CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
118
AFRICA
New ESC/EASD lipid guidelines empahsises need to expand
cholesterol screening and treating to target in clinical practice
‘Clinicians are not measuring cholesterol
levels often enough in at-risk patients
worldwide, and the new ESC/EAS
(European Society of Cardiology and
European Atherosclerosis Society) task
force recommends stronger action in this
regard’,
1
Prof Richard Hobbs, professor
and head of Primary Care, University of
Burmingham, UK, noted in his country-
wide talks to South African doctors, spon-
sored by AstraZeneca. Cardiovascular
disease is the most important cause of
premature death on the planet and lipid
levels are one of the major modifiable
factors that drive death and disability
from vascular disease worldwide.
The recently announced South African
Lipid Guidelines are broadly based on
these new guidelines and recommend
immediate treatment of very high risk
patients with established cardiovascular
disease, type 2 diabetes, genetic dyslipi-
daemia and chronic kidney disease to an
aggressive low-density lipoprotein (LDL)
cholesterol target of 1.8 mmol/l or less.
An important differentiation in South
Africa is with regard to screening. ‘In
Europe, screening is advocated for at
least one total cholesterol/low-density
lipoprotein (LDL) cholesterol measure-
ment in men before the age of 40 years
and in women before the age of 50. In
South Africa, with a higher prevalence
of familial hypercholesterolaemia, total
cholesterol screening is recommended at
least once in young adults from 20 years
of age’, Dr Hobbs noted.
Risk algorithms quantify risk in prima-
ry prevention patients and are useful
in allocating limited resources to those
patients with the highest risk who are most
likely to benefit. Europe uses the SCORE
algorithm (cardiovascular mortality only)
while the updated Framingham algorithm
is recommended in South Africa. The new
Framingham algorithm estimates the risk
of vascular events in all arterial territories
and not only coronary artery risk, as in the
previous versions (Table 1).
‘The older risk algorithms tend to
discriminate against women and young
people, so there are some tools avail-
able in the SCORE algorithm to more
accurately assess risk in these patients. In
women, the incorporation of high-density
lipoprotein (HDL) cholesterol measure-
ments into cardiovascular risk assessment
is useful. In the younger population, a
relative risk chart is used to assess the
risk of a young smoker, for example,
compared to a similar aged, normoten-
sive, non-smoker’, Dr Hobbs said.
‘Statins are the recommended therapy
and have an 1A level of evidence to
recommend their use, based on evidence
from 130 000 patients treated for more
than five years in randomised clinical
trials’, Prof Hobbs pointed out. In prima-
ry prevention of patients at low risk with-
out pre-existing vascular disease, statin
therapy results in a 12% reduction in rela-
tive risk of all-cause mortality.
‘Contrary to what we initially believed,
you get early treatment benefit with statin
therapy in the first few months of treat-
ment, maturing over two years, and still
continuing to show benefit with long-term
statin therapy. Also, there is an increasing
benefit with increasing intensity of stain
use, with a third better reduction in rela-
tive risk of vascular events obtained with
the higher doses and more potent statins.
‘In general, we expect a constant
on-going benefit of LDL cholesterol
lowering with a relative reduction of 21%
every year for every 1 mmol/l reduc-
tion in LDL cholesterol levels, even at
levels starting at 2 mmol/l’, Dr Hobbs
noted. ‘Modern man with LDL choles-
terol levels usually markedly above 1.5
mmol/l can be viewed as a completely
abnormal phenotype and our physiologi-
cal system in evolutionary terms has not
been designed for these levels’, he said.
Statins are a remarkably safe group
of drugs, except for the recent caution-
ary on simvastatin 80 mg and the risk of
developing new-onset diabetes in a small
proportion of patients.
2
This has led to
the FDA decision to include this poten-
tial risk in patient information on statin
use. ‘The observation of a higher risk of
developing diabetes must be evaluated in
the context of the greater protection from
cardiovascular events’, Dr Hobbs warned.
Practical interactive session
Dr Dirk Blom, University of Cape Town
In an informative session, Dr Blom
answered questions at a practical clinical
level, providing useful guidance.
Key take-home message
•
Total cholesterol measurement is
good enough for screening in a young
person.
•
A full lipogram should be done for
patients at higher risk. Point-of-care
screening, if done correctly, is useful
and if warranted should then followed
by a full lipogram.
•
The Framingham chart, loved or hated,
is here to stay. The newer charts esti-
mate the risk of all vascular events and
not only coronary heart disease risk.
•
If the target is 1.8 mmol/l you will
need an effective statin, and combina-
tion therapy may be necessary in many
patients. Ezetimibe is the most useful
agent for additional LDL cholesterol
lowering.
•
The PMB (prescribed minimum bene-
fits) algorithms, despite the indus-
try’s involvement in the consultation
processes of the new South African
lipid guidelines, are different from
the professional society’s (LASSA’s)
recommendations
•
An important aspect of statin treatment
is patient motivation; the attrition rate
is very high. Significant benefit is lost
due to discontinuation of medication.
•
Failure to up-titrate statin therapy is a
worldwide problem from which South
Africa is not exempt (CEPHEUS trial).
Dealing with this pragmatically should
lead to clinicians scripting a statin dose
based on the baseline LDL cholesterol
and target levels from the outset.
•
Deprivation or race does not protect
one from cardiovascular disease as it
is not ‘a rich man’s disease’. In the
INTERHEART study, African patients
had their first myocardial infarction at
a younger age than the other patients.
•
The higher the absolute risk, the great-
er the absolute benefit of lowering
LDL cholesterol.
TABLE 1. LDL-C TREATMENT TARGETS
Total Framingham
CVD risk (%)
ESC/EAS risk
score
ESC/EAS
target (mmol/l)
< 3
Low risk
< 3
3–15
Moderate risk < 3
15–30
High risk
< 2.5
> 30
Very high risk < 1.8
