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

Raising HDL Cholesterol

Use Proven Agents

Low HDL cholesterol has been shown to be associated with an increased risk of cardiovascular events. It is tempting to assume that raising HDL cholesterol will provide benefits for primary or secondary prevention.

Should we aim to lower LDL cholesterols further to obtain benefit or should we attempt to raise HDL cholesterol levels?

Unfortunately, the development of a novel agent, torcetrapib, was suspended.

One trial, compared the use of Torcetrapib with Atorvastatin vs Atorvastatin alone. Combination therapy raised HDL cholesterol significantly compared to monotherapy. Despite this, the study found no greater reduction in carotid artery atherosclerosis, as assessed by measurement with ultrasound of carotid arterial wall thickness.

Another trial (ILLUMINATE) that compared Torcetrapib with Atorvastatin vs Atorvastatin alone was suspended when an interim analysis found increased mortality in the combination therapy group.

The ARBITER-2 study did find decreased progression of carotid atherosclerosis with use of extended release niacin. The ARBITER-2 study was not designed to find a reduction in clinical events.

Hitesh Patel, Cardiologist
15/06/07