We return to the topic of dyslipidemia and examined the: "2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults" http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a

Previous episodes on statins can be found here.

Major differences between AHA 2013 guideline and CCS 2012 guideline:

CCS 2012

AHA 2013

Treatment Threshold

LR (FRS<10%): consider lifestyle only

IR (FRS 10-19%), if LDL <3.5mmol/L: consider lifestyle only

Optional alternate target and secondary tests reasonable

HR (FRS >20%), history of CVD, DM aged >40: statins

LDL >5 mmol/L: statins

CVD: statins

LDL > 4.9 mmol/L: statins

DM aged 40-75: statins

10-year risk >7.5%: statins

Treatment Target

LDL >50% reduction

LDL < 2mmol/L for IR and HR groups

No target

Fixed dose statins based on initial risk assessment

Pooled Cohort Equations to estimate 10-year CVD risk: http://www.cardiosource.org/science-and-quality/practice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx

Dr. McCormack's discussion on patient centered EBM on KevinMD: http://www.kevinmd.com/blog/2013/12/cholesterol-guidelines-emphasize-patient-preference.html

(Originally published on January 25, 2014)

In this episode, we listed the life-style management of dyslipidemia and lowering cardiovascular disease risk, and dived into the main classes of medications for lipid lowering: statins, niacin, fibrates, resins, and cholesterol absorption inhibitors. As an important side note, the signs and symptoms of statin-induced myopathies were discussed as well.

CCS 2012 guidelines: http://www.onlinecjc.ca/article/S0828-282X(12)01510-3

DASH diet

Mayo Clinic info sheet: http://www.mayoclinic.com/health/dash-diet/HI00047

Portfolio diet

Original research: http://jama.jamanetwork.com/article.aspx?articleid=1104262

WebMD summary: http://www.webmd.com/cholesterol-management/features/portfolio-diet-lower-cholesterol

Mediterranean Diet

Mayo Clinic info sheet: http://www.mayoclinic.com/health/mediterranean-diet/CL00011

Coming up: AHA guidelines: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf+html

Drug information from:

Drug monographs

CPS: http://www.e-therapeutics.ca/

Therapeutic Choices: http://www.e-therapeutics.ca/

Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx

We covered the key points on risk stratification and treatment targets from the 2012 CCS guideline on dyslipidemia. We also briefly highlighted cardiovascular age and secondary causes of dyslipidemia. Below are a few useful links:

2012 Update of the Canadian Cardiovascular Society (CCS) Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult:

http://www.onlinecjc.ca/article/S0828-282X(12)01510-3

Framingham Risk Score worksheet, and cardiovascular age conversion chart:

http://www.ccsguidelineprograms.ca/images/stories/Dyslipidemia_Program/Tools_Resources/FRSworksheets/Lipids_EN_FRS_worksheet_v2.pdf

Dr. McCormack's graphical FRS tool:

http://bestsciencemedicine.com/chd/calc2.html

We reviewed some evidence on the treatment of hypertension that are contradictory to the CHEP 2013 guidelines summarized in our previous episodes.

Salt restriction for hypertension

CHEP 2013: 1500 mg of sodium per day is recommended for adults age 50 years or less; 1300 mg per day if age 51 to 70 years; and 1200 mg per day if age greater than 70 years

Tools for practice: "Cutting out the sodium: The bland supremacy?" http://www.acfp.ca/Portals/0/docs/TFP/20130204_084845.pdf

"The impact of salt intake on CVD outcomes is controversial. Trials demonstrating beneficial trends enrolled patients with an average sodium intake of 3900 mg/day and reduced their intake on average by 900mg/day. More evidence with clinical outcomes is required to better define benefits/harms with different levels of daily sodium intake."

