Abstract
Since the publication of the 2012 guidelines new literature has emerged to inform
decision-making. The 2016 guidelines primary panel selected a number of clinically
relevant questions and has produced updated recommendations, on the basis of important
new findings. In subjects with clinical atherosclerosis, abdominal aortic aneurysm,
most subjects with diabetes or chronic kidney disease, and those with low-density
lipoprotein cholesterol ≥ 5 mmol/L, statin therapy is recommended. For all others,
there is an emphasis on risk assessment linked to lipid determination to optimize
decision-making. We have recommended nonfasting lipid determination as a suitable
alternative to fasting levels. Risk assessment and lipid determination should be considered
in individuals older than 40 years of age or in those at increased risk regardless
of age. Pharmacotherapy is generally not indicated for those at low Framingham Risk
Score (FRS; <10%). A wider range of patients are now eligible for statin therapy in
the FRS intermediate risk category (10%-19%) and in those with a high FRS (> 20%).
Despite the controversy, we continue to advocate for low-density lipoprotein cholesterol
targets for subjects who start therapy. Detailed recommendations are also presented
for health behaviour modification that is indicated in all subjects. Finally, recommendation
for the use of nonstatin medications is provided. Shared decision-making is vital
because there are many areas in which clinical trials do not fully inform practice.
The guidelines are meant to be a platform for meaningful conversation between patient
and care provider so that individual decisions can be made for risk screening, assessment,
and treatment.
Résumé
Depuis la publication des lignes directrices de 2012, la nouvelle littérature qui
est apparue favorise la prise de décision éclairée. Le principal panel sur les lignes
directrices de 2016 a choisi un certain nombre de questions pertinentes sur le plan
clinique et a procédé à l’actualisation des recommandations en se basant sur les dernières
conclusions importantes. Chez les sujets ayant des signes cliniques d’athérosclérose,
un anévrisme de l’aorte abdominale, chez la plupart des sujets atteints d’un diabète
ou d’une néphropathie chronique, et chez ceux ayant un cholestérol à lipoprotéines
de faible densité ≥ 5 mmol/l, le traitement par statines est recommandé. Pour les
autres, l’accent est mis sur l’évaluation des risques liée à la détermination des
lipides pour optimiser la prise de décision. Nous avons recommandé la détermination
des lipides chez les sujets non à jeun comme alternative convenable à la détermination
des concentrations chez les sujets à jeun. L’évaluation des risques et la détermination
des lipides devraient être considérées chez les individus de plus de 40 ans ou chez
ceux exposés à un risque accru, quel que soit l’âge. La pharmacothérapie n’est généralement
pas indiquée chez ceux dont le score de risque de Framingham est faible (SRF; < 10
%). Un plus grand nombre de patients sont maintenant admissibles au traitement par
statines, soit ceux de la catégorie de risque intermédiaire du SRF (10 % à 19 %) et
ceux de la catégorie de risque élevé du SRF (> 20 %). En dépit de la controverse,
nous continuons de préconiser des valeurs cibles du taux de cholestérol à lipoprotéines
de faible densité chez les sujets qui commencent le traitement. Nous présentons également
des recommandations détaillées sur la modification du comportement en matière de santé
indiquée chez tous les sujets. Finalement, nous recommandons l’utilisation de médicaments
n’appartenant pas au groupe des statines. La prise de décision partagée est indispensable
puisqu’il existe de nombreux domaines dans lesquels les essais cliniques n’éclairent
pas pleinement la pratique. Les lignes directrices sont censées servir de plateforme
à des échanges significatifs entre le patient et le prestataire de soins de sorte
que des décisions individuelles sur le dépistage et l’évaluation des risques, et le
traitement puissent être prises.
