Chronic stable angina treatment lipid management

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] 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, a fasting lipid-profile may be repeated at 5 year intervals 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. A Mediterranean diet consisting of fruits, vegetables, lean meat and fish has also been shown to be beneficial. Omega-3 fatty acid supplementation may be indicated in patients with stable angina for secondary prevention, as it has been shown to reduce elevated triglycerides and also reduce the risk of sudden cardiac death. Fish consumption once a week has also been associated with reduced risk of mortality from coronary artery disease and, for this reason, is strongly recommended.

==Guide to Lipid Management adapted from the European Task Force ==

Supportive trial data

 * The Whitehall Study, a cohort study of 17,718 male civil servants aged 40 through 64 years of age at enrollment with an average follow-up of 18 years of study, evaluated the relationship between plasma cholesterol concentration and mortality from major causes of death. Researchers reported a significant increase in mortality from coronary artery disease associated with increasing cholesterol concentration from the lowest levels (p < 0.01).


 * The GISSI-Prevenizone trial, a multi-center interventional trial involving 11,324 participants (both male and female) with a history of recent MI who were randomized to receive either omega-3 PUFA (1 g daily), vitamin E (300 mg daily) or a combination of both, evaluated the effects of omega-3 polyunsaturated fatty acids and vitamin E as supplements in patients who had myocardial infarction. Researchers observed a significant reduction over 3-5 years in the n-3 PUFA treatment group in the rate of death, non-fatal myocardial infarction and stroke. No effect was cene for the vitamin E treatment group. Based on this evidence and the supporting data of similar trials such as DART, the study investigators concluded that dietary supplementation with omega-3 PUFA provided significant benefit in improving the overall clinical outcome of patients with ischemic heart disease.


 * The GISSI-Prevenzione sub-study, an investigation within the GISSI-Prevenzione trial data of 11,323 patients (both, male and female) with a history of recent (<3 months) myocardial infarction, assessed the time course of benefit of omega-3 polyunsaturated fatty acids. Researchers attributed the anti-arryhthmic effect of omega-3 PUFA, a finding consistent with previous randomized clinical trials, to a significant early reduction in the total mortality (RR 0.59, 95% CI 0.36, 0.97; P=0.037) and sudden cardiac death (RR 0.47, 95% CI 0.219, 0.995; p=0.048).


 * Observational studies have been inconsistent in defining the association between omega-3 polyunsaturated fatty acids and coronary artery disease risk. Therefore, researchers conducted a meta-analysis of randomized controlled trials that compared dietary and non-deitary supplementation of omega-3 polyunsaturated fatty acids on coronary heart disease. The analysis reported a significant reduction in the risk of fatal myocardial infarction (RR 0.7; 95% CI: 0.6, 0.8; p<0.001) and sudden cardiac death (RR 0.7; 95% CI: 0.6, 0.9; p<0.01). Thus, the study concluded omega-3 polyunsaturated fatty acid consumption significantly reduced the overall mortality, mortality due to myocardial infarction and sudden cardiac death; however, these benefits were confined to high-risk patients


 * A 2005 meta-analysis, which reviewed 97 randomized control trials, evaluated the efficacy and safety of different lipid-lowering interventions based on mortality data. Researchers reported a significant reduction in overall cardiovascular mortality associated with omega-3 polyunsaturated fatty acid supplementation. It was further suggested that this therapy could be utilized in patients with stable angina for secondary prevention purposes.

==ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT)  == {{cquote|

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

 * The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina


 * The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina


 * TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina


 * Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology