2021 Canadian Cardiovascular Society Dyslipidemia Guidelines PDF

2021 UPDATE DYSLIPIDEMIA DYSLIPIDEMIA DYSLIPIDEMIA About this Pocket Guide This pocket guide is a quick-reference tool that features diagnostic and treatment recommendations based on the 2021 CCS Dys...

2021 UPDATE DYSLIPIDEMIA DYSLIPIDEMIA DYSLIPIDEMIA About this Pocket Guide This pocket guide is a quick-reference tool that features diagnostic and treatment recommendations based on the 2021 CCS Dyslipidemia Guidelines (as well as, recommendations from the previous dyslipidemia guidelines that remain unchanged [2006, 2009, 2012, and 2016]). These recommendations are intended to provide a reasonable and practical approach to care for physicians, pharmacists, nurses and other healthcare providers. They are subject to change as scientific knowledge/technology advance and practice patterns evolve, and are not intended to be a substitute for clinical judgement. Adherence to these these recommendations will not necessarily produce successful outcomes in every case. For information about the GRADE approach for rating the strength of recommendations and quality of evidence, visit www.ccs.ca. Please visit www.ccs.ca for more information and additional resources. Co-Chairs Glen J. Pearson, PharmD FCCS and George Thanassoulis, MD CCS Dyslipidemia Guidelines Primary Panel Todd J. Anderson MD, Arden R. Barry PharmD, Patrick Couture MD PhD, Natalie Dayan MD, Gordon A. Francis MD, Jacques Genest MD, Jean Grégoire MD, Steven A. Grover MD, Milan Gupta MD, Robert A. Hegele MD, David Lau MD PhD, Lawrence A. Leiter MD, Alexander A. Leung MD, Eva Lonn MD, G. B. John Mancini MD, Priya Manjoo MD, Andre Mattman MD, Ruth McPherson MD PhD, Daniel Ngui MD, Marie-Eve Piché MD PhD, Paul Poirier MD PhD, John Sievenpiper MD PhD, James Stone MD PhD, Rick Ward MD, and Wendy Wray MScN. Table of Contents Summary of 2021 Guideline Changes and Highlights........................................................................................... 2 Screening Who to Screen and How to Screen........................................................................................................ 3 Secondary Testing................................................................................................................................ 5 Risk Assessment Risk Assessment for Primary Prevention................................................................................................ 7 Risk Stratification........................................................................................................................................ 8 Primary and Secondary Lipoprotein Determinants................................................................................ 9 Management When to Consider Pharmacological Treatment........................................................................................ 10 Chronic Kidney Disease............................................................................................................................. 11 Pharmacological Treatment Indications.................................................................................................... 12 Potential Adverse Effects of Statin............................................................................................................ 13 Non-Statin Therapy.................................................................................................................................... 14 Lipid Lowering Medications and Approved Dosing Recommendations.................................................... 16 Health Behaviour Modifications................................................................................................................ 17 Approach for Patients with a Statin Indicated Condition (Algorithm)......................................................... 19 Follow-up and Referral to Specialist Clinics............................................................................................. 24 Summary of 2021 Guideline Changes and Highlights What’s new? Expanded recommendations for preventative care in women with hypertensive disorders of pregnancy Updated recommendations for primary prevention and the importance of lipoprotein measurement, including non-HDL-C, ApoB, and Lp(a) in assessing CV risk The role of CAC as a clinical decision-making tool for determining the need to initiate therapy The benefit of icosapent ethyl (IPE) in patients with TG ≥1.5-5.6 mmol/L and a previous ASCVD event or diabetes and ≥1 additional risk factor Lack of CV benefit from omega-3 fatty acids from dietary sources or over-the-counter formulations/supplements New recommendations for non-statin therapies to reduce ASCVD events Identification of new lipid/lipoprotein thresholds for the intensification of therapy in the management of dyslipidemia, beyond statins Secondary prevention patients demonstrated