Chronic stable angina treatment lipid management

Chronic stable angina Microchapters
Acute Coronary Syndrome Main Page
Home
Patient Information
Overview
Historical Perspective
Classification
Classic Chronic Stable Angina
Atypical Walk through Angina Mixed Angina Nocturnal Angina Postprandial Angina Cardiac Syndrome X Vasospastic Angina
Differentiating Chronic Stable Angina from Acute Coronary Syndromes
Pathophysiology
Epidemiology and Demographics
Risk Stratification
Pretest Probability of CAD in a Patient with Angina
Prognosis
Diagnosis
History and Symptoms
Physical Examination
Test Selection Guideline for the Individual Basis
Laboratory Findings
Electrocardiogram
Exercise ECG
Chest X Ray
Myocardial Perfusion Scintigraphy with Pharmacologic Stress
Myocardial Perfusion Scintigraphy with Thallium
Echocardiography
Exercise Echocardiography
Computed coronary tomography angiography(CCTA)
Positron Emission Tomography
Ambulatory ST Segment Monitoring
Electron Beam Tomography
Cardiac Magnetic Resonance Imaging
Coronary Angiography
Treatment
Medical Therapy
Revascularization
PCI
CABG
Hybrid Coronary Revascularization
Alternative Therapies for Refractory Angina
Transmyocardial Revascularization (TMR)
Spinal Cord Stimulation (SCS)
Enhanced External Counter Pulsation (EECP)
ACC/AHA Guidelines for Alternative Therapies in patients with Refractory Angina
Discharge Care
Patient Follow-Up
Rehabilitation
Secondary Prevention
Guidelines for Asymptomatic Patients
Noninvasive Testing in Asymptomatic Patients
Risk Stratification by Coronary Angiography
Pharmacotherapy to Prevent MI and Death in Asymptomatic Patients
Landmark Trials
Case Studies
Case #1
Chronic stable angina treatment lipid management On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Chronic stable angina treatment lipid management
CDC onChronic stable angina treatment lipid management
Chronic stable angina treatment lipid management in the news
Blogs on Chronic stable angina treatment lipid management
to Hospitals Treating Chronic stable angina treatment lipid management
Risk calculators and risk factors for Chronic stable angina treatment lipid management

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan. M.B.B.S.

Overview

In patients with established coronary artery disease, the recommended goal for total cholesterol is 130 mg/dl and LDL-C is 100 mg/dl, while the HDL-C and triglyceride concentrations serve as preferred markers for risk assessment. In patients with CAD, fasting lipid-profile may be repeated at an interval of every 5-year to assess the overall risk of cardiovascular mortality and morbidity. Based on the individual’s lipid abnormalities, necessary dietary interventions and/or lipid-lowering agents are suggested to prevent the risk of future coronary events. A Mediterranean diet consisting of fruits, vegetables, lean meat and fish has shown to be beneficial. Omega-3 fatty acid supplementation may be indicated in patients with stable angina for secondary prevention, as it has shown to reduce elevated triglycerides and also reduce the risk of sudden cardiac death. Fish consumption once a week has also been associated with reduced risk of mortality from coronary artery disease and hence is strongly recommended.

Guide to Lipid Management based on the European Task Force

“

”

Supportive trial data

• In the Whitehall cohort study, that involved 17,718 patients with a follow-up over 18 years, to evaluate the relationship between plasma cholesterol concentration and mortality from major causes of death, reported a significant increase in mortality from coronary artery disease associated with increasing cholesterol concentration from the lowest levels (p<0.01).

• In the GISSI-Prevenzione trial, that involved 11,324 patients with history of recent MI were randomized to receive either omega-3 PUFA (1 g daily), vitamin E (300 mg daily) or a combination of both, to evaluate the effects of omega-3 polyunsaturated fatty acids and vitamin E as supplements in patients who had myocardial infarction. A significant reduction in the composite primary endpoint was observed in the n-3 PUFA group, during a 3.5 year follow-up. Thus, the study concluded that dietary supplementation with omega-3 PUFA provided significant benefit in improving the over-all clinical outcome in patients with ischemic heart disease.

