The National Heart Foundation of Australia’s summary

The National Heart Foundation of Australia’s summary
of the recommendations for Cholesterol Management
This document summarises the evidence for:
1. Secondary prevention. Secondary prevention describes reducing the risk of a
repeat heart event (such as a heart attack) or worsening heart disease among
people with established heart disease.
2. Primary prevention. Primary prevention describes reducing the risk of a heart
event or heart disease among people who do not have heart disease.
1. The Heart Foundation’s recommendations for management of
secondary prevention of coronary heart disease
Cholesterol lowering drugs, in particular statins are a very effective way of reducing
the risk of having a heart attack, particularly for people who have heart disease.
The Heart Foundation recommends that all individuals who have had a heart attack
or who have a diagnosis of coronary heart disease (CHD) receive lipid lowering
therapy, namely statins (1). This recommendation is strongly supported by other
peak health organisations.
After a heart attack, treatment with a statin is first-line, evidence-based
management (1). Some of the largest studies ever conducted in medicine have
demonstrated that statins decrease further heart attacks and save lives.
Scientific consensus
Our position aligns with the World Health Organisation, American Heart Association,
American College of Cardiology, the National Collaborating Centre for Primary Care,
European Society of Cardiology, New Zealand Heart Foundation and British Heart
Foundation, to name a few.
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The World Health Organisation
http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/index.h
tml
American Heart Association and American College of Cardiology
http://circ.ahajournals.org/content/124/22/2458
British Heart Foundation http://www.bhf.org.uk/
National Collaborating Centre for Primary Care and Royal College of General
Practitioners, United Kingdom
http://www.nice.org.uk/nicemedia/live/11008/30495/30495.pdf
European Society of Cardiology http://www.escardio.org/guidelinessurveys/esc-guidelines/GuidelinesDocuments/guidelines-CVD-prevention.pdf
New Zealand Heart Foundation
http://www.heartfoundation.org.nz/programmes-resources/healthprofessionals/guidelines-and-patient-resources
Heart Foundation summary of recommendations for Cholesterol Management
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Since 1994, large, multi-centre trials including more than 170,000 people have
shown that people taking statins to lower their low-density (LD) cholesterol have
fewer major coronary events (non-fatal heart attack or death from CHD)(2).
- Major coronary events are reduced by a quarter (24%)
- 1 in 5 coronary deaths are prevented (i.e. 20% reduction)
- Death from any-cause is reduced by 10%
- Coronary artery surgery and coronary angioplasty is reduced by a quarter
(25%) and nearly a third (28%) respectively.(3)
The benefits can be seen with every 1.0 mmol/L reduction in LDL cholesterol.
The most recent Cholesterol Treatment Trialists’ Collaboration (CTT) meta-analysis of
26 trials involving approximately 170,000 people confirmed this benefit seen with
every 1.0 mmol/L reduction in LDL cholesterol (4).
A meta-analysis involving 13 individual trials and in excess of 91,000 patients showed
that treating 255 patients with a statin for 4 years led to the prevention of 5.4
cardiovascular events and one extra case of diabetes (5). The strongest predictors of
whether a patient will develop diabetes are older age, increased weight and higher
blood sugar, regardless of statin use.
Key Heart Foundation guidance on secondary prevention
- Reducing risk in heart disease: an expert guide to clinical practice for secondary
prevention of coronary heart disease (2012).
http://www.heartfoundation.org.au/SiteCollectionDocuments/Reducing-risk-inheart-disease.pdf
Heart Foundation summary of recommendations for Cholesterol Management
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2. The Heart Foundation’s recommendations for management of
primary prevention of coronary heart disease
Assessment of cardiovascular disease (CVD) risk on the basis of the combined effect
of multiple risk factors (absolute CVD risk) is more accurate than the use of individual
risk factors, because the cumulative effects of multiple risk factors may be additive
or synergistic (6). The Heart Foundation recommends that all individuals over the
age of 45 years (or 35 years for Aboriginal and Torres Strait Islander peoples) have
their risk assessed using the National Vascular Disease Prevention Alliance (NVDPA)
absolute CVD risk calculator (found here http://www.cvdcheck.org.au/).