to derive the greatest benefit with intensification with PCSK9 inhibitors are identified Values for non-HDL-C and ApoB have been modified to accurately represent the same percentile equivalent as LDL-C for all recommended thresholds 2  5 Who to Screen 3 All patients with any of the following conditions regardless of age: Diabetes mellitus Consider earlier in ethnic groups at increased risk such as South Asian or Indigenous individuals corneal arcus, ** *Men younger than 55 years of age and women younger than 65 years of age in first degree relatives. **Chronic Kidney Disease = eGFR ≤60 mL/min/1.73 m2 or ACR ≥3 mg/mmol for at least 3 months duration. ACR = albumin-to-creatinine ratio; AS = ankylosing spondylitis; BMI = body mass index; COPD = chronic obstructive pulmonary disease; CVD = cardiovascular disease; eGFR = estimated glomerular filtration rate; IBD= inflammatory bowel disease; PsA = psoriatic arthritis; RA = rheumatoid arthritis; SLE, systemic lupus erythematous. Screening How to Screen History and physical examination Standard lipid profile: TC, LDL-C, HDL-C, non-HDL-C, TG Fasting plasma glucose (FPG) or glycated hemoglobin (A1c) eGFR Lipoprotein(a)—once in patient’s lifetime, with initial screening RECOMMENDATION We recommend non-fasting lipid and lipoprotein testing can be performed in adults in whom screening is indicated as part of a comprehensive risk assessment to reduce CVD events (Strong Recommendation, High Quality Evidence). We recommend that for any patient with triglycerides >1.5 mmol/L, non-HDL-C or ApoB be used instead of LDL-C as the preferred lipid parameter for screening (Strong Recommendation, High-Quality Evidence). We suggest that for individuals with a history of triglyceride levels >4.5 mmol/L that lipid and lipoprotein levels be measured fasting (Conditional Recommendation, Low Quality Evidence). Pratical Tip - Compared to fasting lipid values, there will be minimal change with non-HDL-C, a slight decrease in LDL-C and small increase in triglyceride concentrations when most individuals do not fast. 4 Screening Secondary Testing 5 Coronary Artery Calcium (CAC) Measurement - Recommendations We suggest that CAC screening using computed tomography imaging may be considered for asymptomatic adults ≥ 40 years and at intermediate risk (FRS 10%-20%) for whom treatment decisions are uncertain (Strong Recommendation, Moderate-Quality Evidence). We recommend that CAC screening using computed tomography imaging not be undertaken for a) high risk individuals b) patients receving statin treatment: or c) most asymptomatic, low-risk adults (Strong Recommendation, Moderate Quality Evidence). We suggest that CAC screening might be considered for a subset of low-risk middle-aged individuals ≥40 years with a family history of premature ASCVD (men ≤55 years; women ≤65 years) in addition to identifying known genetic causes of ASCVD such as elevated Lp(a) or FH) (Weak Recommendation, Low-Quality Evidence). Values and preferences - Patients with modifiable ASCVD risk factors should be counselled with respect to the potential merit of preventing atherosclerosis itself, the substrate for clinical ASCVD events in the long term, through comprehensive ASCVD risk factor management. As outlined elsewhere, RCTs show the ASCVD risk reduction value of statin therapy in patients with intermediate risk and additional ASCVD risk factors (eg, HOPE 3 and justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin [JUPITER] in the absence of CAC testing or any testing to identify preclinical atherosclerosis. Accordingly, the patient-physician decision often does not require CAC scoring but might be strongly influenced by these other factors, including family history of premature ASCVD, other features suggesting genetic causes of dyslipidemia, or side effects of statin therapy. In some low- to intermediate-risk subjects, it might be reasonable to withhold statin therapy for CAC = 0 AU because of a favourable intermediate-term outcome. Exceptions would include cigarette smokers, patients with diabetes, those with poorly controlled hypertension, genetic dyslipidemias such as FH or elevated Lp(a) level, and patients with strong family history of premature ASCVD events. If available, a CAC >100 AU is an indication for statin therapy regardless of FRS. For those with a CAC of 1-99 AU, individual decision-making is required because risk will not be reclassified and would remain intermediate. If a decision is made to withhold statin or lipid-modifying therapy on the basis of CAC = 0, this decision should be reevaluated during follow-up or if clinical circumstances change. CAC scoring should rarely be performed sooner than within 5 years to aid in this reevaluation. Finally, this section is restricted to application in patients who are at least 40 years of age for whom the traditional FRS assessment applies. Prevalence of calcification is a