Secondary Prevention of Cardio-Vascular Disease

• NZ Guidelines Group

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• Overview

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• Treating to New Targets (TNT) trial
• Supports a lower LDL cholesterol target in stable coronary artery disease
• Comparison of the TNT trial with selected studies
• Apo B in TNT and IDEAL

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• PROVE IT
• Supports more intensive lipid lowering after acute coronary syndromes

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• Looking Beyond LDL
• Apolipoprotein-B and A1
  
  • Notes from ASEANZ 2009
  • Apo B in TNT and IDEAL
• HDL Cholesterol
• Non-HDL cholesterol Levels
• CRP in the PROVE IT trial

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• Diabetes
• New targets for management- notes from ASEANZ 2009
• Controversies- notes from ASEANZ 2009
• Macrovascular complications- more than just HbA1C- notes from ASEANZ 2009

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• Supplements
• Folic Acid

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• South Asians
  • Optimal Risk Factor Status for South Asians for Secondary Prevention
  • BMI measurement leads to underestimation of obesity

Role of non-HDL cholesterol and apo B measurement to guide secondary prevention

TNT and IDEAL examined the role of more intensive LDL cholesterol lowering with statin therapy.

A post-hoc analysis of the TNT and IDEAL studies revealed that, for those that had an LDL cholesterol of less than or equal to 2.6 mmol/l, predictors of the risk of subsequent major cardiovascular events were:
• LDL cholesterol- hazard ratio of 1.08 (not significant)
• non-HDL cholesterol- hazard ratio of 1.15 (p=0.002)
• Apo B- hazard ratio of 1.15 (p=0.002)
• Total/HDL cholesterol- hazard ratio of 1.22 (p=0.001)
• Apolipoprotein B/A-1- hazard ratio of 1.33 (p=0.001).

Similar trends were seen when the analysis was performed in subgroups with non-HDL less than 3.4 mmol/l, or Apo B less than 1.1 g/l, or total/HDL cholesterol less than 4, or Apo B/A-1 ratio of less than 0.8.

Although the ratio or total/HDL cholesterol and Apo B/A-1 were predictive of adverse events, the use of ratios as targets has not been promoted in the absence of clinical trial data that indicates that raising HDL cholesterol leads to fewer events.

These data are seen to provide support for the use of non-HDL cholesterol and apo B measurements to guide the need for more intensive therapy.

Hitesh Patel

June, 2009

Reference. Lipids, Apolipoproteins, and Their Ratios in Relation to Cardiovascular Events With Statin Treatment. Circulation. 2008;117:3002-3009.