Chronic stable angina treatment lipid management: Difference between revisions

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==Overview==
==Overview==
In patients with established [[coronary artery disease]], dietary interventions are effective to prevent future coronary events.<ref name="pmid12964575">De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12964575 European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.] ''Eur Heart J'' 24 (17):1601-10. PMID: [http://pubmed.gov/12964575 12964575]</ref> Based on the individual's lipid abnormalities, necessary dietary modifications may be suggested.<ref name="pmid1727199">Smith GD, Shipley MJ, Marmot MG, Rose G (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727199 Plasma cholesterol concentration and mortality. The Whitehall Study.] ''JAMA'' 267 (1):70-6. PMID: [http://pubmed.gov/1727199 1727199]</ref> A '''Mediterranean diet''' consisting of fruits, vegetables, lean meat and fish are recommended. '''Omega-3 fatty acid''' supplementation may be indicated in patients with [[Chronic stable angina definition|stable angina]] for secondary prevention, as it has shown to reduce elevated [[triglycerides]] and also reduce the risk of [[sudden cardiac arrest|sudden cardiac death]].<ref name="pmid10465168"> (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10465168 Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico.] ''Lancet'' 354 (9177):447-55. PMID: [http://pubmed.gov/10465168 10465168]</ref><ref name="pmid11997274">Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11997274 Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione.] ''Circulation'' 105 (16):1897-903. PMID: [http://pubmed.gov/11997274 11997274]</ref><ref name="pmid11893369">Bucher HC, Hengstler P, Schindler C, Meier G (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11893369 N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials.] ''Am J Med'' 112 (4):298-304. PMID: [http://pubmed.gov/11893369 11893369]</ref><ref name="pmid15824290">Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15824290 Effect of different antilipidemic agents and diets on mortality: a systematic review.] ''Arch Intern Med'' 165 (7):725-30. [http://dx.doi.org/10.1001/archinte.165.7.725 DOI:10.1001/archinte.165.7.725] PMID: [http://pubmed.gov/15824290 15824290]</ref> '''Fish consumption''' once a week is associated with reduced risk of mortality from [[coronary artery disease]] and hence is strongly recommended.<ref name="pmid12588785">Kris-Etherton PM, Harris WS, Appel LJ, Nutrition Committee (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12588785 Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease.] ''Arterioscler Thromb Vasc Biol'' 23 (2):e20-30. PMID: [http://pubmed.gov/12588785 12588785]</ref><ref name="pmid15184295">He K, Song Y, Daviglus ML, Liu K, Van Horn L, Dyer AR et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15184295 Accumulated evidence on fish consumption and coronary heart disease mortality: a meta-analysis of cohort studies.] ''Circulation'' 109 (22):2705-11. [http://dx.doi.org/10.1161/01.CIR.0000132503.19410.6B DOI:10.1161/01.CIR.0000132503.19410.6B] PMID: [http://pubmed.gov/15184295 15184295]</ref>
In patients with established [[coronary artery disease]], the recommended goal for '''[[cholesterol|total cholesterol]] is 130 mg/dl''' and '''[[LDL|LDL-C]] is 100 mg/dl''', while the [[HDL|HDL-C]] and [[triglyceride]] concentrations serve as preferred markers for [[Chronic stable angina risk stratification|risk assessment]]. In patients with [[CAD]], '''fasting lipid-profile''' may be repeated at an interval of every 5-year to assess the overall risk of cardiovascular mortality and morbidity. Based on the individual’s lipid abnormalities, necessary dietary interventions and/or [[Chronic stable angina treatment anti-lipid agents|lipid-lowering agents]] are suggested to prevent the risk of future coronary events.<ref name="pmid12964575">De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12964575 European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.] ''Eur Heart J'' 24 (17):1601-10. PMID: [http://pubmed.gov/12964575 12964575]</ref><ref name="pmid1727199">Smith GD, Shipley MJ, Marmot MG, Rose G (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1727199 Plasma cholesterol concentration and mortality. The Whitehall Study.] ''JAMA'' 267 (1):70-6. PMID: [http://pubmed.gov/1727199 1727199]</ref> A '''Mediterranean diet''' consisting of fruits, vegetables, lean meat and fish has shown to be beneficial. '''Omega-3 fatty acid''' supplementation may be indicated in patients with [[Chronic stable angina definition|stable angina]] for secondary prevention, as it has shown to reduce elevated [[triglycerides]] and also reduce the risk of [[sudden cardiac arrest|sudden cardiac death]].<ref name="pmid10465168"> (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10465168 Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico.] ''Lancet'' 354 (9177):447-55. PMID: [http://pubmed.gov/10465168 10465168]</ref><ref name="pmid11997274">Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11997274 Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione.] ''Circulation'' 105 (16):1897-903. PMID: [http://pubmed.gov/11997274 11997274]</ref><ref name="pmid11893369">Bucher HC, Hengstler P, Schindler C, Meier G (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11893369 N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials.] ''Am J Med'' 112 (4):298-304. PMID: [http://pubmed.gov/11893369 11893369]</ref><ref name="pmid15824290">Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15824290 Effect of different antilipidemic agents and diets on mortality: a systematic review.] ''Arch Intern Med'' 165 (7):725-30. [http://dx.doi.org/10.1001/archinte.165.7.725 DOI:10.1001/archinte.165.7.725] PMID: [http://pubmed.gov/15824290 15824290]</ref> '''Fish consumption''' once a week has also been associated with reduced risk of mortality from [[coronary artery disease]] and hence is strongly recommended.<ref name="pmid12588785">Kris-Etherton PM, Harris WS, Appel LJ, Nutrition Committee (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12588785 Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease.] ''Arterioscler Thromb Vasc Biol'' 23 (2):e20-30. PMID: [http://pubmed.gov/12588785 12588785]</ref><ref name="pmid15184295">He K, Song Y, Daviglus ML, Liu K, Van Horn L, Dyer AR et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15184295 Accumulated evidence on fish consumption and coronary heart disease mortality: a meta-analysis of cohort studies.] ''Circulation'' 109 (22):2705-11. [http://dx.doi.org/10.1161/01.CIR.0000132503.19410.6B DOI:10.1161/01.CIR.0000132503.19410.6B] PMID: [http://pubmed.gov/15184295 15184295]</ref>
 
==Guide to Lipid Management based on the European Task Force<ref name="pmid12964575">De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12964575 European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice.] ''Eur Heart J'' 24 (17):1601-10. PMID: [http://pubmed.gov/12964575 12964575]</ref>==
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==Supportive trial data==
==Supportive trial data==

Revision as of 18:43, 6 September 2011

Chronic stable angina Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan. M.B.B.S.

Overview

In patients with established coronary artery disease, the recommended goal for total cholesterol is 130 mg/dl and LDL-C is 100 mg/dl, while the HDL-C and triglyceride concentrations serve as preferred markers for risk assessment. In patients with CAD, fasting lipid-profile may be repeated at an interval of every 5-year to assess the overall risk of cardiovascular mortality and morbidity. Based on the individual’s lipid abnormalities, necessary dietary interventions and/or lipid-lowering agents are suggested to prevent the risk of future coronary events.[1][2] A Mediterranean diet consisting of fruits, vegetables, lean meat and fish has shown to be beneficial. Omega-3 fatty acid supplementation may be indicated in patients with stable angina for secondary prevention, as it has shown to reduce elevated triglycerides and also reduce the risk of sudden cardiac death.[3][4][5][6] Fish consumption once a week has also been associated with reduced risk of mortality from coronary artery disease and hence is strongly recommended.[7][8]

Guide to Lipid Management based on the European Task Force[1]

“
”

Supportive trial data

  • In the Whitehall cohort study, that involved 17,718 patients with a follow-up over 18 years, to evaluate the relationship between plasma cholesterol concentration and mortality from major causes of death, reported a significant increase in mortality from coronary artery disease associated with increasing cholesterol concentration from the lowest levels (p<0.01).[2]
  • In the GISSI-Prevenzione trial, that involved 11,324 patients with history of recent MI were randomized to receive either omega-3 PUFA (1 g daily), vitamin E (300 mg daily) or a combination of both, to evaluate the effects of omega-3 polyunsaturated fatty acids and vitamin E as supplements in patients who had myocardial infarction. A significant reduction in the composite primary endpoint was observed in the n-3 PUFA group, during a 3.5 year follow-up. Thus, the study concluded that dietary supplementation with omega-3 PUFA provided significant benefit in improving the over-all clinical outcome in patients with ischemic heart disease.[3]
  • In a GISSI Prevenzione sub-study, that assessed the time course of benefit with omega-3 polyunsaturated fatty acids, attributed the anti-arrhythmic effect of omega-3 PUFA consistent with previous experimental studies, being responsible for an early reduction in the total mortality (RR 0.59; 95% CI 0.36 to 0.97; P=0.037) and sudden cardiac death (RR 0.47; 95% CI 0.219 to 0.995; P=0.048).[4]
  • A 2005 meta-analysis that reviewed 97 studies to assess the efficacy and safety of different lipid-lowering interventions based on mortality data, reported significant reduction in over-all cardiovascular mortality associated with omega-3 polyunsaturated fatty acid supplementation and hence can be used in patients with stable angina for secondary prevention.[6]

ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT) [9] [10] [11]

“

Class I

1. Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), transfatty acids, and cholesterol (to less than 200 mg per day). (Level of Evidence: B)

