Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Statinizzati.ppt

632 views

Published on

Presentazione sulle nuove ATP circa il ruolo delle Statine.

Published in: Health & Medicine
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Be the first to like this

Statinizzati.ppt

  1. 1. Statinizzati! Elio Aloia
  2. 2. Uomo caucasico Giuseppe Aloia Eta 62 anni P.A 135 80 Peso 85 kg Altezza 182cm Colesterolo totale 203 colesterolo hdl 37 Nessuna patologia degna di nota in anamnesi FUMATORE Madre ictus 82 anni
  3. 3. A PELLE COSA NE PENSATE…..
  4. 4. Prevenzi one primaria in soggetti ad alto rischio Rischio di CVD fatali SCORE =5%: Target c-LDL <100 mg/dL (2,5 mmol/L) Rischio totale di eventi CV >7,5%: terapia con statine a intensità moderata-alta. Rischio di eventi CV 5-7,5%: terapia con statine a intensità moderata. Differenza fra Europa ed America !
  5. 5. Calcoliamo il rischio
  6. 6. Rischio calcolato con Ominibus software distribuito da AHA in ATP IV
  7. 7. Framingham Risk score (ricordando che statinanizzazione >20% CON LDL>100 mg/dl....secondo ATP III !!!!!!!)
  8. 8. Linee guida inglesi 2014!!!! E la tabellina magica…..
  9. 9. Forse dopo le critiche piovute alle ATPIV  RICORDIAMO CHE LE LINEE GUIDA NICE NON SONO DEFINITIVE, BENSì PROVVISORIE E IL PROCESSO DI CONSULTAZIONE è APERTO FINO AL 26 MARZO.  La stesura definitiva è prevista per Luglio
  10. 10. Ma le GUIDELINES ricalcono le atp IV  Si passa con la prescrizione della tastina con un rischio del 10% a 10 anni, e non del 20% come le precedenti, usando il QRISK (visto in precedenza)
  11. 11. Il nostro, anzi il mio Aloia Giuseppe: 15-20% di rischio a 10 anni di avere un ictus o un infarto…..
  12. 12. Allora una statina a colazione?
  13. 13. Circulation Novembre 2013 …Nejm le segnala a febbraio 2014
  14. 14. e nel corrente numero del nejm….
  15. 15. 144 voci bibliografiche  142. Preiss D, Seshasai SRK, Welsh P et al. Risk of incident diabetes with intensive-dose compared with moderate-dose statin therapy: a meta-analysis. JAMA  141. Bonovas S, Filioussi K, Tsantes A, Sitaras NM. Use of statins and risk of haematological malignancies: a meta-analysis of six randomized clinical trials and eight observational studies. British Journal of Clinical Pharmacology 2007;64:255–62.  139. Bukkapatnam RN, Gabler NB, Lewis WR. Statins for primary prevention of cardiovascular mortality in women: a systematic review and meta-analysis
  16. 16. 138. Brugts JJ, Yetgin T, Hoeks SE et al. 0 disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials. Br Med J 2009;338:b2376. 137. Ray KK, Seshasai SRK, Erqou S et al. Statins and all-cause mortality in high-risk primary prevention: Aa meta-analysis of 11 randomized controlled trials involving 65,229 participants. Arch Intern Med 2010;170:1024–31. 136. Kizer JR, Madias C, Wilner B et al. Relation of different measures of low-density lipoprotein cholesterol to risk of coronary artery disease and death in a meta-regression analysis of large-scale trials of statin therapy. Am J Cardiol 2010;105:1289–96. 135. Messerli FH, Pinto L, Tang SSK et al. Impact of systemic hypertension on the cardiovascular benefits of statin therapy--a meta-analysis. Am J Cardiol 2008;101:319–25.
  17. 17. 134. Cholesterol Treatment Trialists Collaboration, Kearney PM, Blackwell L et al. Efficacy of cholesterol lowering 99. Mills EJ, Rachlis B, Wu P, Devereaux PJ, Arora P, Perri D. Primary prevention of cardiovascular mortality and events with statin treatments: a network meta-analysis involving more than 65,000 patients. J Am Coll 98. Baigent C, Blackwell L, Emberson J 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;376:1670–81. 83. Cholesterol Treatment Trialists C, Mihaylova B, Emberson J et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomized trials .Lancet 2012;380:581-90.
