Secondary Prevention of Cardio-Vascular Disease

• NZ Guidelines Group

---

• Overview

---

• 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

---

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

---

• 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

---

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

---

• Supplements
• Folic Acid

---

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

Risk Factor Modification for South Asians

In South Asians with established coronary artery disease we should aim for

• LDL cholesterol levels below 2.0 and not 2.5 mmol/l.
  • Late in 2004, the USA guidelines were modified to include an option to consider lowering LDL cholesterol levels below 1.8mmol/l for secondary prevention for all patients.
  • The TNT trial using high dose atorvastatin published in March 2005 confirms additional benefits with lower LDL target. The A to Z trial found increased risk of rhabdomyolysis with doses of simvastatin greater than 40mg daily, thus atorvastatin should be the preferred agent when greater LDL reduction is required.
  • It is not certain how much benefit we obtain by raising HDL cholesterol (when it is low) and we may be better just trying to lower LDL cholesterol further.
  • The importance of lowering triglyceride levels (if elevated) once LDL cholesterol targets have been attained should be emphasised.
  • Consider measuring apo-B levels in those with the metabolic syndrome to ensure levels below 0.9 g/l and possibly below 0.8 g/l for secondary prevention. Alternately, ensure the non-HDL cholesterol levels are also satisfactory.
• Optimal control of hypertension (systolic pressures less than 130mmHg and diastolic pressures of around 80mmHg)
• Smoking cessation
• Good control of diabetes
• Attaining optimal body weight (note: for South Asians obesity is defined as body mass index >27 kg/m², truncal obesity may be defined as waist/hip ratio >0.9 in males and >0.8 in females).

There have been many reports on the possible advantages of measurement of apo-B levels. We may now be justified in measuring apo-B levels in selected patients to improve risk stratification for primary prevention and for secondary prevention.

Hitesh Patel, Cardiologist
29th March, 2005
Last update: 7th June, 2005