CVD Risk Guidelines in Russia: what and how to follow? Professor* - - PowerPoint PPT Presentation
CVD Risk Guidelines in Russia: what and how to follow? Professor* Andrey V. Susekov * Department of clinical pharmacology and therapeutics. Academy for Postgraduate Medical Education. Ministry of Health, Moscow. Russia. 14 ctober 2016
Postgraduate Medical Education. Ministry of Health, Moscow. Russia. 14 Оctober 2016
Research Grants/ Clinical Trials Sanofi-Aventis, Novartis, KRKA, Gedeon-Richter, Omthera, Amgen, Merck, AstraZeneca, KOWA. LECTURER AstraZeneca, Pfizer, KRKA, Gedeon-Richter, Semper, TEVA Pharmaceuticals, Amgen, Sanofi-Aventis Member
MSD, Pfizer, AstraZeneca, Amgen, Sanofi-Aventis, Teva Pharmaceuticals, KRKA * Actual over since 1 Jan 2016.
Atherosclerotic Cardiovascular Diseases for Japanese 2012. J. Atherosclerosis and Thrombosis Vol 20. 2016 ESC/EAS Guidelines for the Management of
Journal 2016;doi:10.1093/europheartj/ehj272; National Vascular Disease Prevention Alliance. Guidelines for the management of absolute сardiovascular disease risk. 2012.
High CVD Risk Low CVD Risk
Russian Society of Cardiology www. scario. ru National Atherosclerosis Society www. noathero. ru Antihypertensive League www. ahleague . ru Russian Society of cardio-somatic rehabilitation www. rosokr .ru and secondary prevention Russian Medical Society on arterial hypertension
Scientific Society of specialists on problems www. gzrf.ru
Society of specialists on heart failure www. ossn. ru
Very high CVD risk Target non HDL and LDL cholesterol < 100 mg/dl < 70 mg/dl <2,6mmol/l < 1,8 mmol/l Start therapy with statins Non HDL-C≥ 100 mg/dl (≥ 2.6 mmol/l) LDL-C ≥70 mg/dl (≥1.8 mmol/l)
2016 ESC/EAS Guidelines for the Management of Dyslipideamias. The Task Force for the Management European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). European Heart Journal 2016;doi:10.1093/europheartj/ehj272
LDL-C and Non-HDL-C Therapuetic Goals and LDL-C Percent Reduction According to CVD Risk Degree
Courtesy Andrea Faludi & Raul Santos Raul , personal communications 2016
Metabolic syndrome 2009 Hypertension 2010
Atherosclerosis, 4th Update, 2009 Atherosclerosis, 5th Update ,2012
Cardiovascular Prevention, 2011 CVD risk reduction in women, 2010 Prevention of cardiac complications after major surgery, 2011 Coronary bypass in CHD: Rehab and 2° prevention 2016
Russian Cardiology Journal;2012;4(96), Attachment I
Guidelines: NLA ( 2011) ; NOA (2012) ; IFHF (2015), IAS Consensus Paper 2016
Chapter about FH 2009-12 in NOA Guidelines International FH Foundation 2014 translated into Russian
IAS Consensus Paper for severe FH 2016 just translated into Russian www.lipidology.ru EAS Consensus Paper for FH 2013 translated into Russian www.lipidology.ru EAS Consensus Paper for children 2015 translated into Russian www.lipidology.ru
Expert Panel: Aronov D M, Akhmedjanov N M, Boytsov S A, Bubnova M G , Galyavich A S , Gecht A B,. Drapkina O M, Ezhov M V Konorskiy S G, Koziolova N A, Krasilnikova E I, Kukharchuk V V Lopatin Yu M, Medvedeva I V, Oganov R G, Ostroumova O D, Parfenov V A, Perepech N B, Sergienko I V, Skibitskiy V V, Stakhovskaya L V, Susekov A V, Tralovskaya E I, Tereshenko S N, Tugeeva E F, Shalaev S V.
