Appropriate management of

patients with multiple

cardiovascular risk
Hypertension increases atherogenic
lipoprotein content of arterial vessel walls

Atherogenic
BP VLDL, VLDL-R,
IDL, LDL

Pressure-driven
convection
Intima- Enhanced – LP penetration
media – LP retention

Intima- – Pressure-induced distension

media – Stretching

LP = lipoprotein Sposito AC. Eur Heart J Suppl. 2004;6(suppl G):G8-G12.

Genetics augment effects of environmental
risk factors
ENVIRONMENT

Inactivity Diet Psychosocial Stress Culture

Obesity Diabetes Hypertension

GENES GENES

Inadequate
Medical Care
STROKE / MI GENES
Treatment of Associated Risk Factors

Lipid Lowering Agents

• All hypertensive patients with established cardiovascular disease or with type 2
diabetes should be considered for statin therapy aiming at serum total and LDL
cholesterol levels of, respectively, <4.5 mmol/L (175 mg/dL) and <2.5 mmol/L (100
mg/dL) and lower, if possible
• Hypertensive patients without overt cardiovascular disease but with high
cardiovascular risk should also be considered for statin treatment even if their baseline
total and LDL serum cholesterol levels are not elevated
• Cardiovascular risk factors for consideration of statin therapy in non-dyslipidemic patients with hypertension*

• Risk Factor
• Male sex
• Age 55 years or older
• Left ventricular hypertrophy
• Left bundle branch block, left ventricular strain pattern, abnormal Q-waves, or ST-T changes compatible with ischemic heart
disease
• Microalbuminuria or proteinuria
• Smoking
• Family history of premature cardiovascular disease
• Other ECG abnormalities:
• Total cholesterol to HDL ratio > 6

• *If hypertensive patients have 3 or more of these risk factors, statins should be considered. In addition, patients should be
treated according to the most recent Canadian Lipid Recommendations.
• The concept of total CVD risk replaces the traditional
classification of risk factors in most people.
• The physician asks the question ‘‘What is this person’s
CVD risk?’’ rather than does this person have
‘‘hypertension’’ or ‘‘hypercholesterolaemia’’.
Guidelines and Recommendations Worldwide
Advise LDL-C Lowering Based on CV Risk
ACC/AHA Guideline1,2 ESC/EAS Guidelines3 NLA Recommendations4
4 risk groups (LDL-C Goals)
4 risk groups (LDL-C Goals):
4 risk groups for statin therapy: • Very High (LDL-C < 70 mg/dL)
• Clinical ASCVD • High (LDL-C level < 100 mg/dL) • Very High (LDL-C < 70 mg/dL)
• Primary elevations of LDL-C ≥ 190 mg/dL • Moderate (LDL-C < 115 mg/dL) • High (LDL-C level < 100 mg/dL)
• 40 to 75 years of age with diabetes with LDL-C • Low LDL-C < 115 mg/dL) • Moderate (LDL-C < 100 mg/dL)
70-189 mg/dL • Low (LDL-C < 100 mg/dL)
• Without clinical ASCVD or diabetes 40 to 75 Concomitant diseases used to
years of age with LDL-C 70-189 mg/dL and an stratify risk categorization Risk factors and concomitant
estimated 10-year ASCVD risk of 7.5% or higher diseases used to stratify risk categorization

High (≥ 50% LDL-C ↓) or moderate Absolute value for LDL-C goal

(30-50% LDL-C ↓) intensity statin therapy

Target
Target intensity
intensity of
of statin
statin Target
Target LDL-C
LDL-C levels
levels
therapy and LDL-C reduction
therapy and LDL-C reduction
(percent (absolute
(absolute value)
value)
(percent reduction)
reduction)

Statins are universally recommended as first line therapy across guidelines and recommendations (and
commonly ezetimibe as second line therapy)

ACC/AHA = American College of Cardiology/American Heart Association; ASVCD = atherosclerotic cardiovascular disease; EAS = European Atherosclerosis Society;
ESC = European Society of Cardiology; LDL-C = low-density lipoprotein cholesterol; NLA = National Lipid Association.

