VOLUME 8 NUMBER 4 • NOVEMBER 2011
157
SA JOURNAL OF DIABETES & VASCULAR DISEASE
SPECIAL REPORT
New guidelines recommend lower LDL target in high-risk
cardiovascular patients
PETER WAGENAAR
T
he South African Heart
Association and the Lipid
and Atherosclerosis Soci-
ety of Southern Africa (LASSA)
held their second joint guide-
line collaboration meeting on
15 and 16 October 2011. The
meeting was attended by rep-
resentatives of both societies,
the funding industry and the
Department of Health, as well
as various medical specialists.
With a view to optimising the
management of cardiovascular
disease in South Africa, both
societies adopted the European
Society of Cardiology (ESC)/
European Atherosclerosis Soci-
ety (EAS) dyslipidaemia guide-
lines published in the
European
Heart Journal
in June 2011.
1
These guidelines are now also
the official South African guidelines to determine the most effec-
tive and appropriate diagnostic tests and treatments for dyslipidae-
mic cardiovascular disease. ‘However, we will be tailoring certain
dietary recommendations to our own ethnic groups. A major
difference is that we won’t be using the SCORE risk assessment
system, which was developed based on European epidemiological
data’, said Dr Eric Klug, vice president of the South African Heart
Association.
‘Because South Africa has no comparable data, we’ve always
used the Framingham system and will be adopting the new Fram-
ingham system in future. Women’s risk was underestimated by the
old Framingham system, but the new system has addressed that,
in addition to taking the risk of younger people into account. They
can now be assessed more accurately.’
The key change in the new guidelines is the downward revi-
sion of the target LDL cholesterol level in very high-risk patients
(> 30% Framingham risk). It has been lowered to 1.8 mmol/l
from 2.6 mmol/l. The definition of ‘very high risk’ has also been
expanded to include chronic kidney disease (CKD) in addition to
diabetes, established vascular disease (including previous stroke or
heart attack) and familial hypercholesterolaemia. CKD, defined as
a glomerular filtration rate < 60 ml/minute/1.73m
2
for a period of
more than three months, is now considered a major cardiovascular
risk factor in its own right. In addition, the threshold for ‘high risk’
is now defined as > 15% Framingham risk and the LDL target in
that group is < 2.5 mmol/l (Tables 1, 2).
1
‘The INTERHEART study, published in the
Lancet
in 2004,
2
and
to which Africa contributed 5% of the 30 000 patients involved,
showed that the serum HDL:LDL ratio topped the odds ratio charts
in predicting future myocardial infarction. It is therefore a major
cardiovascular risk factor which, uncontrolled, will lead to a sig-
nificantly greater burden of disease’, says Dr Klug. ‘Atherosclerotic
cardiovascular disease is the global number one killer and the man-
Table 2.
Recommendations for treatment targets for LDL-C
Recommendations
Class
a
Level
b
In patients at VERY HIGH cardiovascular risk
(established cardiovascular disease, type 2 diabe-
tes, type 1 diabetes with target-organ damage,
moderate to severe CKD or a Framingham score
level ≥ 30%) the LDL-C goal is < 1.8 mmol/l and/
or ≥ 50% LDL-C reduction when target level
cannot be reached.
1
A
In patients at HIGH cardiovascular risk (markedly
elevated single risk factor, a Framingham score
level ≥ 15 to < 30%) an LDL-C goal < 2.5 mmol/l
should be considered.
11a
A
In subjects at MODERATE cardiovascular risk
(Framingham score level ≥ 3% and < 15%) an
LDL-C goal < 3.0 mmol/l should be considered.
Low risk (Framingham score level < 3%).
a
Class of recommendation;
b
level of evidence.
Amended from ESC/EAS guidelines.
1
11a
C
Table 1.
Recommendations for lipid profiling in order to assess total
cardiovascular risk
Condition
Class
a
Level
b
Lipid profiling is indicated in subjects with:
Type 2 diabetes mellitus
1
C
Established cardiovascular disease
1
C
Hypertension
1
C
Smoking
1
C
BMI ≥ 30 kg/m
2
or waist circumference > 94 cm
(90 cm
c
) for men, > 80 cm for women
1
C
Family history of premature cardiovascular disease
1
C
Chronic inflammatory disease
1
C
Chronic kidney disease
1
C
Family history of familial dyslipidaemia
1
C
Lipid profiling may be considered in men > 40 and
women > 50 years of age
11b
C
SA Guideline Committee has added HIV-positive
patients on antiretroviral therapy
1
C
a
Class of recommendation;
b
level of evidence;
c
for Asian males.
BMI = body mass index.
Amended from ESC/EAS guidelines.
1
Dr Eric Klug
