.3/-0.1.4 to
2.9/-1.4 cm3 at 6 months (Plt0.02)
luminal volume increase was less accentuated
(from 12.0/-3.9 to 12.2/-3.7 cm3, Plt0.06).
LDL cholesterol decreased by 23 (from 125/-32
to 97/-27 mg/dL, Plt0.05) in 6 months.
?LDL or CRP
Circulation. 2004 Oct 19110(16)2336-41. Lima
JA, Desai MY, Steen H, Warren WP, Gautam S, Lai S.
15
CRP reductions in REVERSAL
CRP Pravastatin, 40 mg (n249) Atorvastatin, 80 mg (n253) p, difference between groups
Median change in CRP -5.2 -36.4 lt0.0001
Final LDL-C , mg/dL
110.4(25.2) 78.9(-46.3)
Reduction of CRP May be related to the magnitude
of LDL reduction
Nissen SE et al. JAMA 2004 2911071-1080.
16

• ACS
• Regression of plaque
• Aggressive lipid lowering
• Guide lines
• Which statin to which pt.?

17
Lower Cholesterol Levels Associated With Lower
CHD Risk
The Framingham Heart Study
150
125
100
CHD Incidence per 1000
75
50
25
0
265-294
? 204
205-234
235-264
? 295
Serum Cholesterol (mg/100 mL)
Castelli WP. Am J Med. 1984764-12.
18
Relation of Serum Cholesterol to CHD Mortality
The MRFIT Study
4
3.42
3
Mortality Relative Risk
2
2.21
1.73
1
n 356,222 (35-57 yrs)
1.29
1
0
lt 182
182-202
203-220
221-244
gt 244
Serum Cholesterol (mg/dL)
Stamler J, et al. JAMA. 19862562823-2828.
19
Increased Relative Risk of CHD Associated With
Increasing LDL Levels
ARIC Study Men
4.50
2.85
Relative Risk of CHD
1.80
Adjusted for age and race 12-year follow-up n
5432
1.15
0.75
2.35
2.85
3.35
3.85
4.35
4.85
(mmol/L)
91
110
130
149
168
188
(mg/dL)
LDL Cholesterol
Adapted from Sharrett AR, et al. Circulation.
20011041108-1113.
20

• ACS
• Regression of plaque
• Aggressive lipid lowering
• Guide lines
• Which statin to which pt.?

21
New Features of ATP III

• Modifications of Lipid Targets
• MAIN TARGET LDL lt100 mg/dL
• HDL lt40 mg/dL considered low (instead of 35
  mg/dL)
• Triglycerides gt200 mg/dL considered to be high
• Focus on Multiple Risk Factors
• Diabetes (without CHD) raised to the level of CHD
  equivalent
• Support for Implementation
• Recommends complete lipoprotein profile (TC, LDL,
  HDL TG) as preferred initial test

NCEP-ATP III National Cholesterol Education
Program-Adult Treatment Panel III Expert Panel
JAMA 2001285(19)2486-2497 Wood D et al
Atherosclerosis 1998140199-270 Sempos CT et
al JAMA 1993269(23)3009-3014 Pearson TA et al
Arch Intern Med 2000160459-467
22
LDL Cholesterol Goals for Therapeutic Lifestyle
Changes (TLC) and Drug Therapy According to NCEP
ATP III
LDL-C Level for Consideration of Drug
Therapy (mg/dL)
LDL-C Level for Initiation of TLC (mg/dL)
LDL-C Goal (mg/dL)
Risk Category
CHD or CHD Risk Equivalents (10-y risk gt 20)
lt 100
? 100

• 130
• (100-129 drug optional)