Why the absolute CVD risk approach is important
In Australia, 64% of the adult population have three or more modifiable risk factors
(7). As CVD is largely preventable, an approach focusing on comprehensive risk
assessment will enable effective management of identified modifiable risk factors
through lifestyle changes and, where needed, pharmacological therapy.
In Australia, the National Vascular Disease Prevention Alliance (NVDPA) produces the
guidelines for assessment and management of absolute cardiovascular disease risk.
These guidelines define risk stratification based on the likelihood of having a
cardiovascular event in the next 5 years (6).
The guidelines recommend lifestyle intervention for all individuals, as well as
pharmacological therapy in some cases, depending on the level of risk.
A breakdown of the risk stratification is as follows:


Low risk (<10% risk of CVD within the next 5 years) – lifestyle intervention
Moderate risk (10-15% risk of CVD within the next 5 years) – lifestyle
intervention initially, consider pharmacological therapy after 6-12 months
review

High risk (>15% risk of CVD within the next 5 years) – lifestyle intervention
and pharmacological therapy
Guidelines currently recommend risk assessment is repeated every 2 years.
Statins and Absolute CVD risk
The use of statins as first line lipid-lowering therapy for the management of absolute
cardiovascular disease risk is at the highest evidence level (Grade A)1 (8, 9, 10). This
recommendation is strongly supported by other peak health organisations Grade A
evidence is defined as a body of evidence that can be trusted to guide practice.
High plasma cholesterol is a well-known, modifiable risk factor for CVD. A 10%
increase in total cholesterol is associated with a 27% increase in the incidence of
coronary heart disease (11), and the relationship persists, irrespective of smoking
status, the presence or absence of elevated blood pressure, or a history with or
without vascular disease (12-15). Lipid lowering therefore plays an important role in
the prevention of cardiovascular events.
Most of the cholesterol in blood plasma is carried by low-density lipoprotein (LDL)
cholesterol and the strong relationship between total cholesterol and CVD suggests
1
Level of evidence is based on National Health and Medical Research Council (NHMRC)
Levels of Evidence and Grades for Recommendations for Developers of Guidelines (2009).
Heart Foundation summary of recommendations for Cholesterol Management
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that LDL cholesterol is a powerful risk factor (16). Moreover, the results of
epidemiological studies, as well as trials with clinical endpoints, confirm that a
reduction in LDL cholesterol must be the primary concern in the prevention of CVD
(17). This section summarises the evidence for lowering blood lipids from systematic
reviews and meta-analyses considered for the primary prevention of cardiovascular
events.
The mass of evidence suggests that, compared with placebo, statins reduce the risk
of death or cardiovascular events in populations without a history of CVD,
irrespective of age and gender and across a wide range of cholesterol levels (8, 9, 10,
18, 19, 20, 21).
As with every guideline, a clinical decision still needs to be made between a patient
and their treating doctor, taking into account their risk level and individual patient
factors, about what the right approach to treatment is.
Endorsement
The Guidelines for the assessment and management of absolute cardiovascular
disease risk were endorsed by the Australian Government through the National
Health and Medical Research Council (NHMRC) as well as the Royal Australian
College of General Practitioners and other members of the NVDPA – Diabetes
Australia, Kidney Australia and the Stroke Foundation.
The NVDPA’s Absolute cardiovascular disease risk management guidelines were
endorsed by the NHMRC in 2012 after exhaustive literature review and expert
review (over 700 reviewers) and contain in excess of 350 individual references to
numerous studies.
The guidelines are reviewed every five years, or as needed.