sequential aspect of the atherosclerotic process and might be absent in the early phases. Although CAC has been studied extensively for ASCVD risk prediction, the prevalence of CAC is lower in young patients compared with middle-aged and older patients and also in women vs men younger than 50 years of age. Screening Secondary Testing Lipoprotein (a) Measurement - Recommendation We recommend measuring Lp(a) level once in a person’s lifetime as a part of the initial lipid screening. (Strong Recommendation; High Quality Evidence). For all patients in the setting of primary prevention with a Lp(a) ≥50 mg/dL (or ≥100 nmol/L), we recommend earlier and more intensive health behaviour modification counselling and management of other ASCVD risk factors (Strong Recommendation, Expert consensus). Values and preferences - There is a large body of evidence supporting the potential causal association between Lp(a) and future ASCVD. The high prevalence of elevated Lp(a), the strength of association with incident and recurrent ASCVD events and the potential to improve CV risk stratification, strongly justify universal screening to identify individuals with very high levels. Identification of high levels of Lp(a) is a useful consideration for shared decision-making in subjects across all ASCVD risk categories, but especially in younger patients, particularly those who have a very strong family history of premature ASCVD. While further evidence that directly lowering Lp(a) reduces ASCVD risk is pending, the finding of high Lp(a) should alert primary care practitioners to more actively pursue an overall ASCVD event risk assessment, including careful discussion of current health behaviours, consideration of age-appropriate vascular imaging studies for detecting early evidence of subclinical atherosclerosis in select individuals (e.g. coronary artery calcium [CAC] score) and earlier introduction of statin or other lipidlowering therapy, especially in intermediate-risk individuals and/or low-risk individuals with moderate elevations of LDL-C between 3.5-5 mmol/L. In the setting of secondary prevention, the presence of high Lp(a) is strongly predictive of recurrent events, and suggests the need for intensification of LDL-lowering therapy, including use of PCSK9 inhibitors. Furthermore, preliminary evidence suggests that treatment with PCSK9 inhibitors post- ACS in patients with high Lp(a) reduces MACE independent of LDL-C lowering. When clinicians are uncertain of the implications of elevated Lp(a), consultation with a lipid specialist may be considered. 6 Screening Risk Assessment for Primary Prevention 7 Calculate risk (unless statin-indicated condition) using the Framingham Risk Score (FRS)✝ or Cardiovasular Life Expectancy Model (CLEM)✝ Repeat screening every 5 years for FRS 1.5 mmol/L, non-HDL-C or ApoB be used instead of LDL-C as the preferred lipid parameter for screening (Strong Recommendation, High-Quality Evidence). Risk Assessment When to Consider Pharmacological Treatment in Risk Management STATIN INDICATED CONDITIONS LDL ≥5.0 mmol/L Most patients with diabetes: Atherosclerotic Cardiovascular (or ApoB ≥1.45 g/L or Age ≥40y Disease (ASCVD): non-HDL-C ≥5.8 mmol/L) Age ≥30y & DM x≥15y duration Myocardial infarction (MI), acute (familial hypercholesterolemia or Microvascular disease coronary syndromes (ACS) genetic dyslipidemia) Stable angina, documented coronary Chronic Kidney Disease artery disease using angiography Age ≥50y and eGFR 3 mg/mmol Peripheral arterial disease, claudication, and/or ABI 3.0 cm or previous aneurysm surgery TIA - transient ischemic attack; ABI - ankle-brachial index; ACR - albumin:creatinine ratio; eGFR - estimated glomerular filtration rate RECOMMENDATION Statin-indicated conditions: We recommend management that includes statin therapy in high risk conditions including clinical atherosclerosis, abdominal aortic aneurysm, most diabetes mellitus, chronic kidney disease (age ≥50 years) and those with LDL-C ≥5.0 mmol/L to lower the risk of CVD events and mortality (Strong Recommendation, High Quality Evidence). We recommend use of high-intensity statin therapy in addition to appropriate health behaviour modifications for all secondary prevention CVD patients. For patients who do not tolerate a high-intensity statins, we recommend the maximally tolerated statin dose (Strong Recommendation, High-Quality Evidence). 10 Management Chronic Kidney Disease 11 RECOMMENDATIONS We recommend treatment with a statin or statin/ezetimibe combination to reduce CVD events in adults ≥50 years with chronic kidney disease not treated with dialysis or a kidney transplant (Strong Recommendation, High Quality Evidence). Values and preferences - If the preference is to engage in early prevention and long-term risk reduction, in subjects 0 AU, family, history of premature CAD, Lp(a), ≥50 mg/dL (≥100 nmol/L) Low-Risk*†‡ We recommend use of high- FRS