Ús de les estatines en els/les pacients d alt risc cardiovascular

Transcripción

1 Ús de les estatines en els/les pacients d alt risc cardiovascular Lluís Masana Unitat de Lípids Catalunya Sud. Hospitals Reus, Tarragona, Tortosa, Valls, Vendrell. Universitat Rovira i Virgili. IISPV. CIBERDEM

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4 Ultrastructural features of arteriosclerosis Ultrastructural Pathology, 37(1), 43 51, 2013

5 Cholesterol-lowering treatment: prospective meta-analysis of data from participants in 14 randomised trials of statins Cholesterol Treatment Trialists (CTT) Collaboration* 40 mg/dl de descenso de LDL se asocian a un 20 % de disminución de RR Lancet 2005; 366: , Lancet 2010; 2015

6 Lowering LDL-C and Cardiovascular Risk Reduction Among Different Therapeutic Interventions JAMA. 2016;316(12):

7 Effect of exposure to lifetime lower low-density lipoprotein cholesterol (LDL-C) by mechanism of LDL-C lowering European Heart Journal (2017) 38,

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9 European Heart Journal doi: /eurheartj/ehw European Guidelines on cardiovascular disease prevention in clinical practice

10 Evaluación del riesgo cardiovascular global PACIENTES CON RIESGO CARDIOVASCULAR MUY ALTO Enfermedad cardiovascular conocida (clínica o subclínica) Diabetes tipo 2 (con un factor de riesgo o LOD/microalbuminuria) Diabetes tipo 1 (con un factor de riesgo o LOD/microalbuminuria) Riesgo cardiovascular global >10 (SCORE) Enfermedad renal crónica (MDRD <30 ml/min/1.73m 2 ) PACIENTES CON RIESGO CARDIOVASCULAR ALTO Un factor de riesgo muy elevado (LDL>190) HFH Diabetes tipo 2 (sin factores de riesgo ni LOD/microalbuminuria) Diabetes tipo 1 (sin factores de riesgo ni LOD/microalbuminuria) Riesgo cardiovascular global 5-10 (SCORE) Enfermedad renal crónica (MDRD <60 >30 ml/min/1.73m 2 )

11 LDL Cholesterol Lowering for the Primary Prevention of CV Among Men With Primary Elevations of LDLCholesterol Levels of 190 mg/dl or Above WOSCOPS Study Circulation. 2017;136:

12 Treatment goals for LDL-cholesterol Recommendations Class Level In patients at VERY HIGH CV risk, an LDL-C goal of <1.8 mmol/l (70 mg/dl) or a reduction of at least 50% if the baseline LDL-C is between 1.8 and 3.5 mmol/l (70 and 135 mg/dl) is recommended. In patients at HIGH CV risk, an LDL-C goal of <2.6 mmol/l (100 mg/dl), or a reduction of at least 50% if the baseline LDL- C is between 2.6 and 5.2 mmol/l (100 and 200 mg/dl) is recommended. I I B B In subjects at LOW or MODERATE risk an LDL-C goal of <3.0 mmol/l ( <115 mg/dl) should be considered. IIa C European Heart Journal doi: /eurheartj/ehw106

13 European Heart Journal doi: /eurheartj/ehw106

14 High-intensity statin therapy High intensity cholesterol-lowering therapy Masana L, Pedro-Botet J, Civeira F. Atherosclerosis 2015; 240: 161-2

15 Average expected LDL % reduction according lipid lowering therapy combination 140 mg/dl 175 mg/dl 437 mg/dl Eze: Ezetimibe LI-St: Low intensity statin HI-St: High intensity statin PCSK9inh: PCSK9 inhibition Masana L et al. Rev Esp Cardiol. 2016;69(3):

16 Patterns of statin use and LDL goal attainment in a high-risk cardiovascular population: A retrospective study of primary care electronic medical records Garcia Gil M et al. J Clin Lipidology (2016) 10,

17 Zamora A et al. Rev Esp Cardiol 2017

18 Els pacients amb alt o molt alt risc cardiovascular no están ben controlats Zamora A et al. Rev Esp Cardiol 2017

19 L optimització del tractament hipolipemiant convencional reduiria la necessitat de tractaments més intensius Zamora A et al. Rev Esp Cardiol 2017

20 VALORES DE LDL ALCANZADOS POR SUCESIVOS RCT CON HIPOCOLESTEROLEMIANTES Masana L submitted

21 Clinical efficacy and safety of achieving very low LDL-cholesterol concentrations with evolocumab: FOURIER trial thelancet.com Published online August 28,

22 El temps d exposició als nivells de colesterol determina el risc cardiovascular European Heart Journal (2017) 38,

23 L objectiu del tractament hipolipemiant es la reducció de la concentració de colesterol LDL No hem de tractar el colesterol alt sino el colesterol dels pacients amb risc CV alt. Els pacients amb risc alt o molt alt han de portar tractament hipocolesterolemiant de alta intensitat Les dianes terapèutiques recomanades s han de considerar com a un nivel de mínims The lower the better & the sooner the better