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Adult Treatment Panel III (ATP III) Guidelines
May 2001
Ipercolesterolemie famigliari
Ipercolesterolemie e rischio cardio vascolare globale
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Chilomicroni (apo B-48, C, E)
MACROFAGO
VLDLApo B-100Apo C, E
IDL
LDLApo B-100
HDL3Apo AI-II
HDL2
TG Fatty AcidsCOL
trasportoinverso
Site of Synthesis of Lipoproteins
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CM VLDL IDL LDL HDL
Lipoprotein Nomenclatureand Composition
Major apoB apoB apoB apoB apoA-IProtein
Major TG TG CE CE CELipid
CM= chylomicron TG=triglycerideVLDL= very low density lipoprotein CE= cholesteryl esterIDL= intermediate density lipoproteinLDL= low density lipoproteinHDL= high density lipoproteinApo = apolipoprotein
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Iperlipoproteinemie secondo FredriksonClassificazione fenotipica
V Chilomicroni, VLDL TG & ColIV VLDL TG & Col
III IDL, VLDL, Chilomicroni Col & TG (1/1)IIb LDL & VLDL Col & TGIIa LDL Col
I Chilomicroni TG
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Iperlipoproteinemie genetiche
Ipercol Fam IV o V 2-3/1000 AD ?
Iperlipidemia IIb o IV 3-5/1000 AD ?FamiliareCombinata
FH IIa o IIb 1/500 AD def recettore LDLFDA IIa 1/500 AD Apo B100 defPoligenica IIa ? ? ?Disß III ? AR Apo E2E2
Iperchilo I o V rara + AR Deficit LPL/Apo C-II
Iper Col > Iper TG
Iper TG > Iper Col
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Diagnosiiperlipoproteinemie genetiche
- Criteri clinici -Famigliarità per ipercolesterolemia (parenti di I grado)
Famigliarità per CVD < 55 anni (parenti di I grado)
Xantomi tendinei
LDL cut off ?? LDL 190 - 220 mg/dl ??
Apo B cut off
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Adult Treatment Panel III (ATP III) Guidelines
May 2001
National Cholesterol Education Program
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ATP I & ATP II
MAJOR GOAL OF THERAPY
LDL-CHOLESTEROL
MAJOR TARGETS OF THERAPY
FH Het & HomFDA apo B-100
PH
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T2DM/T1DMIpotiroidismoCushingIRCSindrome NefrosicaColestasiObesità
Iperlipemia iatrogena
AlcoholHigh-CARBO DietEstrogeniTiclopidinaDiureticiß-blockGlucocorticoidi
Iperlipoproteinemie secondarie
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New Features of ATP III
Multiple metabolic risk factors (metabolic syndrome)
Focus on Multiple Risk Factors
Diabetes: CHD risk equivalent
Framingham projections of 10-year CHD risk
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Diabete e CVD
rischiorelativo
1
2
3
0no DMno IMA
no DMIMA
DMno IMA
DMIMA
Mukamal KJ et al Diabetes Care 24; 1422, 2001
rischio relativo di mortalità CVD
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NEFA
Il paradigma dell’aumentato flusso dei NEFA
Perseghin G. et al. Curr Opin Lipidol, 2005
DietaSedentarietà
Geni
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Eccesso di grasso viscerale e dislipidemia
Pouliot MC et al. Diabetes 1992;41:826-34
310
248
186
124
62
0
60
45
30m
g/d
L
mg
/dL
Trigliceridi
Magri
Colesterolo HDL
Grasso viscerale(soggetti obesi)
Basso Alto Magri
Grasso viscerale(soggetti obesi)
Basso Alto
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L’eccesso di grasso viscerale promuoveun fenotipo aterogeno Elevati trigliceridi, basso C-HDL e
elevate particelle piccole e dense di C-LDL
C-LDL normale C-LDL normaleLDL dense
TGC-HDL
TGC-HDL
Magri grasso viscerale
Rischio CHD
Despres JP. Ann Med 2001;33:534-41
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Fattori di Rischio Cardiovascolare
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Rischio Cardiovascolare Globale
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UKPDS BMJ 316; 823, 1998
Diabete e CVDPRIORITA’
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pazienti con eventivascolari
(%)
0
20
10
Placebo SIMVA
HPS Lancet 360; 7, 2002
Terapia farmacologicaEFFICACIA delle STATINE
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Modulazione dell’intervento
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LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)
and Drug Therapy in Different Risk Categories
190 (160–189: LDL-lowering drug
optional)
160<1600–1 Risk Factor
10-year risk 10–20%: 130
10-year risk <10%: 160
130<1302+ Risk Factors
(10-year risk 20%)
130 (100–129: drug
optional)100<100
CHD or CHD Risk Equivalents
(10-year risk >20%)
LDL Level at Which to Consider
Drug Therapy (mg/dL)
LDL Level at Which to Initiate
Therapeutic Lifestyle Changes
(TLC) (mg/dL)
LDL Goal(mg/dL)Risk Category
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Terapia farmacologicaEFFICACIA delle STATINE
Colesterolo totale 20-40%
LDL-C 30-50%
Trigliceridi 5-20%
HDL-C 5%
Terapia farmacologicaEFFETTI PLEIOTROPICI delle STATINE
• Infiammazione•Funzione endoteliale
• Stabilità di placca
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Drug TherapyHMG CoA Reductase Inhibitors (Statins)
• Major side effects– Myopathy (CK)– Increased liver enzymes (AST, ALT)
• Contraindications– Absolute: liver disease– Relative: use with certain drugs
Fibrati (assoluta controindicazione ad associazione con gemfibrozil, mentre la più tollerata è con fenofibrato), immunosoppressori (CyA), ketoconazolo
– Citocromo P450 (macrolidi, chinolonici)
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Terapia farmacologica
quale statina?
The Curves Study
atorva
simva lova
prava fluva
Jones P et alAm J Cardiol 81: 582, 1998
rosuva
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Prava Simva Fluva Atorva/Rosuva
Emivita
CYP 450
Int Warfarin
Int Digitale
Lipofilia
2h 3h 3h 15h
no yes yes yes
yes yes no yes
no yes yes yes
no yes no yes
Drugs Features
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Drug TherapyBile Acid Sequestrants
• Major actions– Reduce LDL-C 15–30%– Raise HDL-C 3–5%– May increase TG
• Side effects– GI distress/constipation– Decreased absorption of other drugs
• Contraindications– Dysbetalipoproteinemia– Raised TG (especially >400 mg/dL)
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Bile Acid Sequestrants
DrugDose
Cholestyramine 4–16 g
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Bile Acid Sequestrants (continued)
Demonstrated Therapeutic Benefits
• Reduce major coronary events
• Reduce CHD mortality
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Drug TherapyFibric Acids
• Major actions– Lower LDL-C 5–20% (with normal TG)– May raise LDL-C (with high TG)– Lower TG 20–50%– Raise HDL-C 10–20%
• Side effects: dyspepsia, gallstones, myopathy
• Contraindications: Severe renal or hepatic disease
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Fibric Acids
Drug Dose
• Gemfibrozil 600 mg
• Fenofibrate 145/200 mg
• Bezafibrate 400 mg
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Simvastatina+
Ezetimibe
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Age-standardized mortality from cardiovascular disease, i.e. ischaemic heart disease and cerebrovascular disease combined,
in European regions (men; age group 45-74 years; year 2000)
J Muller-Nordhorn, et al. Eur Heart J 2008;29:Epub online