Cardiovascular therapy and prevention (in russian): 2011;10(2) 1)Priority patient groups ( very high and high CVD risk) EAS 2011 2) “The lower the LDL-C level , the better “ Target LDL c-C < 1,8 mmol/l or Δ % LDL-C -50% from baseline 3) Maximal statin exposure , indefinite, long-time duration. 4) Atorvastatin 40-80 mg/d or equivalents without titration
Document Year Statins included Standard Medical Care patients with atherosclerosis, PVD, thrombosis 2006 Lovastatin, Simvastatin, Atorvastatin Guidelines for ACS and STEMI 2007 All statins Standard Medical Care for ischemic stroke (special neurological care) 2007 Simvastatin, Atorvastatin Guidelines VNOC for Heart Failure 2009 (III Revision) Rosuvastatin Guidelines for Metabolic Syndrome 2009 (II Revision) All statins Guidelines for Stable Angina 2009 (II Revision) All statins Guidelines for Arterial Hypertension 2010 All statins Guidelines for dyslipideamia 2012 (V th Revision) All Statins
Ministry of Health, Russia Order 1st July 2015 C10AA
HMG-CO-A reductase inhibitors Atorvastatin 80 mg
Rosuvastatin 40 mg Simvastatin 40 mg
About approval of Standard specialized medical care to Patients with acute coronary syndrome, acute and recurrent NONSTEMI MI (without elevation ST of segment on ECG)
Journal of Hypertension, doi:10.1097/01.hjh.0000431740.32696.cc Russian Cardiology Journal 2014; 1(105):7-94
Guidelines Target LDL-C, mmol/l Class Level Statins in patients with arterial Hypertension with moderate /high CVD risk <3,0 Statins in patients with clinical manifest CHD <1,8
Journal of Hypertension, doi:10.1097/01.hjh.0000431740.32696.cc Российский кардиологический журнал 2014; 1(105):7-94
Journal of Hypertension, doi:10.1097/01.hjh.0000431740.32696.cc Russian Cardiology Journal 2014; 1(105):7-94
Total cholesterol, LDL-C, HDL-C, +non HDL-C Triglycerides NICE LIPID 2014 + apo B В -100 (obesity, MS) NLA Lipid Guidelines Part I Analysis of urine With microscopy of urine sediment Heamoglobin and /or heamatocrit Protein in urine K+ and Na+ in blood serum Analysis of urine and myoglobinuria Uric acid ECG 12 leads Creatinine and GFR + TSH in baseline NICE LIPID 2014
dyslipideamia Target LDL-C Other lipid values
Hypertension+ Very high CVD risk SCORE ≥10% ≤1,8 mmol/l Total cholesterol ≤4,0 mmol/l TG ≤1,7 mmol/l HDL-C > 1,0 mmol/l (m) >1,2 mmol/l (f) Hypertension+ High CVD risk SCORE> 5% <10% ≤2,5 mmo/l Total cholesterol ≤4,5 mmol/l TG ≤1,7 mmol/l HDL-C > 1,0 mmol/l (m) >1,2 mmol/l (f)
CRITERIA of MS (Russia): 1 ) Main criteria: central obesity Waist >80 cm (f), > 94 cm (m) 2)Additional criteria:
mmol/l, if 2H OGTT >7,8
(glucose ≥6,1<7,0) + OGTT ≥7,8 <11,1 mmol/l MS=1 main + 2 of the additional criteria Issued under aegis of Ministry of Health Russia, 2013
OGGT=oral glucose tolerance test Diabetes mellitus (in russian) 2015; 18(1S): 1-112.DOI: 10.14341/DM20151S1-112 Public Organization “ Russian Association of Endocrinologists” 2015
Diagnostic criteria for diabetes mellitus, WHO 1999-2913 Analysis Concentration of glucose, mmol/l Capillary blood Venous plasma Norm Fasting And in 2 h after OGGT* <5,6 <7,8 <6,1 <7,8 Diabetes mellitus type II Fasting ≥6,1 ≥7,0
Or in 2 H after OGGT ≥11,1 ≥11,1
Random sample ≥11,1 ≥11,1
Target lipid levels in patients with DM2 T , mmol/l
Total cholesterol < 4,5 LDL-C (without CHD)/ (CHD or very high risk) <2,5 / <1,8 HDL-C >1,0 (males) >1,3 (females) Triglycerides < 1,7
Blood Pressure Target values, mm Hg Systolic blood pressure + CKD or atherosclerosis > 120* and ≤ 140 > 120* and ≤ 130 Diastolic blood pressure >79 and ≤ 85
Diabetes mellitus (in russian) 2015; 18(1S): 1-112.DOI: 10.14341/DM20151S1-112
Algorithm of individual choice of target HBA1c Macrovasular complications (risk of hypoglycemia) Age
Young Middle age Elderly and/or Life expectancy <5 No severe macrovascular complications And/or risk of severe hypoglycemia
<6,5% <7,0% <7,5%
Severe macrovascular complications And/or risk of severe hypoglycemia
<7,0% <7,5% <8,5%
Russian Journal of Cardiology 2014, 8 (112): 7-37