2 Risk Factors (10-y risk ? 20)
lt 130
? 130
10-y risk 10-20 ? 130 10-y risk lt 10 ? 160
lt 160
? 160
? 190 (160-189 LDL-C-lowering drug optional)
0-1 Risk Factor
NCEP, Adult Treatment Panel III. JAMA.
20012852486-2497.
23
Previous guidelines set the upper limit of normal
according to the risk 160, 130, 100
But
They didnt tell us how low should we go?
24
Changes in the guide lines LDL 100 is not enough
Moderate risk 2-3 RFs
High risk
Diabetic
--------------------------------------------------
--------------------------------------------------
--------
Treatment when gt 130 Optional 100-129
Trigger is 130
ATPIII NCEP update
Targetlt130
--------------------------------------------------
--------------------------------------------------
-------
Target lt130 Optionallt100
Trigger is 100
Treatment when gt100 Aim 30-40 reduction
--------------------------------------------------
--------------------------------------------------
---------
Goal still lt100, optional goal lt70mg/dl Waiting
for TNT, SEARCH and IDEAL (aggressive lowering
in stable Pts)
25
Lipid profile among patients with ACS
incardiology dep. Menoufiya university
No Mean (mg/dl)
TC lt 200mg/dl 25/40 62.5
160.3
Mean BNP 943.2 (N up to 350)
TC gt 200mg/dl 15/40 37.5
238.9
Mean BNP 1376
TGs lt 200 32/40 80
137.2
Mean BNP 988
TGs gt 200 8/40 20
254
Mean BNP 1599.7
Data from file Reda et al 2003
26
Waiting for the big trials Treating to New
Targets (TNT) trial (Atorva80 Vs Atorva
10) 10000 CHD patients and should be completed
in December 2004. In this trial, patients are
treated to different goals to compare the
conventional NCEP guideline of an LDL cholesterol
goal of less than 100 mg/dL with a more
aggressive LDL cholesterol goal of less than 75
mg/dL. The Study of the Effectiveness of
Additional Reduction in Cholesterol and
Homocysteine with Simvastatin and Folic
Acid/Vitamin B12 (SEARCH)
(Simva 20 Vs Simva 80) Compares the
intensity of lipid lowering, rather than specific
goals, in 12000 subjects who have had a prior
MI. The Incremental Decrease in Endpoints
through Aggressive Lipid Lowering (IDEAL) trial
(Atorva 80 Vs Simva 20 or Simva 40)
7600-patient, investigating whether additional
clinical benefits can be achieved by greater
percentage reductions in LDL-cholesterol levels
in patients with existing CHD.
27

• ACS
• Regression of plaque
• Aggressive lipid lowering
• Guide lines
• Which statin to which pt.?

28
Should our targets differ?

• ACS
• Chronic stable CAD
• High LDL
  
• Low HDL
• RACE

29
Pravastatin Primary
prevention (WOSCOPE)
Secondary prevention (CARE, LIPID)
Combination therapy
Fluvastatin PCIACS (LIPS)
Diabetes low HDL
High Apo-B small LDL
Combination therapy
Simvastatin High risk
Diabetes (HPS) Secondary
prevention (4S) ACS (A to Z)
Atorvastatin ACS (MIRACLE,
PROVEIT) Hypertension
Decrease CRP (PROVE-IT, REVERSAL)
Diabetes (CARDS)
30

• ACS
• Regression of plaque
• Aggressive lipid lowering
• Guide lines
• Which statin to which pt.?

31
Thank you
32
Percent of patients who achieved their LDL and
non-HDL cholesterol goals
Davidson MH, et al. Drugs Affecting Lipid
Metabolism 2004 meeting Oct 24-27, 2004 Venice,
Italy Abstract 204.
33
Lipoprotein subclasses by race and gender
Lipoprotein subclass Black women (n40) White women (n108) Black men (n29) White men (n108) p for gender difference p for racial difference
HDL size (nm) 9.17 9.05 8.90 8.67 lt0.0001 0.0004
Small HDL (mg/dL) 17.3 17.1 19.3 19.8 lt0.0001 NS
Large HDL (mg/dL) 35.6 35.7 23.1 18.0 lt0.0001 NS
LDL size (nm) 21.4 21.2 21.0 20.5 lt0.0001 0.002
Small LDL (mg/dL) 8.5 14.3 16.2 34.7 lt0.0001 0.01
Medium LDL (mg/dL) 30.1 35.0 50.3 41.9 0.0034 NS
Large LDL (mg/dL) 85.9 78.1 56.1 40.1 lt0.0001 0.02
VLDL size (nm) 43.6 49.8 47.4 53.9 0.0019 lt0.0001
Small VLDL (mg/dL) 17.4 16.9 20.0 18.3 NS NS
Medium VLDL (mg/dL) 26.0 42.3 35.9 50.5 0.01 0.0001
Large VLDL (mg/dL) 5.98 46.0 22.5 71.2 0.0006 lt0.0001

