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Dyslipidemia: Statin Treatment -2016 Guidelines

my name is Rob Hagley from the

University of Western Ontario and I'm

going to be speaking to you today but

the 2016 Canadian lipid guidelines and

particularly I'm going to be talking

about statin treatment statin as the

foundation of treatment for lipids so we

had statins available in Canada for

almost 30 years now and very very long

track record both in clinical experience

and also clinical trials so this is a

very recent meta-analysis showing the

benefits of statins with respect to

event rate reduction this was a study

done out of the cholesterol trial this

group in Oxford and basically it shows

that really for every year of statin

treatment in the aggregated data from

clinical trials there's a significant

reduction in events even in the first

year or the for that that first symbol

is significant but then certainly by the

second to fifth year very very

significant to 20 to 25 percent

reduction in major vascular events

across all trials this is really the

foundation of why statins are the are

the recommended treatment in properly

selected patients this slide is a

similar meta-analysis from an American

group but very similar message along the

x-axis is showing the absolute between

group difference and achieved LDL levels

in the various clinical trials of

statins and the y-axis showing the

reduction in events and the size of the

symbol is the number of events in the

study again this is a very very same

trend that the greater the difference in

LDL level the greater the reduction in

events both in primary and in secondary

prevention it's a highly highly

consistent result so we know that

statins have benefits and in anything

good in life that has benefits has risks

as well and so the real challenge

clinically is to is to balance those and

then to give the medication or to

recommend the medication to the patients

would benefit the most and those are

patients generally who are at higher

risk and here this is showing death of

all causes so the final piece of the

puzzle so that we know that when given

to properly selected patients patients

live longer they walk the surface of the

earth four more years after having taken

the statin and it's mainly on the upper

half of the slide you can see that's the

reduction of cardiovascular events

vascular deaths and the non vascular

deaths and the bottom half of the slides

are really no significant effect there

in all together about ten percent

reduction in death of all causes so it's

very compelling evidence is one of the

few treatments in medicine that we can

say that patients should take it and

they're going to be alive you know after

five or ten years and they're going to

be living longer so as a result of this

in the new Canadian lipid guidelines we

have reformatted our way of thinking of

it there are certain definite statin

indicated conditions so this would be

for instance shown on this slide

clinical atherosclerosis define there

many many different clinical

manifestations of what clinical

atherosclerosis means also a separate

category for abdominal aortic aneurysm

separate category for diabetic almost

every diabetic certainly patient with

the type two diabetes but even type one

diabetes you know you one would need to

can you know strongly consider the use

of statin drugs now we have compelling

evidence for chronic kidney disease and

then the fifth category is somebody with

a very high level of LDL cholesterol

even without risk factors so this is

really strongly suggestive of a genetic

issue and we know that these patients

over the long term benefit from having

their LDL treated with a statin of

course we're always a recommending diet

and exercise the drugs work better in

the context of a good lifestyle but the

the primary benefit from these various

clinical trials has been shown with with

drug treatment also in the guidelines

this year

primary prevention conditions and so

there are certain than a little more a

little more thinking a little more

clinical you know clinical input

clinical consideration involved in the

patient who is asymptomatic but say who

is at intermediate risk according to

Framingham so if there's intermediate

risk and the LDL is above three and a

half then you would need to consider and

then perhaps initiate the discussion

with the patient about prevention of

cardiovascular disease there are

alternate alternate measurements to the

LDL of three and a half the non HDL of

4.3 or the april-b of a 1.2 am high-risk

patient of course if the patient is even

if they're asymptomatic but if they've

got a lot of risk factors if they're

above say a Framingham risk of 20% then

one would need to have the at least the

conversation ultimately it is the

collaborative effort between the

physician and the patient and it's

ultimately the patient's decision but

this is now what we are recommending in

terms of primary prevention so for the

target levels the target levels so

you've heard our when we've kept the

concept of target level so to millimoles

per liter for high-risk patients

patients in whom the treatment has been

initiated or 50% reduction in in LDL

levels so this slide shows the efficacy

of the various types of statins and say

achieving a 50% reduction so because we

want to treat our high-risk patients

seriously and if you're going to you

know initiate treatment and this becomes

important lifelong treatment for all of

the benefits then that 50% 50% reduction

