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

Lipid Modifying Therapy for Secondary Prevention

Does Raising HDL-Cholesterol Levels Improve Outcome?

The ARBITER 2 study used carotid intima-media thickness as a surrogate measure of progression of atherosclerosis.

Patients with known coronary artery disease with average LDL cholesterol levels of only 2.3 mmol/l and HDL cholesterol levels of 1.1 mmol/l were randomised to extended release niacin or placebo. Statin therapy was continued.

HDL cholesterol levels increased with niacin therapy by over 20% and this was associated with no real change carotid intima-medial thickness. In contrast, the placebo group showed progression. LDL cholesterol levels remained comparable between the two groups.

We do not know, however, if these benefits would still be obtained if we lower our target LDL cholesterol below 1.8 mmol/l for all persons. Studies that use surrogate endpoints such as ARBITER 2 can not inform us of the magnitude of the clinical benefit that we might obtain from treatment with niacin.

• Taylor AJ et al. Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER) 2. Circulation. 2004;110:3512-3517.