34
What about HDL?
35
Framingham StudyRelative Risk for CHD
Impact of High LDL and Low HDL
Kannel WB AJC 1983 52 9B -12B
36
ARBITER-2 Niacin added to statin therapy slows
atherosclerotic progression
CAD pts with Low HDL And LDL at goal with
statin N167
Nov 10, 2004
One year StatinNiacin Vs Statin
Placebo LDLlt89HDLlt45 with statin therapy
HDL39 47(21)
No significant progression in IMT Compared to the
placebo group
2004 American Heart Association (AHA) Scientific
Sessions, lead investigator Dr Allen Taylor
37
Fluvastatin increases HDL cholesterol in type 2
diabetic patients
Fluvastatin
Variable Baseline (mg/dL) Month 3 (mg/dL) change
LDL 149 95 -36
Triglycerides 437 261 -40
HDL 41 46 12
Apo A-1 118 124 5
Apo B 139 97 -30
N50
Atorvastatin
Variable Baseline (mg/dL) Month 3 (mg/dL) change
LDL 141 84 -40
Triglycerides 411 221 -46
HDL 41 40 -2
Apo A-1 117 114 -3
Apo B 131 92 -30
N50
Bevilacqua M et al. Drugs Affecting Lipid
Metabolism 2004 meeting October 24-27, 2004
Venice, Italy Abstract 184.
38
VYVA Primary and secondary end points at six
weeks
End points Atorvastatin 10 mg (n235) EZ/Simva 10/10 mg (n230) Atorvastatin 20 mg (n230) EZ/Simva 10/20 mg (n233)
Percent change in LDL -36.1 -47.1 -43.7 -50.6
Percent change in HDL 6.9 7.7 5.1 7.2
Percentage of patients reaching their NCEP goal for LDL 69.4 86.1 80.9 87.6
Percentage of CHD/CHD risk equivalent patients who reached lt70 mg/dL 6 20 17 39
EZ/SEzetimibe/simvastatin
Ballantyne C. Drugs Affecting Lipid Metabolism
2004 meeting October 24-27, 2004 Venice, Italy.
39
VYVA Primary and secondary end points at six
weeks
End points Atorvastatin 40 mg (n232) EZ/Simva 10/40 mg (n236) Atorvastatin 80 mg (n230) EZ/Simva 10/80 mg (n224)
Percent change in LDL -48.3 -57.4 -52.9 -58.6
Percent change in HDL 3.8 9.0 1.4 7.5
Percentage of patients reaching their NCEP goal for LDL 85.3 93.5 89.1 91.5
Percentage of CHD/CHD risk equivalent patients who reached lt70 mg/dL 23 57 36 64
EZ/SEzetimibe/simvastatin
Ballantyne C. Drugs Affecting Lipid Metabolism
2004 meeting October 24-27, 2004 Venice, Italy.
40
Percent change in study end points
End point Placebo (n64) Ezetimibe 10 mg (n187) Fenofibrate 160 mg (n189) Ezetimibe 10 mg fenofibrate 160 mg (n185)
LDL cholesterol ( change) 0.2 -13.4 -5.5 -20.4
HDL cholesterol ( change) 3.2 3.9 18.8 19.0
Triglycerides ( change) -9.2 -11.1 -43.2 -44.0
Non-HDL cholesterol ( change) -0.2 -14.7 -16.2 -30.4
ApoB ( change) -1.2 -11.3 -15.2 -26.1
High-sensitivity CRP ( change) 9.1 -6.1 -28.0 -27.3
Fibrinogen ( change) -0.3 -0.3 -10.1 -11.5
Indicates primary end point
Farnier M et al. Drugs Affecting Lipid Metabolism
2004 meeting October 24-27, 2004 Venice, Italy.
41
CETP inhibitors
Lipid variables Placebo and pravastatin 40 mg (n52) JTT-705 300 mg and pravastatin 40 mg (n47) JTT-705 600 mg and pravastatin 40 mg (n53) p vs baseline
CETP mass ( change from baseline) 2.4 64.1 102.6 lt0.001
Triglycerides ( change from baseline) -1.8 1.7 -8.2 lt0.05
Total cholesterol ( change from baseline) 0.6 3.4 2.5 lt0.01
ApoA-1 ( change from baseline) 0.4 10.7 13.6 lt0.001
ApoB ( change from baseline) 0.5 -0.4 -4.2 NS
Kuivenhoven JA. Drugs Affecting Lipid Metabolism
2004 meeting October 24-27, 2004 Venice, Italy.
42
Side effects
43
Mortality and incidence of cancer during 10-year
follow-up of the Scandinavian Simvastatin
Survival Study (4S).
Death and cancer incidence in the original
treatment groups ( median total follow-up time
of 10.4 years)
Simva
Placebo
RR 0.85 ,95 CI 0.74-0.97, p0.02
No of deaths
414
468
0.76 0.64-0.90, p0.0018
Coronary mortality 238
300
0.81 0.60-1.08, p0.14
Cancer death 85
100
0.88 0.73-1.05, p0.15
Incident cancer 227
248
Strandberg TE, Pyorala K, Cook TJ, Wilhelmsen L,
Faergeman O, Thorgeirsson G, Pedersen TR,
Kjekshus J 4S Group.
44
Genetic risk factors for statin myopathy found
coenzyme Q10, carnitine supplements might help
the American College of Rheumatology 2004
45
Absence of interaction between atorvastatin or
other statins and clopidogrel results from the
interaction study.
All patients (n 75) received 325 mg of aspirin
daily for at least 1 week and 300 mg of
clopidogrel immediately prior to stent
implantation
atorvastatin (n 25), any other statin (n 25),
or no statin (n 25) for at least 30 days prior
to stenting
conventional aggregometry, rapid analyzers, and
flow cytometry
comparison of platelet biomarkers 4 and 24