  18. 18. 82. Sattar N, Preiss D, Murray HM et al. Statins and risk of incident diabetes: a collaborative meta- analysis of randomised statin trials. Lancet 2010;375:735–42. 50. Cholesterol Treatment Trialists Collaboration. Efficacy of cholesterol- lowering treatment: prospective meta-analysis of data from 90,056 patients in 14 randomized trials of statins. Lancet 2005;366:1267–78. 13. Cholesterol Treatment Trialists Collaboration, Mihaylova B, Emberson J et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012;380:581–90.
  19. 19.  20. Cholesterol Treatment Trialists Collaboration. 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;376:1670–1681  50. Cholesterol Treatment Trialists Collaboration. Efficacy of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 patients in 14 randomized trials of statins. Lancet 2005;366:1267–78.
  20. 20. Evento cardiovascolare…. :  Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.
  21. 21. Probabilmente in prevenzione primaria qualche domanda dovremmo formularla….. Attenzione all’ «ipse dixit» nei riguardi dell’AMERICA
  22. 22. Qualcosa non tornava anche a me nel primo uso del calcolatore di rischio….figuriamoci alla comunità scientifica
  23. 23. Sommariamente le varie critiche che riempono i rotocalchi….ops le riviste scientifiche  Traslazione risultati in prevenzione primaria di studi con coorti di pazienti in prevenzione secondaria  Non considerare l’LDL nell’omnibus è una follia  Abbandonare i target: questo secondo alcuni sarebbe DAVVERO overtrattare o sottotrattare  Seguendo….si stima 930 milioni di persone da trattare SUL GLOBO (facciamo prima a trattare tutti i cinesi)  Risultati degli studi VENGONO TRASLATI ARBITRARIAMENTE IN UN IPOTETICO USO DETTATTO DA UN CALCOLATORE DI RISCHIO SEMPLICISTICO E LARGAMENTE INCOMPLETO e per giunta NON USATO NEGLI STUDI SU CUI SI BASA LA LINEE GUIDA
  24. 24. Solo negli usa 8 milioni di statinizzati in più….. Considerando il registro NHANES (che ha escluso pz con TG>400 mg/dl…… e confrontando gli stessi pz e applicando i criteri di statinizzazione di ATPIII e ATP IV, notiamo che….(nella prox slide)
  25. 25. Con le attuali disposizione il valore medio di LDL negli statinizzati è di poco superiore a 100 mg/dl
  26. 26. Volendo fare gli avvocati del diavolo e come Parmenide insegna…  Da valutare anche i risultati del
  27. 27. Attenzione: che risultati opinabili in prevenzione primaria non screditino tuttò però
  28. 28. Inoltre ricordiamoci che Aloia Giuseppe secondo la nostra European society of Cardiology (ESC) statinizerebbe Aloia Giuseppe se avesse 5 anni in più (65 anni) e mantenesse il fumo/P.sistolica/colesterolo attuali….ma sindacabilità anche su scores ESC
  29. 29. Altri elementi da considerare….  ‡Primary LDL–C ≥160 mg/dL or other evidence of genetic hyperlipidemias, family history of premature ASCVD with onset <55 years of age in a first degree male relative or <65 years of age in a first degree female relative, high-sensitivity C-reactive protein >2 mg/L, CAC score ≥300 Agatston units or ≥75 percentile for age, sex, and ethnicity, ankle- brachial index <0.9, or elevated lifetime risk of ASCVD.  ASCVD indicates atherosclerotic cardiovascular disease; CAC, coronary artery calcium; and LDL–C, low-density lipoprotein cholesterol.
  30. 30. STUDIO JUPITER…RISULTATI SULLA STELLA LINEA NELLO STUDIO PROVE-IT  Nello studio Jupiter, l’uso delle statine in prevenzione primaria, riduzione hsPCR si è dimostrata un miglior marker di predittività negativa per eventi cardiovascolari, rispetto a riduzione LDL, in prevenzione primaria….miglior outcome per i pazienti con riduzione congiunta di 2,2 mg/dl per hsPCR, e LDL<70 mg/dl  I risultati confermavano già l’orientamento delle linee guida canadesi del 2009 nel considerare fortemente la valutazione della hsPCR
