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8/6/2019 LDL dan PJK

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Low-Density Lipoprotein Cholesteroland C oronary H eart Disease:The Im portance of Reaching Target Goalswith Statin Therapy

Sandra J. Lewis, MD, FACCNorthwest Cardiovascular InstituteDepartment of MedicineOregon Health and ScienceUniversityDivision of Cardiac RehabilitationLegacy Good Samaritan HospitaiPortland, O regonCorrespondenceSandra J. Le wis, MD , FACCNorthwest Cardiovascular institute2222 NW Lovejoy #606Portiand, OR 97210Email: [email protected]

AcknowledgmentsTiie author thani200 mg/dL (45%), hypertension(33%), tobacco use (21%), sedentary lifestyle (69%), excessive body w eight(body mass index >25; 67%), diabetes (8%), or pre-diabetes (26% ).'The objective of comprehensive therapeutic interventions in CHD,from diet and lifestyle changes, to smoking cessation, to medications,is to prevent new (primary prevention) or recurrent (secondary preven-tion) cardiovascular events, with the ultimate goal of preventing disabilityand death.^'' Family physicians have the distinct advantage of seeing pa-tients' health status from a global perspective, giving them a greater op-

portunity to recognize risk and initiate preventive interventions. Althoughtherapeutic efforts have been directed traditionally at patients with estab-lished CHD and asymptomatic patients at high risk for cardiac events,^'^new data are emerging that suggest that earlier, more aggressive treat-ment increases clinical benefit. This article (1) reviews the importance ofreaching target goals for LDL-C and other biomarkers of risk in the pri-mary and secondary prevention of CHD, and (2) addresses dosing issuesand other practical methods of identifying and treating family medicinepatients who are at risk. Therapeutic lifestyle changes are discussed inDr Davidson's article in this supplement.^Beginning with the initial lipid-lowering trials com paring reductions incardiovascular event rates among highest-, intermediate-, and more aver-age-risk populations, data have become more compelling for LDL-C low-ering in every risk group. However, there is still much we can do to bet-ter identify appropriate candidates for lipid lowering, implement the mostappropriate effective treatments, and improve acceptance by patients andphysicians of these treatments. This article will review current guidelines,upda te available evidence of benefit in various patient groups, and providesimple sample tools for identification of patients and goal-directed appro-priate treatment options. The hope is that these tools will help physiciansand pa tients achieve safe, timely, effective, patien t-oriented preventive car-diovascular care.


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TABLE 1LDL-C targets from National CholesterolEducation Program Adult Treatment Panel I update

LDL-C decision points

Risk categoryVery high risk(CHD + otinerrisi< factors)High risk(CHD or riskequivaients;10-year risk>20%)Moderatelyhigh risk(i 2 risk factors;10-year risk10% to 20%)Moderate risk(i 2 risk factors;10-year risk

Lower risk(0 to 1 riskfactor)

LDL-C goal


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LDL-C and CHD: Importance of reaching goals

TABLE 2S e c o n d a r y p r e v e n t i o n w i t h s ta t in s : F in d i n g s f r o m l a r g e , r a n d o m i z e d , c o n t r o ll e d c l in i c a l o u t c o m e t r i a ls o fin t e n s i v e l ip i d - lo w e r i n g r e g i m e n s

TrialA t o Z "

IDEAL"

PROVE IT-TIMI22"TNr

Durationof foiiow-up6 to 24 months

4.8 years

2 years

4.9 years

PopuiationACS

Previous myocardialinfarctionACS

Stable CHD, LOL-C


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TABLE 3B e n e f i t s o f p r im a r y p r e v e n t io n w i th s t a t i n s : f in d i n g s f r o m i a r g e , r a n d o m i z e d , c o n t ro l le d c l in i c a i o u t c o m e t r ia l s

TrialJUPITER

AFCAPS/Tex-CAPS"ASCOT-LLA

ALLHAT-LLT

WOSCOPS

MEGA'

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