2. Daily physical activity and weight management are recommended for all patients. (Level of Evidence: B)

3. Recommended lipid management includes assessment of a fasting lipid profile.

a. LDL-C should be less than 100 mg per dL. (Level of Evidence: A)
b. If baseline LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL-lowering medications are used in high-risk or moderately high-risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in LDL-C levels. (Level of Evidence: A)
c. If on-treatment LDL-C is greater than or equal to 100 mg per dL, LDL-lowering drug therapy should be intensified. (Level of Evidence: A)
d. If TG are 200 to 499 mg per dL, non–HDL-C should be less than 130 mg per dL. (Level of Evidence: B)
e. If TG are greater than or equal to 500 mg per dL, therapeutic options to lower the TG to reduce the risk of pancreatitis are fibrate or niacin; these should be initiated before LDL-C lowering therapy. The goal is to achieve non–HDL-C less than 130 mg per dL if possible. (Level of Evidence: C)

4. Drug combinations are beneficial for patients on lipid lowering therapy who are unable to achieve LDL-C less than 100 mg per dL. (Level of Evidence: C)

5. Lipid-lowering therapy in patients with documented CAD and LDL-LDL cholesterol greater than 130 mg/dL with a target LDL of less than 100 mg/dL. (Level of Evidence: A)

Class IIa

1. Adding plant stanol or sterols (2 g per day) and/or viscous fiber (greater than 10 g per day) is reasonable to further lower LDL-C. (Level of Evidence: B)

2. Lipid-lowering therapy in patients with documented CAD and LDL cholesterol 100 to 129 mg/dL, with a target LDL of 100 mg/dL. (Level of Evidence: B)

3. Recommended lipid management includes assessment of a fasting lipid profile.

a. Reduction of LDL-C to less than 70 mg per dL or high-dose statin therapy is reasonable. (Level of Evidence: A)
b. If baseline LDL-C is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL. (Level of Evidence: B)
c. Further reduction of non–HDL-C to less than 100 mg per dL is reasonable, if TG are greater than or equal to 200 to 499 mg per dL. (Level of Evidence: B)

4. Therapeutic options to reduce non–HDL-C are:

a. Niacin can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C–lowering therapy) (Level of Evidence: B)
b. Fibrate therapy as a therapeutic option can be useful to reduce non–HDL-C (after LDL-C–lowering therapy). (Level of Evidence: B)

5. The following lipid management strategies can be beneficial:

a. If LDL-C less than 70 mg per dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost. When LDL-C less than 70 mg per dL is not achievable because of high baseline LDL-C levels, it generally is possible to achieve reductions of greater than 50% in LDL-C levels by either statins or LDL-C–lowering drug combinations. (Level of Evidence: C)

Class IIb

1. For all patients, encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per day) for risk reduction may be reasonable. For treatment of elevated TG, higher doses are usually necessary for risk reduction. (Level of Evidence: B)

”

Vote on and Suggest Revisions to the Current Guidelines

Sources

  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [9]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [10]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [11]
  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [12]

References

  1. ↑ 1.0 1.1 De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J et al. (2003) European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J 24 (17):1601-10. PMID: 12964575
  2. ↑ 2.0 2.1 Smith GD, Shipley MJ, Marmot MG, Rose G (1992) Plasma cholesterol concentration and mortality. The Whitehall Study. JAMA 267 (1):70-6. PMID: 1727199
  3. ↑ 3.0 3.1 (1999) Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico. Lancet 354 (9177):447-55. PMID: 10465168
  4. ↑ 4.0 4.1 Marchioli R, Barzi F, Bomba E, Chieffo C, Di Gregorio D, Di Mascio R et al. (2002) Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction: time-course analysis of the results of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-Prevenzione. Circulation 105 (16):1897-903. PMID: 11997274
  5. ↑ 5.0 5.1 Bucher HC, Hengstler P, Schindler C, Meier G (2002) N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med 112 (4):298-304. PMID: 11893369
  6. ↑ 6.0 6.1 Studer M, Briel M, Leimenstoll B, Glass TR, Bucher HC (2005) Effect of different antilipidemic agents and diets on mortality: a systematic review. Arch Intern Med 165 (7):725-30. DOI:10.1001/archinte.165.7.725 PMID: 15824290
  7. ↑ Kris-Etherton PM, Harris WS, Appel LJ, Nutrition Committee (2003) Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Arterioscler Thromb Vasc Biol 23 (2):e20-30. PMID: 12588785
  8. ↑ He K, Song Y, Daviglus ML, Liu K, Van Horn L, Dyer AR et al. (2004) Accumulated evidence on fish consumption and coronary heart disease mortality: a meta-analysis of cohort studies. Circulation 109 (22):2705-11. DOI:10.1161/01.CIR.0000132503.19410.6B PMID: 15184295
  9. ↑ 9.0 9.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).Circulation 99 (21):2829-48. PMID: 10351980
  10. ↑ 10.0 10.1 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58. PMID: 12515758
  11. ↑ 11.0 11.1 Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[1] PMID: 17998462
  12. ↑ Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). [url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367 [2] "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology"] Check |url= value (help). Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.


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