  31. 31. Aterosclerosi, più che malattia di accumulo del colesterolo, malattia infiammatoria….. Eventi cardiovascolari correlati ad aumento di Pcr, per rottura- trombosi vasale
  32. 32. Inoltre….  Invece s. longitudinali : PCR elevata = marcatore di rischio ipertensione nuova insorgenza e la progressione accelerata del danno d’organo….forse oltre quanto spiegato dal solo aumento della PA Inoltre studi trasversali mostrano forti correlazioni tra PCR elevata e rigidità arteriosa e pressione differenziale elevata.
  33. 33. Inoltre….  Migliore accuratezza nel 5,7- 11,8% dei casi La ristratificazione considerando i valori di hsPCR nei pazienti nel framingham risk score,
  34. 34. Insomma….state dormendo?
  35. 35. ( immagine di copertina della rivista: dormire sano)
  36. 36. Il punto in generale…..  Use of LDL–C targets may result in under- treatment with evidence-based statin therapy or overtreatment with nonstatin drugs that have not been shown to reduce ASCVD events in RCTs (even though the drug may additionally lower LDL–C and/or non-HDL–C) 
  37. 37. Il punto in prevenzione secondaria….
  38. 38. A. Secondary prevention — Evidence supports high-intensity statin therapy for this group to maximally lower LDL–C. It does not support the use of an LDL–C target. For example, if a secondary prevention patient achieves an LDL–C of 78 mg/dL on a dose of 80 mg of atorvastatin, he/she is receiving evidence- based therapy. As of yet, there are no data to show that adding a nonstatin drug(s) to high-intensity statin therapy will provide incremental ASCVD risk reduction benefit with an acceptable margin of safety
  39. 39. LDL–C >190 mg/dL ( una miriade di dati…)
  40. 40. In many cases, individuals with FH are unable to achieve an LDL–C goal <100 mg/dL For example, an individual with FH may only achieve an LDL–C of 120 mg/dL despite use of 3 cholesterol-lowering drugs. Although this patient may have fallen short of the 100 mg/dL goal, they have decreased their LDL–C by >50% (starting from an untreated LDL–C level of ~325-400 mg/dL). These patients are not treatment failures
  41. 41. Estimated 10-year ASCVD risk ≥7.5%  Data has shown that statins used for primary prevention have substantial ASCVD risk reduction benefits across the range of LDL–C levels of 70-189 mg/dL. Moreover, the Cochrane meta- analysis (15), as well as a meta-analysis by the Cholesterol Treatment Trialists (13), confirms that primary prevention with statins reduces total mortality as well as nonfatal ASCVD events. 
  42. 42. Nel caro diabetico  For those 40-75 years of age with risk factors, the potential benefits of LDL–C lowering with a high-intensity statin are substantial. Because those with diabetes often have lower LDL– C levels than those without diabetes, "goal" directed therapy often encourages use of a lower statin dose than is supported by the RCTs, and nonstatin drugs may be added to address low HDL–C or high triglycerides, for which RCT evidence of an ASCVD event reduction is lacking. Giving a maximally-tolerated statin intensity should receive primary emphasis because it most accurately reflects the data that statins reduce the relative risk of ASCVD events similarly in individuals with and without diabetes, and in primary and secondary prevention in those with diabetes, along with evidence that high-intensity statins reduce ASCVD events more than moderate-intensity statins. 