To read this article in full you will need to make a payment
Purchase one-time access:
PDF Download and 24 Hours Online AccessSubscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The effect of giving global coronary risk information to adults: a systematic review.Arch Intern Med. 2010; 170: 230-239
- Value and limitations of existing scores for the assessment of cardiovascular risk: a review for clinicians.J Am Coll Cardiol. 2009; 54: 1209-1227
- Patient knowledge of coronary risk profile improves the effectiveness of dyslipidemia therapy: the CHECK-UP study: a randomized controlled trial.Arch Intern Med. 2007; 167: 2296-2303
- Effectiveness of the heart age tool for improving modifiable cardiovascular risk factors in a southern European population: a randomized trial.Eur J Prev Cardiol. 2015; 22: 389-396
- Preventing cardiovascular disease among Canadians: what are the potential benefits of treating hypertension or dyslipidemia?.Can J Cardiol. 2007; 23: 467-473
- 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association task force on practice guidelines.Circulation. 2014; 129 ([erratum in 2014;129(25 suppl 2):S74-5]): S49-S73
- Application of new cholesterol guidelines to a population-based sample.N Engl J Med. 2014; 370: 1422-1431
- General cardiovascular risk profile for use in primary care: the Framingham Heart Study.Circulation. 2008; 117: 743-753
- Parental cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults: a prospective study of parents and offspring.JAMA. 2004; 291: 2204-2211
- Estimating the benefits of modifying risk factors of cardiovascular disease: a comparison of primary vs secondary prevention.Arch Intern Med. 1998; 158: 655-662
- Individualized statin benefit for determining statin eligibility in the primary prevention of cardiovascular disease.Circulation. 2016; 133: 1574-1581
- Multiple risk factor interventions for primary prevention of coronary heart disease.Cochrane Database Syst Rev. 2000; : CD001561
- ESC/EAS guidelines for the management of dyslipidaemias: the Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS).Eur Heart J. 2011; 32: 1769-1818
- Use of global coronary heart disease risk assessment in practice: a cross-sectional survey of a sample of U.S. physicians.BMC Health Serv Res. 2012; 12: 20
- The distribution of 10-year risk for coronary heart disease among US adults: findings from the National Health and Nutrition Examination Survey III.J Am Coll Cardiol. 2004; 43: 1791-1796
- The effect of the change in the Framingham Risk Score calculator between the 2006 and 2009 Canadian lipid guidelines.Can J Cardiol. 2011; 27: 167-170
- Prediction is difficult, particularly about the future.Arch Intern Med. 2007; 167: 2286-2287
- Evaluation of a cardiovascular disease risk assessment tool for the promotion of healthier lifestyles.Eur J Cardiovasc Prev Rehabil. 2010; 17: 519-523
- Perceptions of Canadian primary care physicians toward cardiovascular risk assessment and lipid management.Can J Cardiol. 2012; 28: 14-19
- The role of global risk assessment in hypertension therapy.Can J Cardiol. 2006; 22: 606-613
- Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial.Lancet. 2002; 360: 1623-1630
- Benefits of statins in elderly subjects without established cardiovascular disease: a meta-analysis.J Am Coll Cardiol. 2013; 62: 2090-2099
- Gestational diabetes and hypertensive disorders of pregnancy as vascular risk signals: an overview and grading of the evidence.Can J Cardiol. 2014; 30: 765-773
- Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study.Lancet. 2005; 366: 1797-1803
- Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort.Hypertension. 2010; 56: 166-171
- Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association.Circulation. 2011; 123: 1243-1262
- Fasting and nonfasting lipid levels: influence of normal food intake on lipids, lipoproteins, apolipoproteins, and cardiovascular risk prediction.Circulation. 2008; 118: 2047-2056
- Fasting time and lipid levels in a community-based population: a cross-sectional study.Arch Intern Med. 2012; 172: 1707-1710
- Review of an article: nonfasting triglycerides and risk of myocardial infarction, ischemic heart disease and death in men and women. Nordestgaard B, Benn M, Schnohr P, Tybjaerg-Hansen A. JAMA 2007;298:299-308.J Vasc Nurs. 2008; 26: 27
- Postprandial plasma lipoprotein changes in human subjects of different ages.J Lipid Res. 1988; 29: 469-479