• Statins in general, and atorvastatin in
  particular, do not affect
• the ability of clopidogrel to inhibit platelet
  function.
• statins may inhibit platelets directly via yet
  unknown mechanism(s)
• possibly related to the regulation of the PAR-1
  thrombin receptors

Arch Intern Med. 2004 Oct 11164(18)2051-7 Serebr
uany VL, Midei MG, Malinin AI, Oshrine BR, Lowry
DR, Sane DC, Tanguay JF, Steinhubl SR, Berger PB,
46
Stopping statins in the short-term is okay for
stable patients Oct 13, 2004

• ACS Abrupt discontinuation increase the risk
• Chronic stable condition Up to 6 weeks my not be
  risky

Dr Mary P McGowan (New England Heart Institute,
Manchester, NH) and colleagues from the Treating
to New Target (TNT)
47
Scientific Board Directors Prof. Dr. Ikram
Sadek. Prof. Dr. Abdel Fattah Ferer. Prof. Dr.
Samir Abdel Kader. Prof. Dr. Helmy Bakr. Prof.
Dr. Saeid Shalaby. Prof. Dr. Ahmed Abdel
Moneim. Prof. Dr. Abdulla Moustafa. Prof. Dr.
Osama Sanad.
48

Conference Guest Faculty
(Chairpersons Speakers
are ordered alphabetically) Abdallah Abou
Hashem Zagazig Abdallah Moustafa Menoufiya Abd
el Moneim Ibrahim Cairo Adel Allam Al
Azhar Adel El Banna NHI Adel El Etreby Ain
Shams Ahmed Abdel Moneim Banha Ahmed
Nassar Ain Shams Ahmed Shafie
Amar Zagazig Aliaa Abdel Fattah Cairo Aly
Ramzy Ain Shams Amany Serag Menoufiya Amr
Serag Tanta Amr Zaki Alexandria Ashraf
Ragab Cairo Ashraf Reda Menoufiya Ayman Abu
El Magd Al Azhar Galal El Saied Cairo Hala
Mahfouz Menoufiya Hany Ragui NHI Helmi
Bakr Mansoura Hesham El Ashmawy Alexandria He
sham Hassan Menoufiya Hossam Kandil Cairo Ibte
hag Hamdy Alexandria Ihab Abdel
Fattah Menoufiya Ihab Attia Ain Shams Ikram
Sadek Tanta Kawkab Khedr Alexandria Khairy
Abd El Dayem Ain Shams Khaled
Sorour Cairo Mahmoud Hassanein Alexandria May
Salama Tanta Medhat El Ashmawy Tanta Mohamed
Ashraf Cairo
49
Mohamed Awad Taher Ain Shams Mohamed El
Noomany Menoufiya Mohamed El Seteiha Tanta Moh
amed Gamal Assiut Mohamed Hamed
Badr Tanta Mohamed Sobhy Alexandria Mohamed
Wafaii Zagazik Mohsen Ibrahim Cairo Mokhtar
Gomaa Al Azhar Moustafa El Sayed Al
Azhar Moustafa Nawar Alexandria Nabil El
Kafrawy Menoufiya Nasser Rasmy Cairo Nesim
Shaaban Tanta Omar Awwad Ain Shams Ossama
Abd El Aziz Tanta Ossama Sanad Banha Ramez
Guindy Ain Shams Ramzi El Mawardi Ain
Shams Rania Gaber Tanta Saeid El
Malah Menoufiya Saied Khaled Ain Shams Saied
Shalaby Menoufiya Sameh Zaghloul Cairo Samir
Abdel Kader Assiut Samir Rafla Alexandria She
rif El Beltagui Alexandria Sherif El
Tobgi Cairo Sherif Mokhtar Cairo Taher El
Kadi NHI Tarek Helmy Cairo Tarek Zaki Ain
Shams Wagdy Ayad Alexandria Wagdy Galal Ain
Shams
50
Cairo 13 Ain shams
12 Menoufiya 10 Alex
10 Tanta 9 Alazhar
4 Zagazig 3 NHI
3 Banha 2 Assuite
2 Mansoura 1 Military
1
51
Lipidology Plenary- 1 Chairperson(s) Mahmoud
Hassanein, Alex 1630-1830
Ossama Abd El Aziz, Tanta Samir Abdel
Kader, Assiut
Wagdy Ayad, Alex 1630-1655 Statin and
ACS When?, how and for whom ?
Mohamed Wafaii Zagazig 1700-1725 The
pleotropic effects of statin Do they really
matter? Omar Awad
Ain Shams 1730-1755 Controversial issues in
Dyslipidemia Ashraf Reda
Menoufiya 1800-1825 HDL
The Forgotten target Ihab
Attia Ain Shams
52
Action- 1 1900 - 2000 Case
Presentation Panel Discussion 1900-1930 Case1
Aorto osteal restenotic lesion Management of
unexpected procedural complications Mohamed
Ashraf Cairo Panelist(s) Ihab Abdel Fattah,
Menoufiya Amr Zaki, Alexandria

