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HYPERLIPIDEMIA

HYPERLIPIDEMIA. DR L RABANYE. 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)

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HYPERLIPIDEMIA

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  1. HYPERLIPIDEMIA DR L RABANYE

  2. 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)

  3. 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 < 3 mmol/L in asymptomatic patients • LDL-C < 2.5 mmol/L in established CVD and diabetic patients

  4. Developmental Process of Atherosclerosis

  5. Burden of Diseases (CV) The three leading causes of disease in 2030 HIV/ AIDS Unipolar depressive disease Ischaemic heart Disease

  6. Prevalence of Chronic Conditions in Registered Schemes • The most prevalent conditions (per 1000 beneficiaries): • Hypertension (86) • Hyperlipidaemia (42) • Asthma (24) • T2DM (19) • CAD (17)

  7. Multiple Risk Factors Cause Cumulative Increase in Risk for CVD

  8. RISK FACTORS • Obesity • Smoking • Diabetes Mellitus • Lack of physical Exercise • Hypertension • Genetics

  9. Types Of Lipid Lowering Drugs • Statins • Fibrates • Niacin • Resins • Selective cholesterol inhibitor

  10. Primary Prevention:Are We Identifying the Right Patients?

  11. 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 Statistics—2005 Update.

  12. 45% Reductionin CVD 10% Reductionin BP + 10% Reductionin TC = 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. 2004;25:484-491.

  13. 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 • 1950’s:average of 3 patients/annum identified with AMI • 1975-80:Total of 50 cases – average of 8 patients/annum • 2004: 64patients 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

  14. 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, Cushing’s Syndrome • PREGNANCY • ↑ Cholesterol & severe hypertriglyceridaemia in susceptible • MEDICATION • Progestins ; Steroids ; some beta-blockers ; high dose diuretics ; retinoids ; Protease inhibitors

  15. Treatment Rates For Dyslipidemia in US Are High but Few Patients Reach Goals < 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)

  16. 1996 2000 Hypertensive 55% 54% On BP Medication 84% 90% % controlled to <140/90mm Hg 44% 45% Hyperlipidemic 86% 59% On statins 19% 58% % controlled to < 5.0 mmol/L 21% 49% CVD Patients in Europe: Fewer than One-Half Reach Goal Very little improvement Some improvement, but still large gap in treatment

  17. 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 > 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

  18. % Achieving Guideline-specified LDL-C Goals The SA-NAG study. A. Ramjeeth, N. Butkow, F. Raal, M. Maholwana-Mokgatlhe, CVJA, Vol19:2, 88-94

  19. Low Risk vs.. High Risk Patients 0.7 3.7 3.0 1.1 3.6 2.5

  20. High Risk – LDL-C reduction needed (by gender & age group) The SA-NAG study. A. Ramjeeth, N. Butkow, F. Raal, M. Maholwana-Mokgatlhe, CVJA, Vol19:2, 88-94

  21. 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 (< 4 %)

  22. CVD Treatment Gap - Community Dr Awareness of Treatment Guidelines Patient Treated to Goal Provider awareness does not equal successful implementation

  23. 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

  24. THANK YOU!!!!

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