International comparison
The process of absolute cardiovascular risk screening has already been implemented
in New Zealand with 60% of the eligible population (those aged 45 and over) being
screened in the past five years (22). They are moving toward a goal of 90% of the
eligible population screened by the end of next year. Already, anecdotal evidence
suggests a decrease in disease progression as a result of the intervention.
Key Heart Foundation guidance on primary prevention
- National Vascular Disease Prevention Alliance. Guidelines for the assessment of
Absolute cardiovascular disease risk (2009).
http://www.heartfoundation.org.au/SiteCollectionDocuments/guidelinesAbsolute-risk.pdf
- National Vascular Disease Prevention Alliance. Guidelines for the management
of Absolute cardiovascular disease risk (2012).
http://strokefoundation.com.au/site/media/AbsoluteCVD_GL_webready.pdf
Scientific consensus
Our position aligns with the National Health and Medical Research Council and
other members of the National Vascular Disease Prevention Alliance, as well as the
World Health Organisation, American Heart Association, American College of
Cardiology, New Zealand Heart Foundation, British Heart Foundation, National
Heart Foundation summary of recommendations for Cholesterol Management
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Institute of Health and Clinical Excellence, and the European Society of Cardiology to
name a few.
-
-
The World Health Organisation
http://www.who.int/cardiovascular_diseases/publications/Prevention_of_Cardi
ovascular_Disease/en/index.html
American Heart Association and American College of Cardiology
http://circ.ahajournals.org/content/100/13/1481.full
New Zealand Heart Foundation http://www.heartfoundation.org.nz/
British Heart Foundation http://www.bhf.org.uk/heart-health/prevention/riskfactors.aspx
National Institute for Health and Clinical Excellence (NICE), United Kingdom
http://www.nice.org.uk/nicemedia/pdf/cg67niceguideline.pdf
European Society of Cardiology http://www.escardio.org/guidelinessurveys/esc-guidelines/GuidelinesDocuments/guidelines-CVD-prevention.pdf
http://www.escardio.org/guidelines-surveys/escguidelines/guidelinesdocuments/guidelines-dyslipidemias-ft.pdf
Heart Foundation summary of recommendations for Cholesterol Management
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References
1. National Heart Foundation of Australia and the Cardiac Society of Australia
and New Zealand. Reducing risk in heart disease: an expert guide to clinical
practice for secondary prevention of heart disease. Melbourne: National
Heart Foundation of Australia, 2012.
2. Clinical Trial Service Unit and Epidemiological Studies Unit. CTT (Cholesterol
Treatment Trialists’ Collaboration). Available at:
http://www.ctsu.ox.ac.uk/research/meta-trials/ctt/ctt-website (accessed
October 2013)
3. Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy and safety of
cholesterol-lowering treatment: prospective meta-analysis of data from
90,056 participants in 14 randomised trials of statins. Lancet 2005; 366:126778.
4. Cholesterol Treatment Trialists’ (CTT) Collaboration, Baigent C, Blackwell L, et
al. Efficacy and safety of more intensive lowering of LDL cholesterol: a metaanalysis of data from 170,000 participants in 26 randomised trials. Lancet.
2010 Nov 13;376 (9753): 1670-1681. Available at
http://www.ncbi.nlm.nih.gov/pubmed/21067804
5. Shah RV, Goldfine AB. Statins and risk of new-onset diabetes mellitus.
Circulation 2012; 126:e282-e284.
6. National Vascular Disease Prevention Alliance. Guidelines for the
management of absolute cardiovascular disease risk. Melbourne: National
Stroke Foundation, 2012.
7. Australian Institute of Health and Welfare (AIHW). Health determinants: the
key to preventing chronic disease. Cat No. PHE 157. Canberra: AIHW, 2011.
8. Brugts JJ, Yetgin T, Hoeks SE, Gotto AM, Shepherd J, Westendorp RG, et al.
The benefits of statins in people without established cardiovascular disease
but with cardiovascular risk factors: meta-analysis of randomised controlled
trials. BMJ. 2009;338:b2376.