1. Stone NJ, et al. J Am Coll Cardiol. 2014;63:2889-2934. 2. Keaney JF Jr, et al. N Engl J Med. 2014;370:275-278.
3. Catapano AL, et al. Atherosclerosis. 2016;253:281-344. 4. Jacobson TA, et al. J Clin Lipidol. 2015;9:129-169.
Patient CV risk assessment translated into patient Classification:

ACC/AHA guidelines 2018: Patient classification into High risk/Moderate risk

Diabetes, aged 40 – 75
years, with LDL-C 70 – 189
Clinical ASCVD LDL-C ≥ 190 mg/dL
mg/Dl, estimated 10
years ASCVD risk of ≥ 7.5

Diabetes, aged 40 years, Estimated 10 year risk of

with LDL-C 70 – 189 ASCVD of ≥7.5%, 40 – 75
mg/Dl, estimated 10 years of age and with
years ASCVD risk of <7.5 LDL-C 70 – 189 mg/dL

. Stone NJ, et al J. Am . Coll Cardiol 2018: doi:10.1016/j.jacc.2018.11.002.

Focus on ASCVD Risk Reduction:
4 statin benefit groups*

Clinical ASCVD† LDL-C level ≥190 mg/dL

Estimated 10-year risk of

Diabetes, aged 40-75 ASCVD of ≥7.5%,‡ 40-75
years, with LDL-C 70- years of age, and with
189 mg/dL LDL-C 70-189
mg/dL
* Moderate- or high-intensity statin therapy recommended for these 4 groups
†
Clinical ASCVD defined as acute coronary syndromes, history of MI, stable or unstable angina, coronary or arterial revascularization, stroke,
transient ischemic attacks, or peripheral artery disease
‡
Estimated using Pooled Cohort Risk Assessment Equations

• Stone NJ, et al. J Am Coll Cardiol. 2013: doi:10.1016/j.jacc.2013.11.002. Available at: 25

 Physicians Often Underestimate Their Patients’ CV Risk

Comparison of actual vs perceived 10-y risk among 80 Swedish GPs asked to

estimate the risk of a number of given patient profiles
60

50
Framingham calculated risk
40
Risk estimate (%)

33 Perceived risk
30 27
20
14
10 10 10
5
0
Man 61 years of age Woman 66 years of age Woman 51 years of age
Smoker Diabetic Smoker
LDL-C 6.3 mmol/L LDL-C 4.6 mmol/L LDL-C 4.1 mmol/L
244 mg/dL 178 mg/dL 166 mg/dL TC 6.5
TC 8.2 mmol/L TC 6.9 mmol/L 255 mg/dL
317 mg/dL mmol/L 267 mg/dL

Backlund L, et al. Prim Health Care Res Dev. 2004;5:145-152.

AACE 2017 Guidelines Recommend Aggressive LDL
Reduction for Diabetic Patients
Multiple Risk Factor Management Results in Greater CVD
Risk Reduction
“Likelihood of a Major Cardiovascular Event in the
Next 10 Years in 100 People Like You”

Cardiovascular Events Expected

Without Drug Therapy
Williams B. J Am Coll Cardiol. 2005;45:813-827. Reproduced with permission from Professor Bryan Williams.
 Multiple Risk Factor Management Results in Greater CVD
Risk Reduction
“Likelihood of a Major Cardiovascular Event in the
Next 10 Years in 100 People Like You”

Cardiovascular Events Prevented

by Antihypertensive Therapy
Williams B. J Am Coll Cardiol. 2005;45:813-827. Reproduced with permission from Professor Bryan Williams.
 Multiple Risk Factor Management Results in Greater CVD
Risk Reduction
“Likelihood of a Major Cardiovascular Event in the
Next 10 Years in 100 People Like You”

Optimising Hypertension Management by Addition of

Statin Therapy May Reduce CV Events by Half

Events Prevented by Events Prevented by

Antihypertensive Therapy Adding Statin
Williams B. J Am Coll Cardiol. 2005;45:813-827. Reproduced with permission from Professor Bryan Williams.
Therapy
Please see prescribing information at the end of this slide presentation.
Despite an overall prevalence of Dyslipidemia in Saudi population ranging
from 20 – 40%, Hypercholesterolemia remains undertreated¹

In spite of therapy, only 59% patients receiving Primary Prevention (n=2242), and 32% on Secondary
prevention (n=473) could achieve recommended LDL-C goals: CEPHEUS Study in 6 Gulf countries1

1. Al-Kaabba AF et al. Open Journal of Endocrine and Metabolic Diseases 2012; 2: 89-97
Dyslipidemia in Saudi population is associated with other CV risk factors¹

• Hypertension
• Diabetes
• Obesity / overweight
Low HDL High LDL-C

38.3% 39.6%
35.5%

26.7% 25.9% 26.9%

Hypertension Diabetes Overweight

1. Al-Kaabba AF et al. Open Journal of Endocrine and Metabolic Diseases 97-89 :2 ;2012