EXECUTIVE SUMMARY OF 2020 CPG FOR DYSLIPIDEMIA

MANAGEMENT IN THE PHILIPPINES

Introduction
 Dyslipidemia
o Cardiovascular risk factor that is increasing in prevalence in the
country
 Need to treat and manage elevated cholesterol levels, both
pharmacologic and non-pharmacologic, is of utmost importance
 Different medical societies and groups formulated the 2020 CPG
o Philippine Heart Association (PHA)
o Philippine Lipid and Atherosclerosis Society (PLAS)
o Philippine Society of Endocrinology, Diabetes, and Metabolism
(PSEDM)
o *Philippine Society of Nephrology (PSN)
o *Philippine Neurological Association (PNA)
Limitations of 2020 CPG
o *Philippine Pediatric Society (PPS)
 Evidence obtained from RCTs and some meta-analyses
(*) consulted because of different issues regarding special populations
 Observational studies were only used as references
Issues with 2015 CPG  Did not include Filipino patients
 Questions about management of special populations (e.g. kidney disease,
CLINICAL QUESTION 1: Lifestyle Modifications
pediatric population)
Among individuals with dyslipidemia, regardless of their present condition or
 Issues on adverse events of statin therapy
risk profile, should lifestyle modification (i.e., reduced fat diet, smoking
 Did not include new clinical data on ezetimibe for secondary prevention cessation, regular physical activity) be advised to reduce overall
Objectives of 2020 CPG cardiovascular risk?
 Provide evidence-based recommendations to effectively manage Statements
individuals with dyslipidemia For individuals at any level of CV risk, the following are recommended:
 Recommendations aim to identify effective and feasible treatment  Low-fat, low-cholesterol diet rich in fruits and vegetables
regimens, both pharmacologic and non-pharmacologic o Utilize Pinggang Pinoy (1/2 green leafy vegetables, 1/4 meat, 1/4
 For the Filipino physician to confidently care for the individual with fiber-rich carbohydrates)
dyslipidemia and eventually lower his risk for CV disease  Cigarette smoking cessation (strongly recommended)
Methodology  E-cigarette smoking/vaping cessation
 Technical research committee (TRC) was formed – comprised of experts  Adequate exercise
in the fields of the ff: o At least 150 minutes per week at moderate- to high-intensity
o Dyslipidemia
o Cardiology PRIMARY PREVENTION
o Endocrinology CLINICAL QUESTION 2.1: individuals with no prior ASCVD
o Pediatrics Among non-diabetic individuals without ASCVD but with multiple risk
o Neurology factors, should statin therapy be given?
o Nephrology Statement
o Clinical epidemiology Statins are RECOMMENDED for prevention of CV events for individuals
 TRC formulated 9 clinical questions that dealt with: with the ff. criteria:
1. Non-pharmacologic management  Without DM
2. Primary prevention for both non-DM DM individuals  Aged 45 years and above
3. Familial hypercholesterolemia  LDL-C ≥ 130 mg/dL
4. Secondary prevention
 2 or more risk factors*
5. Adverse events of statins
 Without atherosclerotic cardiovascular disease
6. Use of other lipid parameters
 Various clinical outcomes were rated and ranked using GRADE (*) Risk factors include:
categories of importance  Male sex
o Ranking outcomes by their relative importance can help to focus  Postmenopausal women
attention on those that are considered most important and help to  Smoking
resolve or clarify disagreements  Hypertension
 BMI >25 kg/m2
 Family hx of premature CHD, proteinuria, and left ventricular
hypertrophy

 Team looked at most common adverse events affecting individuals on

statin treatment
  Basis is early identification and control of pediatric dyslipidemia to
reduce risk and severity of CVD in adulthood
 Selective screening for those at risk
 Universal screening at 9-11 y/o and 17-21 y/o
o To identify those with risk factors for FH

CLINICAL QUESTION 5: individuals with CKD

Among individuals with chronic kidney disease who are not on dialysis,
should statins be given to reduce CV risk?
Statement
Statins are RECOMMENDED for prevention of CV events among individuals
with CKD not on dialysis
 Dyslipidemia is common but not universal in CKD
o Kidney dysfunction  profound dysregulation of lipoprotein
metabolism  multiple lipoprotein abnormalities
NOTE: individuals on renal replacement therapy and post-transplant are
referred to nephrologists for lipid management
CLINICAL QUESTION 2.1: Primary Prevention for Individuals with
DM SECONDARY PREVENTION
Among individuals with diabetes without ASCVD, should statins be
CLINICAL QUESTION 6: Individual with Acute Coronary Syndrome
recommended?
Among individuals with acute coronary syndrome (ACS), should statins be
Statements given?
 Statins are RECOMMENDED for primary prevention in those with DM Statement
without ASCVD Statins should be given IMMEDIATELY
o Statin dose must be optimized to reach LDL-C <100mg/dL for
 Timing is critical for px with acute coronary syndrome
most persons with DM
o Early intervention  optimized recovery, less complications
o For those with more than 1 risk factor: LDL-C <70mg/dL
o “Time is muscle”: immediate action during golden period in which
 For secondary prevention in those with DM with extremely high risk of
MI damage is still potentially reversible/myocyte necrosis can be
recurrent CV events due to previous occurrence of major CV events (e.g.
contained, much of the myocardium in the ischemic penumbra can
MI, unstable angina, stroke): LDL-C of <55mg/dL
still be salvaged
CLINICAL QUESTION 3: Familial Hypercholesterolemia (FH)  Early high-intensity statin that is maximally tolerated
Among high risk individuals identified to have familial hypercholesterolemia  Statin therapy should not be discontinued
(FH), should statin therapy be initiated?
Statement
Statin is STRONGLY RECOMMENDED for prevention of CV events for all
identified FH individuals
 FH is a dominantly inherited gene disorder
o Results from gene mutations in LDL-receptor pathway
o Causes elevated LDL-C from birth
o Untreated, leads to premature death from CAD d/t accelerated
atherosclerosis
 Recommended statin therapy: high-intensity dose
o In patients WITHOUT target organ damage: LDL-C <70 mg/dL
o In patients WITH target organ damage: LDL-C <55 mg/dL

