What is the New in Current

Lipid Guideline

Indonesian Perspectives

Anwar Santoso
Dept. Cardiology – Vascular Medicine
Faculty of Medicine - Universitas Indonesia
Harapan Kita Hospital ~ National Cardiovascular Centre
National Health and Nutrition Examination Survey (NHANES)*

*Based on 7,399 subjects in NHANES from 1999-2002

Keevil JG et al. Circulation 2007;115:1363-1370
 100

Acute Coronary Syndrome

n=22379
80
Adherence Rate (%)

60
Primary Prevention
n=85020 Coronary Artery Disease
40 n=36106

20

0
0 3 6 9 12 15 18 21 24

Months

Source: Jackevicius CA et al. JAMA 2002;288:462-467

 Gaps in Practice in Indonesia

Courtesy and analyzed by Clara Chow; The George Institute for Global Health; 2017
Cardiovascular Risk Assessment

What is the new and what is the same

Cardiovascular Risk Assessment
Cardiovascular Risk Assessment
 SCORE risk model suitable for Indonesian
and other ethnicity?
The new

The following correction factors could be

applied when assessing CVD risk using
SCORE among this ethnicity:

• Southern Asia: multiply the risk by 1.4

• Sub-Saharan Africa / Caribbean: multiply by 1.3
• Western Asia: multiply the risk by 1.2
• Northern Africa: multiply the risk by 0.9
• Eastern Asia/South America: multiply the risk by 0.7

Piepoli MF, et al. Eur Heart J 2016; 37: 2315 - 81

The Necessity of Fasting for Lipid Measurements :
The new

Driver SL, et al. J Am Coll Cardiol 2016; 67(10): 1227 - 34

Targets, Goals, and Thresholds
Lipoprotein targets of therapy

Eur Heart J doi: 10.1093/eurheartj/ehw272

Lipoprotein targets of therapy

J Am Coll Cardiol 2014; 63: 2889 - 2934

Lipoprotein targets of therapy

Endocrine Practice 2017: DOI: 10.4158/EP171764.GL

Lipoprotein targets of therapy

Diabetes Care 2017; 40: 575 - 87

Lipoprotein goals of therapy

Eur Heart J doi: 10.1093/eurheartj/ehw272

Lipoprotein goals of therapy

J Am Coll Cardiol 2014; 63: 2889 - 2934

 Lipoprotein goals of therapy

2013/ACC-AHA Blood Cholesterol Guideline

J Am Coll Cardiol 2014; 63: 2889 - 2934

 Intensity of Statin Therapy
High Moderate Low
 LDL-C ≥50%  LDL-C 30 to <50%  LDL-C <30%
Atorva 40-80 mg Atorva 10-20 mg Simva 10 mg
Rosuva 20-40 mg Rosuva 5-10 mg Prava 10-20 mg
Simva 20-40 mg Lova 20 mg
Pravas 40 mg Fluva 20-40 mg
Lova 40 mg Pitava 1 mg
Fluva XL 80 mg
Fluva 40 mg bid
Pitava 2-4 mg

Statins in bold were evaluated in randomized controlled trials;

those in italics were not

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce

Atherosclerotic Cardiovascular Risk in Adults, p 34
Lipoprotein goals of therapy

Endocrine Practice 2017: DOI: 10.4158/EP171764.GL

Lipoprotein goals of therapy

JAMA 2016; 316(19): 1997 - 2007

LDL-C Response Variability to High-Intensity Statins and
Implications to PCSK-9 inhibitors

Ridker PM, et al. Eur Heart J 2016. doi:10.1093/eurheartj/ehw046

Determining when to add non-statin treatment:
The new

Robinson JG, et al. J Am Coll Cardiol 2016; 68: 2412 - 21

ESC CP Guidelines ~ Highlight: Dyslipidemia
The new

Eur Heart J doi: 10.1093/eurheartj/ehw272

ESC CP Guidelines ~ Highlight: Dyslipidemia
The new

Eur Heart J doi: 10.1093/eurheartj/ehw272

 Highlights
• Perubahan dari Pedoman Tatalaksana
Dislipidemia tahun 2013:
– Acuan utama: ESC/EAS Guidelines tahun 2016
– Sumber lain: bukti baru yang dipandang patut
mengubah praktek klinik
 Kategori Risiko CVD
Guideline Dislipidemia 2011 Guideline Dislipidemia 2016
Rekomendasi Rekomendasi
Risiko Sangat Tinggi: Risiko Sangat Tinggi:
- CVD yang diketahui - CVD yang diketahui
- DM atau DM Tipe 1 dengan target organ - DM atau DM Tipe 1 dengan target organ
damage damage
- GFR <60 mg/mL/1,73m2 - Disfungsi ginjal berat: GFR <30
- SCORE ≥10% mg/mL/1,73m2
Risiko Tinggi: - SCORE ≥10%
- Faktor risiko tunggal yang nyata tinggi Risiko Tinggi:
- SCORE ≥5% dan <10% - Faktor risiko tunggal yang nyata tinggi
Risiko Menengah: - SCORE ≥5% dan <10%
- SCORE ≥1% dan <5% - Disfungsi ginjal sedang: GFR 30-59
mg/mL/1,73m2
Risiko Rendah:
- SCORE <1% Risiko Menengah:
- SCORE ≥1% dan <5%
Risiko Rendah:
- SCORE <1%
 Target Pengobatan
Guideline Dislipidemia 2011 Guideline Dislipidemia 2016
Rekomendasi Class Lvl Rekomendasi Class Lvl
Risiko Sangat Tinggi: I A Risiko Sangat Tinggi: I B
LDL-C <70 mg/dL dan/atau LDL-C <70 mg/dL dan/atau
penurunan 50% bila target tidak bisa penurunan 50% bila baseline adalah
dicapai 70-135 mg/dL
Risiko Tinggi: IIa A Risiko Tinggi: I B
LDL-C <100 mg/dL LDL-C <100 mg/dL atau penurunan
Risiko Menengah: IIa C 50% bila baseline adalah 100-200
LDL-C <115 mg/dL mg/dL
Risiko Menengah: IIa C
LDL-C <115 mg/dL
 Tatalaksana Dislipidemia 2017
• Data tambahan:
– Terapi non-statin:
• Studi klinis fase 2 dan 3 proprotein convertase
subtilisin/kexin tipe 9 (PSCK9)
• Studi luaran klinis gabungan statin-ezetimibe
(IMPROVE-IT) pada populasi SKA
SUMMARY