HYPERLIPIDEMIA

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HYPERLIPIDEMIA

• DR L RABANYE

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DEFINITION

• Major risk factor for atherosclerosis as a result
  of elevated levels of serum cholesterol
• Major component of Serum Cholesterol
• - LDL-C ( Low density level lipoprotein)
• - HDL-C (High density level lipoprotein)
• - TG ( Triglycyrides)

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Objective of Treatment Guidelines

• Identify patients at cardiovascular risk
• In-line with advances in diagnosis
• Incorporating newly identified/quantified risk
  factors
• Metabolic syndrome
• Diabetes
• Treatment guidelines based on evidence pool
  available at the time of publication
• Can be expected to change with the emergence of
  new evidence
• As evidence accumulates that greater LDL-C
  reductions are associated with greater reductions
  in CVD risk, guidelines are updated to reflect
  lowered LDL-C goals

TARGET CHOLESTEROL LEVELS LDL-C lt 3 mmol/L in
asymptomatic patients LDL-C lt 2.5 mmol/L in
established CVD and diabetic patients
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Developmental Process of Atherosclerosis
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Burden of Diseases (CV)

• The three leading causes of disease in 2030
• HIV/ AIDS
• Unipolar depressive disease
• Ischaemic heart Disease

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Prevalence of Chronic Conditions in Registered
Schemes

• The most prevalent conditions (per 1000
  beneficiaries)
• Hypertension (86)
• Hyperlipidaemia (42)
• Asthma (24)
• T2DM (19)
• CAD (17)

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Multiple Risk Factors Cause Cumulative Increase
in Risk for CVD
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RISK FACTORS

• Obesity
• Smoking
• Diabetes Mellitus
• Lack of physical Exercise
• Hypertension
• Genetics

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Types Of Lipid Lowering Drugs

• Statins
• Fibrates
• Niacin
• Resins
• Selective cholesterol inhibitor

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Primary PreventionAre We Identifying the Right
Patients?
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Economic Burden of Cardiovascular Disease in the
US Estimated for 2005
Billions of Dollars
Heart disease
Coronary heart disease
Stroke
Hypertensive disease
Congestive heart failure
Total CVD
American Heart Association. Heart Disease and
Stroke Statistics2005 Update.
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Effect of Long-Term Modest Reductions in CV Risk
Factors
Effect of Long-Term Modest Reductions in CV Risk
Factors
Emberson et al. Eur Heart J. 200425484-491.
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Heart of Soweto Study

• Cross-Sectional Study at Chris Hani Baragwanath
• Objective Describe recent ? in ACS among urban
  black South Africans
• Epidemiological transition due to urbanization
• adoption of Western lifestyle and diet
• vs. traditional (cardio-protective) African
  lifestyle
• 1950s average of 3 patients/annum identified
  with AMI
• 1975-80 Total of 50 cases average of 8
  patients/annum
• 2004 64 patients with ACS in one year alone
• Annual incidence of ACS (based on population
  size)
• 1975-80 0.5 1 per 100 000
• 2004 7 per 100 000

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Rule out Secondary Causes

• LIFETSYLE FACTORS
• DIET Triglycerides HDL-C and LDL-C
• SMOKING HDL-C
• ALCOHOL Triglycerides
• UNDERLYING DISEASES
• ? CHOL Hypothyroidism, Renal disease, liver
  disease, DM
• ? TRIGS Truncal Obesity, Diabetes, Cushings
  Syndrome
• PREGNANCY
• ? Cholesterol severe hypertriglyceridaemia in
  susceptible
• MEDICATION
• Progestins Steroids some beta-blockers high
  dose diuretics retinoids Protease inhibitors

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Treatment Rates For Dyslipidemia in US Are High
but Few Patients Reach Goals
lt 50 receive treatment
Patients On Lipid-Lowering Treatment
Patients with Dyslipidaemia
Treated to Goal
There is more that can be done to improve quality
of care delivered to patients
NHANES 1999-2002, Home Mec., Aged 20
Unweighted N 3,655 - Weighted Sample
211,125,161 (2004 Census)
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CVD Patients in Europe Fewer than One-Half
Reach Goal

• 1996 2000
• Hypertensive 55 54
• On BP Medication 84 90
• controlled to lt140/90mm Hg 44 45
• Hyperlipidemic 86 59
• On statins 19 58
• controlled to lt 5.0 mmol/L 21 49

Very little improvement
Some improvement, but still large gap in treatment
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And in South Africa?

• The South African Not at Goal study (SA-NAG)
• Evaluation of LDL-C goals achieved in patients
  with established
• CVD and/or hyperlipidaemia receiving lipid
  lowering therapy
• Pts on therapy gt 4mnths
• 1201 pts recruited across SA
• 41 defined as low risk, 59 defined as high risk
• SA guidelines used to define risk and evaluate
  achievement of goal
• Conclusion
• Majority fell into not at goal category
• These pts were also far above their LDL-C targets

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Achieving Guideline-specified LDL-C Goals
The SA-NAG study. A. Ramjeeth, N. Butkow, F.
Raal, M. Maholwana-Mokgatlhe, CVJA, Vol192, 88-94
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Low Risk vs.. High Risk Patients
0.7
3.7
3.0
1.1
3.6
2.5
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High Risk LDL-C reduction needed (by gender
age group)
The SA-NAG study. A. Ramjeeth, N. Butkow, F.
Raal, M. Maholwana-Mokgatlhe, CVJA, Vol192, 88-94
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Key points SA-NAG Study

• Significant treatment gap exists between lipid
  guidelines and goal attainment in dyslipidaemic
  patients with or without established CVD
• All patient were on lipid-lowering therapy
  deficit still exists
• Begs the question - how many events could be
  averted if patients reached treatment goal?
• Potential reasons for the study result
• Inadequate titration of doses
• Patient long-term compliance
• Financial constraints
• In the entire study (N 1201) only 45 pts were
  using the highest doses of statin therapy (lt 4 )

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CVD Treatment Gap - Community
Dr Awareness of Treatment Guidelines
Patient Treated to Goal
Provider awareness does not equal successful
implementation
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WHAT ARE WE DOING WRONG???

• Not identifying patients for treatment
  intervention
• Identifying patients but not providing treatment
• Lifestyle and/or pharmacological intervention?
• Identifying patients, initiating treatment, but
  lost to follow-up
• Not achieving treatment goals
• inadequate dosage
• adherence/compliance issues

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THANK YOU!!!!