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Canadian Journal of Cardiology

2016 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult

      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.
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