Mohamed Sobhy, Alexandria Tarek
Zaki, Ain Shams 1930 - 2000 Case 2
Coronary intervention in a diabetic
patients Hossam Kandil Cairo Panelist(s) Ad
el El Banna, Ain Shams Mohamed El
Seteiha, Tanta Sherif El Tobgi,
Cairo Nabil El Kafrawy, Menoufiya
53
Plenary- 2 2000- 2130 Chairperson(s) Ahmed
Nassar, Ain Shams Helmi Bakr, Mansoura
Ikram Sadek, Tanta Moustafa
Nawar, Alexandria Thrombosis and anti
thrombotics 2000-2025 PCI LMWH From A to Z
to synergy Ramez Guindy Ain
Shams 2030-2055 Clopidogrel 1 month, 9 months
or 12 months ? Adel El Etriby Ain
Shams 2100-2125 Reduction of infract size
after AMI PCI or Lytics Abdallah
Moustafa Menoufiya
54
Flash- 1 2130 - 2300 Chairperson(s) Abdallah
Abou Hashem, Zagazig Hala Mahfouz,
Menoufiya Kawkab Khedr, Alexandria
May Salama,
Tanta
Adel Allam, Al Azhar Immaging ECG Case
Presentation 2130-2145 Case1 Tissue Doppler
imaging IHD or cardiomyopathy ? Mohamed El
Noomany Menoufiya 2145-2200 Case 2 Carotid A-V
fistula Rania Gaber Tanta 2200-2215 Case 3
Myocardial aneurysms Sameh Zaghloul Cairo 2215
2230 Case4 Unusual myocardial
infiltration Abdallah Abou Hashem Zagazig 2230
2245 Case 5 ECG commentary Samir
Rafla Alexandria 2245 2300 Case 6
Perfusion imaging in ACS Aliaa Abdel Fattah
Cairo
55
Friday, 19/Nov/2004 Action- 2 1600 - 1630
Case Presentation Panel Discussion 1600-16
30 Case1 Interventional vs. medical therapy for
arteritis Galal El Saied Cairo Panelist(s) Khale
d Sorour, Cairo Medhat El Ashmawy,
Tanta Saeid El Malah, Menoufiya
Gaafer Ragab, Cairo 1630-1700 Case 2 Decision
making in prosthetic valve endocarditis
with renal failure Amany
Serag Menoufiya Panelist(s) Amr Serag, Menoufiya
Ibtehag Hamdy, Alexandria Nasser Rasmy,
Cairo Ossama Sanad, Banha 1700-1730 Case
3 Drug Elluting Stent pitfalls of the
technique Sherif El Beltagui Alexandria Panelist(
s) Aly Ramzy, Ain Shams Hany Ragui,
NHI Hesham El Ashmawy, Alex Wagdy Galal, Ain
Shams
56
Flash- 2 1730 1800 Chairperson(s) Ahmed
Shafie Amar, Zagazig Nessim Shaaban,
Tanta Taher El Kadi Tarek Helmy,
Cairo Surgery PCI Case Presentations 1730-1745
Case I Volume reduction surgery in heart
failure Adel El Banna NHI 1745-1800 Case II
Mulivessel PCI Hesham Hassan
Menoufiya Plenary -3 1800 - 1900 Chairperson
(s) Ashraf Reda, Menoufiya Mohamed Sobhy,
Alexandria Peripheral Vascular Disease 1800-1820
Molecular bases Abdel Moneim Ibrahim Cairo 183
0-1850 Current therapy and recent trends in the
medical therapy PVD Mohamed Awad Taher Ain
Shams 1900 1930 TEA TIME
57
Plenary- 4 1930 - 2100 Chairperson(s) Khairy
Abd El Dayem, Ain Shams Mohamed Hamed Badr,
Tanta Mokhtar Gomaa, Al
Azhar Hypertension Risk Reduction 1930-1955 T
herapeutic strategies in hypertension control
Minimal or optimal? Mohsen
Ibrahim Cairo 2000-2025 ARBs and the value
of life A, B, or C. Ramzi El Mawardi Ain
Shams 2030-2055 ACEI and reduction of CV
risk Saied Khaled Ain Shams
58
Plenary- 5 2100 - 2300 Chairperson(s) Mohamed
Gamal, Assiut Moustafa El Sayed, Al
Azhar Saied Shalaby, Menoufiya Sherif
Mokhtar, Cairo Controversial Issues 2100-2125 D
iabetes with multivessal disease PCI or
CABG Mohamed Sobhy Alexandria 2130-2155 Ther
apeutic strategies for ACS cooling off or
aggressive Ahmed Abdel Moneim Banha 2200
-2225 Would oral sirolimous replace drug eluting
stents ? Ayman Abu El Magd Al
Azhar 2230-2255 Metabolic approache in the
management of IHD Adel El Etriby Ain
Shams 23
00 Gala Dinner
( Sponsored by Novartis )
59
A to Z Changes in LDL cholesterol
Group Baseline LDL cholesterol (mg/dL) 4 months (mg/dL) 24 months (mg/dL)
Placebo/ simvastatin 20 mg 111 124 81
Simvastatin 40 mg/ simvastatin 80 mg 112 62 66

