CURRICULUM VITAE - PAPDI. SAN PIN 2019 (materi...stage 3 or 4 CKD, or HeFH –History of premature...

CURRICULUM VITAE

SALLY AMAN NASUTION, MD, FINASIM, FACP

- Born in Medan, August 8th 1967

- Internist – Cardiologist

- Faculty Member Division of Cardiology, Department of Internal Medicine at Faculty of Medicine University of

Indonesia, Jakarta

- Head of Intensive Coronary Care Unit (ICCU), Integrated Cardiac Services Cipto Mangunkusumo National General

Hospital Jakarta

- President of the Indonesian Society of Internal Medicine

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Updates in Dyslipidemia Guidelines:

How to apply in clinical practice

Dr dr SALLY AMAN NASUTION, SpPD-KKV, FINASIM, FACP

Division of Cardiology Department of Internal Medicine

Faculty of Medicine Universitas Indonesia

Cipto Mangunkusumo National General Hospital

Jakarta

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Prevalence of raised lipid levels

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LDL-Cholesterol and Blood Presssure

Sub-analysis DYSIS (Dyslipidemia International Study) II in Indonesia

% Patients at LDL-C goals Recommended by the 2004 updated NCEP ATP III* guidelines

% of Patients at LDL-C goals recommended by 2004 updated NCEP ATP III* guidelines

Indonesia patients had the lowest LDL-C attainment rate (31.3 – 52.7%)

Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.

Management of Hypercholesterolaemia remains Sub-optimal: Pan-Asian CEPHEUS

Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.

Attainment of LDL-C

https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019

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https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease

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The global CVD crisis

www.who.int/global_hearts 2017

http://www.who.int/global_hearts

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https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019Cannon B. Nature 2013; 493: S2 – S3

https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease

American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 201713

ASCVD Risk Categories and LDL-C Treatment Goals

Risk category Risk factors/10-year riskTreatment goals

LDL-C

(mg/dL)

Non-HDL-C

(mg/dL)

Apo B

(mg/dL)

Extreme risk

– Progressive ASCVD including unstable angina in individuals after achieving an LDL-C <70 mg/dL

– Established clinical cardiovascular disease in individuals with DM, stage 3 or 4 CKD, or HeFH

– History of premature ASCVD (<55 male, <65 female)

<55 <80 <70

Very high risk

– Established or recent hospitalization for ACS, coronary, carotid or peripheral vascular disease, 10-year risk >20%

– DM or stage 3 or 4 CKD with 1 or more risk factor(s)

– HeFH

<70 <100 <80

High risk– ≥2 risk factors and 10-year risk 10%-20% – DM or stage 3 or 4 CKD with no other risk factors

<100 <130 <90

Moderate risk ≤2 risk factors and 10-year risk <10% <100 <130 <90

Low risk 0 risk factors <130 <160 NR

Barter PJ, et al. J Intern Med. 2006;259:247-258; Boekholdt SM, et al. J Am Coll Cardiol. 2014;64(5):485-494; Brunzell JD, et al. Diabetes Care. 2008;31:811-822; Cannon CP, et al. N Engl J Med. 2015;372(25):2387-2397; Grundy SM, et al. Circulation. 2004;110:227-239; Heart Protection Study Collaborative Group. Lancet. 2002;360:7-22; Jellinger P, Handelsman Y, Rosenblit P, et al. Endocr Practice. 2017;23(4):479-497; Lloyd-Jones DM, et al. Am J Cardiol. 2004;94:20-24; McClelland RL, et al. J Am Coll Cardiol. 2015;66(15):1643-1653; NHLBI. NIH Publication No. 02-5215. 2002; Ridker PM, J Am Coll Cardiol. 2005;45:1644-1648; Ridker PM, et al. JAMA. 2007;297(6):611-619; Sever PS, et al. Lancet. 2003;361:1149-1158; Shepherd J, et al. Lancet. 2002;360:1623-1630; Smith SC Jr, et al. Circulation. 2006;113:2363-2372; Stevens RJ, et al. Clin Sci. 2001;101(6):671-679; Stone NJ. Am J Med. 1996;101:4A40S-48S; Weiner DE, et al. J Am Soc Nephrol. 2004;15(5):1307-1315.

Abbreviations: ACS, acute coronary syndrome; apo, apolipoprotein; ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; DM, diabetes mellitus; HeFH, heterozygous familial hypercholesterolemia; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NR, not recommended.

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Heart SCORE (Systematic Coronary Risk Estimation)

1 mmol/L = 38.67 mg/dLEuropean Heart Journal (2019) 00, 178

• Social deprivation and psychosocial stress set the scene for increased risk. For those at moderate risk, other factors—including metabolic factors such as increased ApoB, Lp(a), TGs, or C-reactive protein; the presence of albuminuria; the presence of atherosclerotic plaque in the carotid or femoral arteries; or the coronary artery calcium (CAC) score—may improve risk classification

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Factors modifying heart SCORE

European Heart Journal (2019) 00, 178

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Risk categories

aTarget organ damage is defined as microalbuminuria, retinopathy, or neuropathy


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Intervention strategies as a function of total cardiovascular risk & untreated LDL-C levels


dThe term ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C-lowering medication.

In people who are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based on the average LDL-C-lowering efficacy of the given medication or combination of medications.

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Recommendations for treatment goals for LDL-C


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Treatment goal for LDL-C


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Treatment algorithm for pharmacological LDL-C lowering


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Recommendations for the treatment of dyslipidaemiasin metabolic syndrome & DM


Challenges in dyslipidemia management

American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 2017

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Patients(%) reporting statin non-adherence behaviors in the last 12 months by statin PDC (proportion of days covered) level

Note: Weighted for sampling proportions; p<0.05

Fung V, GraetzI, Reed M, Jaffe MG (2018) Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk. PLoS ONE 13(2): e0191817.

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Doubling statin dose

Statin intolerance• 20% of individuals with a clinical indication for statin therapy are unable to take a daily statin because of some

degree of intolerance, and 40–75% of patients discontinue their statin therapy within 1–2 years after initiation

Toth PP, et al. Management of Statin Intolerance in 2018: Still More Questions than Answers. Am J Cardiovasc Drugs (2018) 18:157–

17326

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Further improvement from what NLA proposed

Rosenson RS, et al. Cardiovasc Drugs Ther (2017) 31:179–186

How to apply in clinical practice

CASE

Patient : M.K.

Profile : 43 years old male

BMI : 29.7 kg/m2

BP : 140/75 mm Hg

HR : 65 bpm

Medical History:

Type 2 Diabetes Mellitus with microalbuminuria

Previous MI last month

Heavy smoker

Lab results:

TC : 210 mg/dl

LDL :135 mg/dl

HDL : 38 mg/dl

TG : 500 mg/dl

Current medication:

Chinese herbal medicine

He comes to your clinic for follow up

How would you manage this patient?

• During anamnesis, what other questions would you like to ask? Why?

• Is there any other lab tests would you order? Why?• Would you change his current medication? Why?

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CURRICULUM VITAE - PAPDI. SAN PIN 2019 (materi...stage 3 or 4 CKD, or HeFH –History of premature...

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