1. Things we knew, things we did… Things we have learnt, things we should do LIPID MANAGEMENT IN PRIMARY CARE: HOW WELL DO WE DO? Dr. Carlos Brotons Research Unit Sardenya Primary Health Care Center Barcelona- Spain International Congress of Medicine for Everyday Practice

2. Things we knew, things we did… Things we have learnt, things we should do

3. 50%SBP >115 mm Hg 31% Cholesterol >4.5 mmol/L World Health Report 2002; available at: http://www.who.int/whr/2002/en/ Joint effects of risk factors on CVD risk burden worldwide CVD = cardiovascular disease Tobacco 14%

4. Things we knew, things we did… Things we have learnt, things we should do

5. 45% OF MI IN WESTERN EUROPE AND 35% OF MI IN CENTRAL AND EASTERN EUROPE ARE DUE TO ABNORMAL LIPIDS PATIENTS WITH ABNORMAL LIPIDS ARE AT OVER THREE TIMES THE RISK OF MI COMPARED TO THOSE WITH NORMAL LIPIDS

6. Things we knew, things we did… Things we have learnt, things we should do

7. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90056 participants in 14 randomised trials of statins Cholesterol Treatment Trialists (CTT) Collaborators* Lancet 2005; 366;1267-78

8. Things we knew, things we did… Things we have learnt, things we should do

9. Shalev V, et al. Arch Intern Med 2009;169:260–8 229,918 patients enrolled in a HMO in Israel Initiated statins for primary and secondary prevention of CVD in 1998 through 2006 PDC with statin was recorded Follow-up means 4–5 yrs Primary outcome: total mortality PDC = proportion of days covered

10. Things we knew, things we did… Things we have learnt, things we should do Primary prevention: mortality reduction versus PDC With statin 1.6 1.2 1.0 0.8 0 Hazard Ratio Any follow-up Follow-up >1 year Follow-up >5 year <10 [Ref] 1.4 0.6 0.4 0.2 10– 19 19– 29 30– 39 40– 49 50– 59 60– 69 70– 79 80– 89 90 Shalev V, et al. Arch Intern Med. 2009;169:260–8 PDC with statins (%)

11. Things we knew, things we did… Things we have learnt, things we should do Mortality reduction with statins in the real world When comparing statin PDC >90% versus PDC <10%, there was a 40– 50% reduction in mortality in primary and secondary prevention groups Benefits in real world clinical practice exceed those seen in clinical trials Emphasises the importance of promoting statin therapy to a wider group of at risk people and the need to continued therapy Shalev V, et al. Arch Intern Med. 2009;169:260–8

12. Things we knew, things we did… Things we have learnt, things we should do Cardioprotective drug treatment across the EUROASPIRE surveys Patients with CHD EUROASPIRE I (%) EUROASPIRE II (%) EUROASPIRE III (%) Antiplatelet therapies 80.8 83.6 93.2 Beta blockers 56.0 69.0 85.5 BPlowering drugs 84.5 90.6 96.8 All lipid-lowering drugs 32.2 62.7 88.8 Kotseva K, Lancet 2009; 373: 929-940.

13. Things we knew, things we did… Things we have learnt, things we should do

14. Proportion of patients attaining LDL-C target levels in each country. Waters DD, et al Circulation 2009;120:28-34

15. Things we knew, things we did… Things we have learnt, things we should do Proportion of patients attaining LDL-C target levels in each country according to risk group. Waters DD, et al Circulation 2009;120:28-34

16. Things we knew, things we did… Things we have learnt, things we should do Prevalence of ATP III Risk Categories and Lipid lowering treatment in the United Sates (NHANES, 1999-2006) Kuklina, E. V. et al. JAMA 2009;302:2104-2110

17. Things we knew, things we did… Things we have learnt, things we should do Trends in High Levels of LDL-C in the United States (NHANES, 1999-2006) Kuklina, E. V. et al. JAMA 2009;302:2104-2110

18. Things we knew, things we did… Things we have learnt, things we should do Trends in Mean Levels of LDL-C levels in the United Sates (NHANES, 1999-2006) Kuklina, E. V. et al. JAMA 2009;302:2104-2110

19. Things we knew, things we did… Things we have learnt, things we should do CONCLUSIONS 65% of CV risk can be attributed to the joint effects of high blood pressure, dislipidemia and tobacco. About 40% of MI in Europe are due to abnormal blood lipids Statins use is associated with large reductions in the risk of major CV events Lipid lowering therapy is being applied now much successfully although there is room for improvement Mean LDL-c levels is decreasing at population level S

20. Things we knew, things we did… Things we have learnt, things we should do Questions? ~ Answers! International Congress of Medicine for Everyday Practice

21. Things we knew, things we did… Things we have learnt, things we should do ¿Cuestiones? ~ ¡Respuestas! International Congress of Medicine for Everyday Practice