De Lemos J et al. European Society of Cardiology
Congress 2004 August 28-September 1, 2004
Munich, Germany.
60
VYVA Primary and secondary end points at six
weeks
End points All atorvastatin (n927) All EZ/S (n923)
Percent change in LDL cholesterol -45.3 -53.4
Percent change in HDL cholesterol 4.3 7.9
Percentage of patients reaching their NCEP goal for LDL cholesterol 81.1 89.7
Percentage of CHD/CHD risk equivalent patients who reached lt70 mg/dL NA NA
EZ/SEzetimibe/simvastatin
Ballantyne C. Drugs Affecting Lipid Metabolism
2004 meeting October 24-27, 2004 Venice, Italy.
61
Comparing hyperlipidemia control with daily
versus twice-weekly simvastatin.
nonrandomized, open-label, proof-of-concept study
simvastatin 10 or 20 mg daily 40 or 80 mg
twice weekly, respectively, for 12 weeks.

• The twice-weekly regimen safely maintained most
  of the patients at their LDL-C goal level,
• and over half the patients found this regimen to
  be the same or easier to follow than a daily
• regimen. Large outcome studies evaluating this
  approach are needed.

• Estimated cost-savings at our institution
  associated with this regimen would be 32 000 per
• 1000 patients per year.

Ann Pharmacother. 2004 Nov38(11)1789-93.
Mangin EF, Robles GI, Jones WN, Ford MA, Thomson
SP. University of Arizona Center for Health
Outcomes Pharmaco-Economic Research,
62
LDL cholesterol potentiates the proatherogenic
activity of C-reactive protein
high levels of LDL and CRP resulted in a potent
attenuation of endothelium-dependent vasodilation
Dr Erik S Stroes ,2004 Drugs Affecting Lipid
Metabolism
63
Mean common carotid IMT of the 182 patients who
completed the study
Two-year statin therapy does not alter the
progression of IMT in type 2 diabetic patients
Patients Baseline IMT (mm) 2-year IMT (mm) Mean change (mm) 95 CI p
Placebo (n79) 0.780 0.774 -0.006 -0.022 to 0.011 0.50
Statin (n103) 0.763 0.765 0.002 -0.011 to 0.015 0.78
Beishuizen ED. Drugs Affecting Lipid Metabolism
2004 meeting October 24-27, 2004 Venice, Italy