• In a GISSI Prevenzione sub-study, that assessed the time course of benefit with omega-3 polyunsaturated fatty acids, attributed the anti-arrhythmic effect of omega-3 PUFA consistent with previous experimental studies, being responsible for an early reduction in the total mortality (RR 0.59; 95% CI 0.36 to 0.97; P=0.037) and sudden cardiac death (RR 0.47; 95% CI 0.219 to 0.995; P=0.048).

• A meta-analysis that evaluated the effects of dietary and non-dietary supplementation of omega-3 polyunsaturated fatty acids on coronary artery disease, reported a significant reduction in the risk of fatal myocardial infarction (RR 0.7; 95% CI: 0.6 to 0.8; p<0.001) and sudden cardiac death (RR 0.7; 95% CI: 0.6 to 0.9; p<0.01). Thus, the study concluded omega-3 polyunsaturated fatty acid consumption significantly reduced the overall mortality, mortality due to myocardial infarction and sudden cardiac death; however, these benefits were confined to high-risk patients.

• A 2005 meta-analysis that reviewed 97 studies to assess the efficacy and safety of different lipid-lowering interventions based on mortality data, reported significant reduction in over-all cardiovascular mortality associated with omega-3 polyunsaturated fatty acid supplementation and hence can be used in patients with stable angina for secondary prevention.

ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT)

“

Class I 1. Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), transfatty acids, and cholesterol (to less than 200 mg per day). (Level of Evidence: B) 2. Daily physical activity and weight management are recommended for all patients. (Level of Evidence: B) 3. Recommended lipid management includes assessment of a fasting lipid profile. a. LDL-C should be less than 100 mg per dL. (Level of Evidence: A) b. If baseline LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL-lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in LDL-C levels. (Level of Evidence: A) c. If on-treatment LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be intensified. (Level of Evidence: A) d. If TG are 200 to 499 mg per dL, non–HDL-C should be less than 130 mg per dL. (Level of Evidence: B) e. If TG are greater than or equal to 500 mg per dL, therapeutic options to lower the TG to reduce the risk of pancreatitis are fibrate or niacin; these should be initiated before LDL-C lowering therapy. The goal is to achieve non–HDL-C less than 130 mg per dL if possible. (Level of Evidence: C) 4. Drug combinations are beneficial for patients on lipid lowering therapy who are unable to achieve LDL-C less than 100 mg per dL. (Level of Evidence: C) 5. Lipid-lowering therapy in patients with documented CAD and LDL-LDL cholesterol greater than 130 mg/dL with a target LDL of less than 100 mg/dL. (Level of Evidence: A) Class IIa 1. Adding plant stanol or sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C. (Level of Evidence: B) 2. Lipid-lowering therapy in patients with documented CAD and LDL cholesterol 100 to 129 mg/dL, with a target LDL of 100 mg/dL. (Level of Evidence: B) 3. Recommended lipid management includes assessment of a fasting lipid profile. a. Reduction of LDL-C to less than 70 mg per dL or high-dose statin therapy is reasonable. (Level of Evidence: A) b. If baseline LDL-C is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL. (Level of Evidence: B) c. Further reduction of non–HDL-C to less than 100 mg per dL is reasonable, if TG are greater than or equal to 200 to 499 mg per dL. (Level of Evidence: B) 4. Therapeutic options to reduce non–HDL-C are: a. Niacin can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C–lowering therapy) (Level of Evidence: B) b. Fibrate therapy as a therapeutic option can be useful to reduce non–HDL-C (after LDL-C–lowering therapy). (Level of Evidence: B) 5. The following lipid management strategies can be beneficial: a. If LDL-C less than 70 mg per dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When LDL-C less than 70 mg per dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of greater than 50% in LDL-C levels by either statins or LDL-C–lowering drug combinations. (Level of Evidence: C) Class IIb 1. For all patients, encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per day) for risk reduction may be reasonable. For treatment of elevated TG, higher doses are usually necessary for risk reduction. (Level of Evidence: B)

”

Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

References

Template:WikiDoc Sources