Hypertension treatment target for diabetes

CHEP 2013: BP target for diabetes is 130/80mmHg, and 140/90 for others

Cochrane: "Blood pressure targets for hypertension in people with diabetes mellitus" http://summaries.cochrane.org/CD008277/blood-pressure-targets-in-people-with-diabetes

"The only significant benefit in the group assigned to 'lower' systolic blood pressure was a small reduction in the incidence of stroke (ACCORD 1.1%ARR SBP <140 vs <120), but with a significantly larger increase in the number of other serious adverse events (ARI 2%). The effect of systolic blood pressure targets on mortality was compatible with both a reduction and increase in risk. There was no benefit associated with a 'lower' diastolic blood pressure target (trend towards less stroke RR 0.67, 95% CI 0.42 to 1.05)"

Tools for Practice: "When Treating Blood Pressure, what is the Evidence for Specific Targets?" http://www.acfp.ca/Portals/0/docs/TFP/20111028_103346.pdf

Treating mild hypertension

CHEP 2013: treatment threshold 160/100, treatment target 140/90 for uncomplicated hypertension

Cochrane: "Pharmacotherapy for mild hypertension" http://summaries.cochrane.org/CD006742/benefits-of-antihypertensive-drugs-for-mild-hypertension-are-unclear

"For individuals with mildly elevated blood pressures(systolic blood pressure (BP) 140-159 mmHg and/or diastolic BP 90-99 mmHg) treatment for 4 to 5 years with antihypertensive drugs as compared to placebo did not reduce total mortality (RR 0.85, 95% CI 0.63, 1.15). In 7,080 participants treatment with antihypertensive drugs as compared to placebo did not reduce coronary heart disease (RR 1.12, 95% CI 0.80, 1.57), stroke (RR 0.51, 95% CI 0.24, 1.08), or total cardiovascular events (RR 0.97, 95% CI 0.72, 1.32). Withdrawals due to adverse effects were increased by drug therapy (RR 4.80, 95%CI 4.14, 5.57), Absolute risk increase (ARI) 9%."

Which first line agent for hypertension is actually first line?

CHEP 2013:  beta-blocker is considered a first line choice in patients younger than 60 years of age (Grade B), among ACEI, ARB, thiazides, CCB

Therapeutics Initiative Letter #82: "Clinical Hypertension Pearls from The Cochrane Library" http://www.ti.ubc.ca/letter82

Cochrane: "First-line drugs for hypertension" http://summaries.cochrane.org/CD001841/thiazides-best-first-choice-for-hypertension

mortality

stroke

CHD

CVS

Thiazides (19 RCTs)

RR 0.89, 95% CI 0.83, 0.96

RR 0.63, 95% CI 0.57, 0.7

RR 0.84, 95% CI 0.75, 0.95

RR 0.70, 95% CI 0.66, 0.76

Low-dose thiazides (8 RCTs)

RR 0.72, 95% CI 0.61, 0.84

high-dose thiazides (11 RCTs)

RR 1.01, 95% CI 0.85, 1.20

Beta-blockers (5 RCTs)

RR 0.96, 95% CI 0.86, 1.07

RR 0.83, 95% CI 0.72, 0.97

RR 0.90, 95% CI 0.78, 1.03

RR 0.89, 95% CI 0.81, 0.98

ACE inhibitors (3 RCTs)

RR 0.83, 95% CI 0.72-0.95

RR 0.65, 95% CI 0.52-0.82

RR 0.81, 95% CI 0.70-0.94

RR 0.76, 95% CI 0.67-0.85

Calcium-channel blocker (1 RCT)

RR 0.86 95% CI 0.68, 1.09

RR 0.58, 95% CI 0.41, 0.84

RR 0.77 95% CI 0.55, 1.09

RR 0.71, 95% CI 0.57, 0.87

ARB (no RCT)

Listen to Tina the pharmacist discuss the 5 first-line antihypertensives:

Thiazides

ACE Inhibitors

Angiotensin Receptor Blockers

Beta Blockers

Calcium Channel Blockers

She lists the mechanism of action, dosing, side effects, drug interactions, and cautionary notes of each drug classes and their representative drug.

This episode is wrapped up with Billy's summary of the learning points from the 3-episode series on Hypertension:

essential hypertension is a diagnosis of exclusion. we need to consider treatable causes of hypertension especially for people who do not have the usual risk factors.

diagnosing a patient with hypertension is a careful process. for those without comorbidities or cardiovascular treatment, it can take a many as 5 visits averaging a BP of 140/90 to make a diagnosis. use home BP measurement if you suspect white coat hypertension.

the treatment threshold for uncomplicated patients is 160/100, and threshold for those with end organ damage or increased CV risk is 140/90.

a trial of lifestyle management to control BP is appropriate for most uncomplicated patients. it should always be a part of the management plan even for those who are on medication.