we're really then talking about a torva

statin and receive a statin has the two

main types of statins that will allow

your patient to achieve that level of

reduction of course there's an inter

individual variation there's some

patients that can take other statins and

we'll get a 50% or close to 50%

reduction but essentially we're talking

about

moderate to high doses of the more

potent statins so here the you know the

patients are conscious of and certainly

I mean we're all conscious of than the

relative risks or benefits versus of

statins so and and we hear a lot about

the risks but I think on this slide I

think it really puts the benefits into

context so this is for and this again

comes from the Oxford group so this is a

sort of a calculated scenario so for

10,000 patients at high risk who've been

treated with statins for five years and

have had their LDL lowered by two so

let's say they started off at four and

they came down to two so 50% reduction

and they hit their target of two so in

those 10,000 patients you would have

prevented a thousand major

cardiovascular events including deaths

so that's that's actually you know if

you have to put that in perspective I

mean that's that's a that's actually a

huge benefit now on the right-hand side

of the slide then ours is the trade off

anything that has good effects are

pretty much anything in life anything

that has good effects there is always

the risk of side effects and so then you

balance it so these are them the risk

for instance of muscle weakness without

any enzymatic changes may be 50 to 100

patients of those 10,000 myopathy I say

an elevated the CKD with symptoms may be

five patients rhabdomyolysis so very

serious complication may be one patient

you do a lot of talk about new onset of

diabetes probably 50 cases of diabetes

and then hemorrhagic stroke although

that's still controversial but let's say

a few gazes a hemorrhagic stroke so

that's the that's the that's the trade

off that's the benefit or that that's

the risk to benefit ratio

you've got the benefits of a thousand

events prevented versus the the adverse

effects and most of these are actually

really you know reversible or mitigate a

bull with with met with

medical monitoring statin

discontinuation is a big problem a big

issue in clinical practice so basically

once a patient discontinues a statin for

whatever reason usually perceived side

effects or concern over side effects

this translates directly and to reduce

to survival

so side effects are the most common

reasons that patients discontinue

statins and this slide shows then what

happens once a statin statin is

discontinued for whatever reason so the

the the bottom curve is first shows the

survival in a patient who in the patient

group that stopped taking their statin

and then interestingly even if the

statin is continued in a non daily dose

so say alternating day dose of something

the the as long as they continue taking

their statins their survival does not

drop so it's important then if there is

the concern that your patient who you

are concerned about cardiovascular risk

reduction is possibly considering

stopping their statin you need to have

the conversation obviously weigh it on a

case-by-case basis but there is a price

to be paid if the statin is is stopped

statin intolerance very very commonly

seen clinically these are

recommendations then from the canadian

cardiovascular society guidelines on

what to do if your patient develops

statin intolerance so we recommend not

to withhold them on the basis of this

small risk of diabetes we say we

evaluate any purported or reported

statin associated symptoms

systematically we say perhaps you can do

a bit of a drug holiday can reinitiate

and switch to a different statin you can

try this altered dosing frequency that I

mentioned anything to that can help the

patient find a tolerated statin based

therapy that works for them and then the

final thing is that there is talk of you

know has been talked about you know

vitamins or minerals or supplements to

alleviate the symptoms of myalgia that

are perceived to be statin associated

really we really do

recommend those we don't think that

those and there's really much good

evidence to support that so final slide

the take-home points of statins so

statins have really revolutionized

medicine AI statins became available

when I first started practicing so

thirty years ago and said I've really

watched how they have changed

cardiovascular medicine and certainly my

practice and and and also you know

community medicine and the world at

large so they're proven they're

evidence-based their life saving their

life extending they have saved so many

lives there's thirty thirty years now a

real-world experience with them there

are first-line treatment and our

guidelines we have of course as I

mentioned the five statin eligible

conditions and then the intermediate

risk primary prevention

not to mention high risk primary

prevention there are risks to statins

there are side effects but the benefits

hugely hugely outweigh the risks in the

properly selected patients we don't say

give them to everybody obviously but you

need to think about it select the

patient have the discussion with the

patient but once the patient dies in the

benefits for that patient are enormous

and then of course once the patient

starts on treatment we need to encourage

compliance in order to make sure they

get the maximum benefit from their

statin so I wanted to thank you very

much for your attention today