Diagnostic Criteria for chronic kidney disease (CKD) Markers of kidney damage (1 or more) Albuminuria (albumine excretion rate with urine ≥ 30 mg/24 h) Changes of urine sediment Tubular dysfunction Histologic changes Structural changes (visualization technic) History of renal transplantation Reduction of GFR GFR < 60 ml/min/1,73 m2 ( GFA 3a- 5)
Russian Journal of Cardiology 2014; 8(112):7-37 NO CKD or stage 1-2 CKD 3 stage CKD 4-5 stage Renal transplantation Statins Atorvastatin 10-80 10-80 10-80 10-20 Fluvastatin 20-80 20-80 10-80 10-80 Lovastatin 10-80 10-80 10-40 10-40 Pravasatain 10-40 5-20 10-20 10-20 Rosuvastatin 5-40 5-20 5-10 5 Simvastatin 5-40 5-40 5-20 Fenofibrate 96 48
10 10 10
LDL-C ≥ 100 mg/dl (2,6 mmol/l) 0-9 years ≥ 130 мг/дл (3,4 ммоль/л) 10-19 years Translated into Russian For children with FH 8-10 years: LDL-C ↓ 50% For children ≥ 10 years target LDL <3,5 mmol/l Low limit Upper limit High Total cholesterol
≥200 LDL-C
≥130 Tg (0-9 years)
≥100 Tg (10-19)
≥130 HDL-C < 40 40-45
Farrukh, 15 years Tashkent, UZ Maya, 7 years Rostov Distrit, RF Maria, 2 years Chita District, RF
Diagnosis Homozygous FH Homozygous FH Beta-sito Familial hyperchylo syndrome Baseline total cholesterol 18,9 mmol/l 20.9 mmol/l 4,37 mmol\l TC=7,87 LDL-C 17,3 18.3 mmol/l 2,54 mmol/l TG=21,8 Family history +++ ++++ +/- + On examination/ Anamnesis morbi Carotid stenosis 30-40% Arcus lipoidea Xantomatosis
Xantomatosis Homozygous Mutation ABCG8 Recurrent pancreatitis Mutation in LPL gene: rs 118204061
Irina, 8 years Kiev, Ukraine
Age years Males Females n Number with TC ≥6,2 mmol/l, % n Number with TC ≥6,2 mmol/l, % 20-39 7729 19,4 7331 12,8 40-44 2799 31,7 2133 21,7 45-49 2997 33,7 2434 31,2 50-54 3148 35,1 3290 45,6 55-59 3191 34,9 3848 55,1 60-64 3369 33,0 4510 54,1 65-69 1930 31,2 2464 55,6 Group 40-69 years 17437 33,5 18673 46,3 All (20-70 years) 25274 29,3 % 26751 37,4 %
Igoninina N.A, Zhuravleva E A., Kondrasheva E A et al. The cholesterol level in Russian adults aged 20-70 years. Atherosclerosis and dyslipideamias 2012;4:68-72/ (In Russian)
Number of adults(%) of adults with the level of total cholesterol > 6,2 mmol/l
Risk factors
АТР
Survey***
n=1653 2001
OSKAR*
n=7098 2005-2006.
ATLANTIKA
n=655 2006-2008
PORA!**
n=615 2007-2009
Perspectiva* **
n=2768 2009-2010
BP systolic,
145 146 139 136 146
BP diastolic
88 89 85 83 88 IMT, kg/m2 27,9 28,0 29,3 29,0 28,3 Total cholesterol 6,1 6,6 6,4 6,3 5,6 LDL-C 4,2 4,4 4,2 4,2 3,6 Hear Rate, 73 73
74
OSKAR - Shalnova S, 2006. ATLANTIKA: Mareev V Yu et al 2008; PORA and PERSPECTIVA:Bubnova M G and Aronov, 2010
BP=blood pressure. mmGH, total cholesterol , and LDL-C in mmol/l; heart rate – in beats per minutes
Variables Odds Ratio, (95% ,CI) P= Doctor’s speciality (Cardio/Endocrin/Internist) 1,66 (1,04-2,65) 0,03 Females 1.45 (1.14-1.86) 0.0028 Peripheral atherosclerosis 1.63 (1.02-2.62) 0.04 BP ≥140/90 mm GH 1.79 (1.39-2.30) <0.0001
High ( ~ Simvastatin 80) vs low (~ Simvasatin 10 mg) doses of statins OR 0 .44 (0.24-0.81) , p=0.081
Oganov R G et al. *Cardiovascularnaya therapia I profilactica (in russian) 2012; 11(4):1-10 3
Journal of Hypertension, doi:10.1097/01.hjh.0000431740.32696.cc Rossiyskiy Cardiology Journal (in russian) 2014; 1(105):7-94
АСС/AHA 2013 + Positive family history for CHD, ↑ hs-CRP, Agatson Score>300
Pulse pressure ( in elderly and senile patients ≥ 60 mm GH ECG signs of LVH ( index Sokolov- Layon > 3,5 mV; RaVL >1,1 mV; Cornell index >244 mv [ msec ) or ECHO signs of LVH( index Myocardial Mass > 115 g/m2 (males) and 5 g/mm2 (females) Intima Media Thickening (IMT) > 0,9 or carotid plaque Velocity of carotid-femoral wave > 10 m/sec Ankle Brachial index <0,9 CKD with GFR 30-60 ml/min /1,73 m2 Microalbuminuria (30-300 mg/mmol) or ration albumin/creatinin (30-300 mg/mmol/l)
2015-16 > 16.500 copies have been in Russia distribute for free
EAS Consensus HoFH 2014
Clinical features of HoFH Treatment options for HoFH
Anjeo Health Communication. OOO Group “REMEDIUM”. 2015 Pocket Guidelines for doctors “Dyslipideamia and atherosclerosis” . Under edition of professor Andrey V Susekov.
www.lipidology.ru
Papers