CLINICAL QUESTION 4: Dyslipidemia in Pediatric Population

Among pediatric population at risk for premature CV disease, should
screening with fasting lipid profile be recommended?
Statement
Screening with fasting lipid profile is RECOMMENDED among pediatric
population (≤19 years old) at risk for development of atherosclerosis and
premature CV disease NON-STATIN THERAPY
 CLINICAL QUESTION 7.1: Us of Ezetimibe
Among individuals with ASCVD, should ezetimibe be given on top of statin
therapy?
Statement
Ezetimibe MAY BE ADDED on top of statin therapy to get goal LDL-C for
individuals with ff. criteria:
 Documented ACS
 Target LDL-C not reached despite maximally-tolerated high-intensity
statin therapy

CLINICAL QUESTION 7.2: Use of Fibrates

Among individuals with ASCVD, should fibrates be given on top of statin
therapy once LDL-C goal is achieved?
Statements
 Adding fibrates is NOT RECOMMENDED for primary or secondary
prevention among the ff. individuals:
o Individuals without DM not at goal LDL-C
o Individuals with DM
 Adding fibrates MAY BE CONSIDERED among individuals with the ff.
criteria:
o Male sex
o Controlled DM
o Low LDL-C (<35 mg/dL)
o Persistently high triglycerides (>200 mg/dL)

CLINICAL QUESTION 7.3: Use of Omega Fatty Acids

Among individuals with ASCVD, should omega fatty acids be given on top of
statin therapy once LDL-C goal is achieved?
Statements
 Omega fatty acids (EPA+DHA) NOT RECOMMENDED among
individuals with ASCVD
 But MAY BE GIVEN (as pure EPA) to individuals with ff. factors:
o With ASCVD
o On statin therapy at goal LDL-C
o Persistently high triglyceride levels of 150-499 mg/dL

FOUR PATIENT GROUPS

ADDITIONAL TARGETS TO REDUCE CV RISK

CLINICAL QUESTION 9.1: Use of non-HDL-C
Among individuals on statin therapy who have achieved their LDL-C goal,
should non-high density lipoprotein cholesterol (non-HDL-C) be used as
additional target to reduce CV events?
Statement
Elevated computed non-HDL-C MAY BE USED as additional therapeutic
target to further reduce CV events
 Recommended in individuals with atherogenic dyslipidemia
(e.g. (+) metabolic syndrome, T2DM, obesity) as an additional tool to
provide a better estimate of risk beyond LDL-C

Non-HDL-C
 Difference between total cholesterol levels and HDL-C
 Quantifies all atherogenic lipoprotein particles
 Target non-HDL-C is 30 mg/dL above target LDL-C
 Has prognostic value in clinical trials as a therapeutic target

CLINICAL QUESTION 9.2: Use of Apolipoprotein B-100

STATIN ADVERSE EFFECTS
CLINICAL QUESTION 8: Use of Statin Therapy
Among individuals taking statin therapy, what is the risk of developing
adverse effects?
- Statin-associated Muscle Symptoms (SAMS)
- New-onset Diabetes
- Dementia/cognitive dysfunction/intracerebral hemorrhage
Statements
 LOW RISK of SAMS; benefits of CV risk reduction > risk
 INCREASED RISK of new-onset DM; benefits > risk
 NOT associated with dementia, cognitive dysfunction, increased risk of
intracerebral hemorrhage
Among individuals on statin therapy who have achieved their LDL-C goal,
should apolipoprotein B-100 be used as additional target to reduce CV events?
Statement
Elevated apolipoprotein B-100 MAY BE USED as an additional therapeutic
target to further reduce CV events
Conclusions
 Lifestyle modification should be recommended to ALL patients
regardless of their CVD risk
 Dosing of statin therapy should be based on individual risk factors
 Lower LDL-C target is recommended for secondary prevention
 CPG is simply a guide for dyslipidemia management
 CPG does not replaced sound clinical judgement; decision making
must involve both clinician and patient