Treatment target is 140/90, unless the patient has diabetes, for this the threshold is 130/80.

For an elderly patient above 80 yo, systolic treatment target is 150

the first line agents are thiazides, ACEI, ARB, BB, and CCB. specific agents may be indicated for specific comorbidities

antihypertensive are among the most commonly used medications, but one must not forget that they carry many potentially serious side effects and can interact with other medications. when in doubt, consult your favorite pharmacist

We looked to the CHEP guidelines again for their recommendations on hypertension treatment thresholds, targets, lifestyle management, pharmacologic treatments, and suggested medications for specific comorbidities.

Treatment guidelines on CHEP:

http://www.hypertension.ca/chep

DASH diet:

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3862329/k.4F4/Healthy_living__The_DASH_Diet_to_lower_blood_pressure.htm

This is the first episode of the Family Pharm Podcast. In a series of 3 podcasts, we covered one of the most important disease entities in family practice and community pharmacies: hypertension. In episode 1, we focussed on the diagnosis of hypertension, and we also discussed briefly the secondary causes of hypertension, screening, and investigations.

I have summarized the CHEP guidelines used in this podcast on my website:

http://www.drbillylin.com/chep-summary/

CHEP guidelines on diagnosis, investigations, and management:

http://www.hypertension.ca/chep

level of CHEP recommendations explained (many of the guideline recommendations on diagnosis, lab investigations, and follow up are Level D):

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560862/

CFPC endorses the CHEP guidelines for hypertension: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=1538&langType=4105

Canadian Task Force on Preventive Health Care guideline on screening:

http://canadiantaskforce.ca/guidelines/screening-for-hypertension/

Hi, my name is Tina Lien, and I am a 4th year pharmacy student at the University of British Columbia. And my name is Billy Lin, a family medicine resident at UBC.

Welcome to episode 0 of what we hope to be a long and fruitful adventure, affectionately named: Family Pharm Podcast. (Pharm spelt with a PH, for pharmacy).

The Family Pharm Podcast will cover many priority topics in family medicine and community pharmacy, drawing from the "CFPC 99 topics" as well as topics from the pharmacy bible "Therapeutic Choices". We plan to summarize the established clinical guidelines that will be used for Canadian pharmacy, med school, and family medicine licensing exams, and we hope these would be a good review for practicing clinicians and pharmacists as well.

A sample of our priority topics include hypertension, dyslipidemia, diabetes, asthma, and depression. Each podcast will present an approach to one of these diseases, including its diagnosis, common signs and symptoms, and the treatment choices including pharmacologic and nonpharmacologic options. We will include a review of the relevant drug classes associated with each disease as well.

Besides covering guidelines for exam preparation and general practice recommendations, when we feel more confident, we may also try to include evidence-based information especially if it conflicts with the guidelines. Things are always more interesting but much trickier when evidence and guidelines clash.  Given that we are strong believers in EBM, we do want to stay true to our scientific conscience whenever possible. Besides, if we don't shed light to some of the hot controversies, our colleagues and mentors in evidence-based practice might leave angry comments on iTunes Store, and we definitely don't want that!

This podcast will of course be purely educational. None of what we say here should be taken as medical advice, and don't assume the guidelines are always based on high quality evidence. I mean, even TC and UpToDate have this disclaimer, so please don’t take this student podcast as anything more than it is.

And what it is is a student podcast geared towards medical learners and pharmacy students, covering mostly guidelines and established clinical practices used by their exams. Occasionally, the podcast will be punctuated with EBM outbursts when we need an outlet. For a more regularly updated EBM podcast for primary care, we do recommend Mike and James' Best Sciences Medicine Podcast.

So that’s all for today! Please stay tuned, relax, and keep your eyes on the road. Thanks for listening and we’ll talk to you next time.