La Dra. Begoña Benito Villabriga repasa los puntos clave del documento presentado en ESC Congress 2019.

1. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias Begoña Benito VillabrigaGuidelines for the management of dyslipidaemiasGuidelines for the management of dyslipidaemias

2. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemiasGuidelines for the management of dyslipidaemias
BACKGROUND: New evidence:
• LDL-C (and ApoB-contaning LP) are key elements in atherogenesis.
• Mendelian randomization studies have confirmed that LDL-C is causally
related to ASCVD.
• Raising HDL-C with available therapies do not reduce the ASCVD risk.
• The addition of ezetimibe or PCSK9 monoclonal antibodies provides
further benefit:
• Further reduction in LDL-C  further reduction in ASCVD.
• The lower LDL-C levels, the better:
• No J-curve effect, apparent safety of low LDL-C values (<1.4 mmol/L - 55 mg/dL).

3. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
NEW CONCEPTS AND RECOMMENDATIONS:
• RISK STRATIFICATION:
• CV imaging for assessment of ASCVD risk:
• Arterial (carotid/femoral) plaque burden (US)
• CAC score assessment (CT)
• SPECIAL POPULATIONS:
• > 65 years, DM, FH, hypertriglyceridaemia, ACS, CHF, PCI, CKD, prior
stroke.
Risk modifiers in
low/moderate
risk patients

4. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
NEW CONCEPTS AND RECOMMENDATIONS:
• Assessment of predicted benefit:
Pre-treatment
LDL-C levels
Lipid-lowering
strategy
Relative
reduction of
LDL-C
Baseline
CV risk
ABSOLUTE
CARDIOVASCULAR RISK
REDUCTION

5. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
NEW CONCEPTS AND RECOMMENDATIONS:
• Assessment of predicted benefit:
Pre-treatment
LDL-C levels
Lipid-lowering
strategy
Relative
reduction of
LDL-C
Baseline
CV risk
ABSOLUTE
CARDIOVASCULAR RISK
REDUCTION

6. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
RISK CATEGORIES:
Very high risk High risk Moderate risk Low risk
Documented
ASCVD
Always - - -
DM • Target organ
damage,
• > 20 years
• No target
organ damage
• > 10 years
• No other RF
• < 10 years
-
FH + ASCVD Without RF - -
CKD eGFR < 30 30-60 - -
SCORE
(10y-risk)
≥ 10 5-10 1-5 <1

7. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
NEW CONCEPTS AND RECOMMENDATIONS:
• Assessment of predicted benefit:
Pre-treatment
LDL-C levels
Lipid-lowering
strategy
Relative
reduction of
LDL-C
Baseline
CV risk
ABSOLUTE
CARDIOVASCULAR RISK
REDUCTION

8. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
RECOMMENDED
STRATEGIES:
Pre-treatment
LDL-C levels
Baseline
CV risk

9. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
NEW CONCEPTS AND RECOMMENDATIONS:
• LDL-C goals:
2P:
1P:
CTT meta-analysis (Lancet 2010)
IMPROVE-IT (NEJM 2015)
FOURIER (NEJM 2017)
ODYSSEY (NEJM 2018)

10. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
ALGORYTHM OF PHARMACOLOGICAL LDL-C LOWERING (I):
1. High potency statin
at highest
recommended dose
Reevaluation at 4-6 wks

11. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
ALGORYTHM OF PHARMACOLOGICAL LDL-C LOWERING (I):
Reevaluation at 4-6 wks
2. + Ezetimibe
3. + PCSK9 inhibitor

12. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
CONCLUSIONES:
• El manejo del perfil lipídico para mejorar el riesgo CV viene condicionado por:
1) Riesgo CV basal
2) Niveles de LDL-C basales
• Además de hábitos de vida saludables, se recomienda inicio farmacológico para
reducir los niveles de LDLD-C en:
Considerar Iniciar Objetivo
Prev. secundaria Cualquier LDL-C LDL-C ≥ 55  50% + < 55
Prev. primaria - VHR LDL-C ≥ 55 LDL-C ≥ 70  50% + < 55
Prev. primaria – HR LDL-C ≥ 70 LDL-C ≥ 100  50% + < 70
Prev. primaria - MR LDL-C ≥ 100 LDL-C ≥ 190 < 100
Prev. primaria – LR LDL-C ≥ 116 LDL-C ≥ 190 < 116

13. Begoña Benito VillabrigaGuidelines for the management of dyslipidaemias
CONCLUSIONES:
• El tratamiento hipolipemiante debe realizarse de forma escalonada:
Estatinas de alta potencia: primera elección
Aumentar estatinas a máxima dosis tolerada
Añadir Ezetimibe
Añadir inhibidores de PCSK9
(en prev. secundaria y prev. primaria + HF o prev. primaria – VHR)