- Prognostic value of fasting versus nonfasting low density lipoprotein cholesterol levels on long-term mortality: insight from the National Health and Nutrition Survey III (NHANES-III).Circulation. 2014; 130: 546-553
- Increased small low-density lipoprotein particle number: a prominent feature of the metabolic syndrome in the Framingham Heart Study.Circulation. 2006; 113: 20-29
- 2012 Update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult.Can J Cardiol. 2013; 29: 151-167
- Fasting compared with nonfasting triglycerides and risk of cardiovascular events in women.JAMA. 2007; 298: 309-316
- Nonfasting triglycerides and risk of ischemic stroke in the general population.JAMA. 2008; 300: 2142-2152
- Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points-a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine.Eur Heart J. 2016; 37: 1944-1958
- Major lipids, apolipoproteins, and risk of vascular disease.JAMA. 2009; 302: 1993-2000
- Canadian Cardiovascular Society position statement on familial hypercholesterolemia.Can J Cardiol. 2014; 30: 1471-1481
- The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials.Lancet. 2012; 380: 581-590
- Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas coronary atherosclerosis prevention study.JAMA. 1998; 279: 1615-1622
- Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group.N Engl J Med. 1995; 333: 1301-1307
- Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial.Lancet. 2003; 361: 1149-1158
- Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein.N Engl J Med. 2008; 359: 2195-2207
- Cholesterol lowering in intermediate-risk persons without cardiovascular disease.N Engl J Med. 2016; 374: 2021-2031
- The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (study of heart and renal protection): a randomised placebo-controlled trial.Lancet. 2011; 377: 2181-2192
- HMG CoA reductase inhibitors (statins) for people with chronic kidney disease not requiring dialysis.Cochrane Database Syst Rev. 2014; : CD007784
- KDIGO clinical practice guideline for lipid management in CKD: summary of recommendation statements and clinical approach to the patient.Kidney Int. 2014; 85: 1303-1309
- 10-Year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) with validation in the HNR (Heinz Nixdorf Recall) study and the DHS (Dallas Heart Study).J Am Coll Cardiol. 2015; 66: 1643-1653
- Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals.JAMA. 2012; 308: 788-795
- ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance.Circulation. 2010; 122: e525-e555
- Impact of statins on serial coronary calcification during atheroma progression and regression.J Am Coll Cardiol. 2015; 65: 1273-1282
- Lipoprotein (a): coming of age at last.J Lipid Res. 2016; 57: 336-339
- Genetically elevated lipoprotein(a) and increased risk of myocardial infarction.JAMA. 2009; 301: 2331-2339
- Lipoprotein(a) concentration and the risk of coronary heart disease, stroke, and nonvascular mortality.JAMA. 2009; 302: 412-423
- Lipoprotein(a) as a cardiovascular risk factor: current status.Eur Heart J. 2010; 31: 2844-2853
- MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial.Lancet. 2002; 360: 7-22
- Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174,000 participants in 27 randomised trials.Lancet. 2015; 385: 1397-1405
- Very low levels of atherogenic lipoproteins and the risk for cardiovascular events: a meta-analysis of statin trials.J Am Coll Cardiol. 2014; 64: 485-494
- Percent reduction in LDL cholesterol following high-intensity statin therapy: potential implications for guidelines and for the prescription of emerging lipid-lowering agents.Eur Heart J. 2016; 37: 1373-1379
- 2013 Cholesterol guidelines revisited: percent LDL cholesterol reduction or attained LDL cholesterol level or both for prognosis?.Am J Med. 2016; 129: 384-391
- Ezetimibe added to statin therapy after acute coronary syndromes.N Engl J Med. 2015; 372: 2387-2397
- Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy.N Engl J Med. 2011; 365: 2255-2267
- Effects of extended-release niacin with laropiprant in high-risk patients.N Engl J Med. 2014; 371: 203-212
- 2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology task force on clinical expert consensus documents.J Am Coll Cardiol. 2016; 68: 92-125
Authors/Task Force Members, Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur J Prev Cardiol 2016;23:NP1-96.
- Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.Lancet. 2004; 364: 937-952
- Primary prevention of coronary heart disease in women through diet and lifestyle.N Engl J Med. 2000; 343: 16-22
- Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications.Circulation. 2006; 114: 160-167
- Effect of sustaining lifestyle modifications (nonsmoking, weight reduction, physical activity, and Mediterranean diet) after healing of myocardial infarction, percutaneous intervention, or coronary bypass (from the REasons for Geographic and Racial Differences in Stroke study).Am J Cardiol. 2014; 113: 1933-1940
- Effects of the National Cholesterol Education Program's step I and step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis.Am J Clin Nutr. 1999; 69: 632-646
- Reduction in saturated fatty acids intake for cardiovascular disease.Cochrane Database Syst Rev. 2015; : CD011737
- Use of dietary linoleic acid for secondary prevention of coronary heart disease and death: evaluation of recovered data from the Sydney diet heart study and updated meta-analysis.BMJ. 2013; 346: e8707
- Saturated fats compared with unsaturated fats and sources of carbohydrates in relation to risk of coronary heart disease: a prospective cohort study.J Am Coll Cardiol. 2015; 66: 1538-1548
- Intake of carbohydrates compared with intake of saturated fatty acids and risk of myocardial infarction: importance of the glycemic index.Am J Clin Nutr. 2010; 91: 1764-1768
- Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis.Ann Intern Med. 2014; 160: 398-406
- Benefits of fish oil supplementation in hyperlipidemia: a systematic review and meta-analysis.Int J Cardiol. 2009; 136: 4-16
- N-3 fatty acids and cardiovascular outcomes in patients with dysglycemia.N Engl J Med. 2012; 367: 309-318
- Food and dietary pattern-based recommendations: an emerging approach to clinical practice guidelines for nutrition therapy in diabetes.Can J Diabetes. 2013; 37: 51-57
- Primary prevention of cardiovascular disease with a Mediterranean diet.N Engl J Med. 2013; 368: 1279-1290
- Effect of a dietary portfolio of cholesterol-lowering foods given at 2 levels of intensity of dietary advice on serum lipids in hyperlipidemia: a randomized controlled trial.JAMA. 2011; 306: 831-839
- Diet quality as assessed by the healthy eating index, the alternate healthy eating index, the dietary approaches to stop hypertension score, and health outcomes: a systematic review and meta-analysis of cohort studies.J Acad Nutr Diet. 2015; 115: 780-800.e5
- Associations of glycemic index and load with coronary heart disease events: a systematic review and meta-analysis of prospective cohorts.J Am Heart Assoc. 2012; 1: e000752
- Vegetarian diet, Seventh Day Adventists and risk of cardiovascular mortality: a systematic review and meta-analysis.Int J Cardiol. 2014; 176: 680-686
- Consumption of nuts and legumes and risk of incident ischemic heart disease, stroke, and diabetes: a systematic review and meta-analysis.Am J Clin Nutr. 2014; 100: 278-288
- Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies.BMJ. 2014; 349: g4490
- Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis.BMJ. 2013; 347: f6879
- Meta-analysis of the association between whole grain intake and coronary heart disease risk.Am J Cardiol. 2015; 115: 625-629
Stone J, ed. Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention: Translating Knowledge into Action. 3rd ed. Winnipeg: Canadian Association of Cardiac Rehabilitation, 2009.