9. Taylor F, Ward K, Moore TH, Burke M, Davey Smith G, Casas JP, et al. Statins
for the primary prevention of cardiovascular disease. Cochrane Database Syst
Rev. 2011(1):CD004816.
10. Baigent C, Blackwell L, Emberson J, Holland LE, Reith C, Bhala N, et al. Efficacy
and safety of more intensive lowering of LDL cholesterol: a meta-analysis of
data from 170,000 participants in 26 randomised trials. Lancet. 2010 Nov
13;376(9753):1670-81.
11. Law MR, Wald NJ, Thompson SG. By how much and how quickly does
reduction in serum cholesterol concentration lower risk of ischaemic heart
disease? BMJ. 1994 Feb 5;308(6925):367-72.
12. Neaton JD, Wentworth D. Serum cholesterol, blood pressure, cigarette
smoking, and death from coronary heart disease. Overall findings and
differences by age for 316,099 white men. Multiple Risk Factor Intervention
Trial Research Group. Arch Intern Med. 1992 Jan;152(1):56-64.
13. Neaton JD, Blackburn H, Jacobs D, Kuller L, Lee DJ, Sherwin R, et al. Serum
cholesterol level and mortality findings for men screened in the Multiple Risk
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Factor Intervention Trial. Multiple Risk Factor Intervention Trial Research
Group. Arch Intern Med. 1992 Jul;152(7):1490-500.
14. GD, Shipley MJ, Marmot MG, Rose G. Plasma cholesterol concentration and
mortality. The Whitehall Study. JAMA. 1992 Jan 1;267(1):70-6.
15. Stamler J, Wentworth D, Neaton JD. Is relationship between serum
cholesterol and risk of premature death from coronary heart disease
continuous and graded? Findings in 356,222 primary screens of the Multiple
Risk Factor Intervention Trial (MRFIT). JAMA. 1986 Nov 28;256(20):2823-8.
16. United States. National Heart, Lung, and Blood Institute. Third report of the
National Cholesterol Education Program (NCEP) Expert Panel on detection,
evaluation, and treatment of high blood cholesterol in adults (adult
treatment panel III): final report. Washington; National Institutes of Health:
2002. [cited Feb 2011] Available from url:
http://www.nhlbi.nih.gov/guidelines/cholesterol/
17. Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, et al.
European guidelines on cardiovascular disease prevention in clinical practice:
executive summary. Fourth Joint Task Force of the European Society of
Cardiology and other societies on cardiovascular disease prevention in clinical
practice (constituted by representatives of nine societies and by invited
experts). Eur J Cardiovasc Prev Rehabil. 2007 Sep;14 Suppl 2:E1-40.
18. Ray KK, Seshasai SR, Erqou S, Sever P, Jukema JW, Ford I, et al. Statins and allcause mortality in high-risk primary prevention: a meta-analysis of 11
randomized controlled trials involving 65,229 participants. Arch Intern Med.
2010 Jun 28;170(12):1024-31.
19. Thavendiranathan P, Bagai A, Brookhart MA, Choudhry NK. Primary
prevention of cardiovascular diseases with statin therapy: a meta-analysis of
randomized controlled trials. Arch Intern Med. 2006 Nov 27;166(21):2307-13.
20. Ward S, Lloyd Jones M, Pandor A, Holmes M, Ara R, Ryan A, et al. A
systematic review and economic evaluation of statins for the prevention of
coronary events. Health Technol Assess. 2007 Apr;11(14):1-160, iii-iv.
21. Delahoy PJ, Magliano DJ, Webb K, Grobler M, Liew D. The relationship
between reduction in low-density lipoprotein cholesterol by statins and
reduction in risk of cardiovascular outcomes: an updated meta-analysis. Clin
Ther. 2009 Feb;31(2):236-44.
22. Bramwell N. Call for routine CV health checks. Medical Observer 2013, 6 Aug.
Available from url: http://www.medicalobserver.com.au/news/call-forroutine-cv-health-checks
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