  43. 43. RCTs are used to identify those who are unlikely to benefit from statin therapy despite being at high ASCVD risk, such as those with higher NYHA classes of heart failure or those on hemodialysis.
  44. 44. INFATTI…..  Effects of pitavastatin in Japanese patients with chronic heart failure: the Pitavastatin Heart Failure Study (PEARL Study).  Takano H, Mizuma H, Kuwabara Y, Sato Y, Shindo S, Kotooka N, Fujimatsu D, Kobayashi Y, Inoue T, Node K, Komuro I; PEARL Study Investigators.  Recent clinical trials using rosuvastatin, a hydrophilic statin, did not show beneficial effects on cardiovascular events in patients with heart failure. We examined the cardioprotective effects of pitavastatin, a lipophilic statin, on Japanese patients with chronic heart failure (CHF).  METHODS AND RESULTS:  A total of 574 Japanese patients with CHF were randomly assigned to the pitavastatin group (n=288) or the control group (n=286). There was no significant difference between the 2 groups for the primary outcome, which was a composite of cardiac death and hospitalization for worsening HF (adjusted hazard ratio (aHR): 0.922, 95% confidence interval (CI): 0.632-1.345, P=0.672). A strongly significant statistical interaction between the effect of pitavastatin and left ventricular ejection fraction (LVEF) was found (P=0.004). In patients with LVEF ≥30%, a significant reduction in the primary outcome (aHR: 0.525, 95% CI: 0.308-0.896, P=0.018) was observed in the pitavastatin group. Pitavastatin did not show any effects on the primary outcome (aHR: 1.582, 95% CI: 0.890-2.813, P=0.118) in the subgroup of patients with LVEF <30%.  CONCLUSIONS:  Pitavastatin did not reduce cardiac death or hospitalization for worsening HF in Japanese patients with CHF. (UMIN-ID: UMINC000000428).
  45. 45. Infatti anche nelle ATP IV…
  46. 46. I 2 studi su cui si basa la raccomandazione…oltre al noto e recente studio (CORONA) pubblicato su CIRCULATION
  47. 47. …….E il noto studio MEGA (Pubblicato su JAMA)….  Insomma….credo che ci siamo convinti che iniziare la terapia statinizzante in un gruppo determinato di pazienti non abbia senso, in base all’evidenze attuali….
  48. 48. Stiamo quasi per finire  ….solo 1 minuto….
  49. 49. Qualcosa che non va c’è in molti casi pensandoci bene…..
  50. 50. Topcat study (Dallas 2013) Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist(3445 pz)  Risultati…..riduzione, rispetto a placebo del 2% dell’ospedalizzazioni per scomenso cardiaco, in popolazione randomizzata a doppio cieco di pz affetti da scompenso diastolico con l’aggiunta di spironolattone a terapia standard (ACE, b- bloccanti)….  Ancora più interessanti sono i dati eco pubblicati su Circulation (GENNAIO 2014)
  51. 51. Criteri selezione pazienti…  TOPCAT enrolled 3445 patients at 270 sites in 6 countries,  who met the following key inclusion criteria: (1) age ≥50 years old;  (2) heart failure defined by the presence of ≥1 symptom at the time of  screening and 1 sign in the previous 12 months; (3) LVEF ≥45% per  local reading and obtained within 6 months before randomization and  ≥6 months after myocardial infarction or other event that would affect  LVEF; (4) controlled systolic blood pressure defined as systolic blood  pressure <140 mm Hg or 140 to 160 mm Hg if on ≥3 antihypertensive  medications; and (5) assignment to 1 of 2 strata within which subjects  were randomized: either ≥1 hospitalization in the previous 12 months  for which heart failure was a major component of hospitalization, or  B-type natriuretic peptide (BNP) in the previous 60 days ≥100 pg/mL  or N-terminal pro-BNP (NT-proBNP) ≥360 pg/mL. (nuove evidenze suggeriscono di abbassare la soglia da 100 a 60 per questi pazienti…..)
  52. 52. Concludendo…..
  53. 53. Gli autori concludono così….
  54. 54. Grazie x l’attenzione

×