- Physical activity recommendations and decreased risk of mortality.Arch Intern Med. 2007; 167: 2453-2460
- Health benefits of physical activity: the evidence.CMAJ. 2006; 174: 801-809
- Effect of aerobic exercise training on serum levels of high-density lipoprotein cholesterol: a meta-analysis.Arch Intern Med. 2007; 167: 999-1008
- Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study.Lancet. 2011; 378: 1244-1253
- New Canadian physical activity guidelines.Appl Physiol Nutr Metab. 2011; 36 (47-58): 36-46
- New hope for lipid-lowering beyond statins: effect of IMPROVE-IT on understanding and implementation of atherosclerosis prevention.Can J Cardiol. 2015; 31: 585-587
- Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial.Lancet. 2005; 366: 1849-1861
- Effects of combination lipid therapy in type 2 diabetes mellitus.N Engl J Med. 2010; 362: 1563-1574
- Nonstatin low-density lipoprotein-lowering therapy and cardiovascular risk reduction-statement from ATVB council.Arterioscler Thromb Vasc Biol. 2015; 35: 2269-2280
- The lipid research clinics coronary primary prevention trial results. I. reduction in incidence of coronary heart disease.JAMA. 1984; 251: 351-364
- Rationale and design of the further cardiovascular OUtcomes research with PCSK9 inhibition in subjects with elevated risk trial.Am Heart J. 2016; 173: 94-101
- Efficacy and safety of evolocumab in reducing lipids and cardiovascular events.N Engl J Med. 2015; 372: 1500-1509
- Efficacy and safety of alirocumab in reducing lipids and cardiovascular events.N Engl J Med. 2015; 372: 1489-1499
- Diagnosis, prevention, and management of statin adverse effects and intolerance: proceedings of a Canadian working group consensus conference.Can J Cardiol. 2011; 27: 635-662
- Diagnosis, prevention, and management of statin adverse effects and intolerance: Canadian working group consensus update.Can J Cardiol. 2013; 29: 1553-1568
- Diagnosis, prevention, and management of statin adverse effects and intolerance: Canadian consensus working group update (2016).Can J Cardiol. 2016; 32: S35-S65
- Coenzyme Q10 supplementation decreases statin-related mild-to-moderate muscle symptoms: a randomized clinical study.Med Sci Monit. 2014; 20: 2183-2188
- Effects of coenzyme Q10 on statin-induced myopathy: a meta-analysis of randomized controlled trials.Mayo Clin Proc. 2015; 90: 24-34
- Association of vitamin D and incident statin induced myalgia–a retrospective cohort study.PLoS One. 2014; 9: e88877
- Low plasma vitamin D levels and muscle-related adverse effects in statin users.Isr Med Assoc J. 2014; 16: 42-45
- Muscle-related side-effects of statins: from mechanisms to evidence-based solutions.Curr Opin Lipidol. 2015; 26: 221-227
- HMG-coenzyme A reductase inhibition, type 2 diabetes, and bodyweight: evidence from genetic analysis and randomised trials.Lancet. 2015; 385: 351-361
- Association between familial hypercholesterolemia and prevalence of type 2 diabetes mellitus.JAMA. 2015; 313: 1029-1036
- Statin use and risk for cataract: a nested case-control study of 2 populations in Canada and the United States.Can J Cardiol. 2014; 30: 1613-1619
- Statins for the treatment of dementia.Cochrane Database Syst Rev. 2014; : CD007514
- Association of statin use with risk of dementia: a meta-analysis of prospective cohort studies.Geriatr Gerontol Int. 2013; 13: 817-824
- Statins in the prevention of dementia and Alzheimer’s disease: a meta-analysis of observational studies and an assessment of confounding.Pharmacoepidemiol Drug Saf. 2013; 22: 345-358
- Statins and cognition: a systematic review and meta-analysis of short- and long-term cognitive effects.Mayo Clin Proc. 2013; 88: 1213-1221
- Statins and cognitive function: a systematic review.Ann Intern Med. 2013; 159: 688-697
- Statins for treating Alzheimer's disease: truly ineffective?.Eur Neurol. 2015; 73: 360-366
- Do statins impair cognition? A systematic review and meta-analysis of randomized controlled trials.J Gen Intern Med. 2015; 30: 348-358
- Statins, cognition, and dementia-systematic review and methodological commentary.Nat Rev Neurol. 2015; 11: 220-229
- The new dyslipidemia guidelines: what is the debate?.Can J Cardiol. 2015; 31: 605-612
Article Info
Publication History
Published online: July 24, 2016
Accepted:
July 13,
2016
Received:
June 28,
2016
Footnotes
The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.
Identification
Copyright
© 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
