CURRICULUM VITAE

SALLY AMAN NASUTION, MD, FINASIM, FACP

- Born in Medan, August 8th 1967
- Internist – Cardiologist
- Faculty Member Division of Cardiology, Department of
Internal Medicine at Faculty of Medicine University of
Indonesia, Jakarta
- Head of Intensive Coronary Care Unit (ICCU), Integrated
Cardiac Services Cipto Mangunkusumo National General
Hospital Jakarta 1
Updates in Dyslipidemia
Guidelines:
How to apply in clinical practice

Dr dr SALLY AMAN NASUTION, SpPD-KKV, FINASIM, FACP

Division of Cardiology Department of Internal Medicine
Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo National General Hospital
Jakarta
Prevalence of raised lipid levels

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LDL-Cholesterol and Blood Presssure

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Sub-analysis DYSIS (Dyslipidemia International Study) II in Indonesia
 % Patients at LDL-C goals
Recommended by the 2004 updated NCEP ATP III* guidelines

% of Patients at LDL-C goals recommended by 2004 updated NCEP ATP III* guidelines

Indonesia patients had the lowest LDL-C attainment rate (31.3 – 52.7%)
Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.
Management of Hypercholesterolaemia remains Sub-optimal:
Pan-Asian CEPHEUS

Attainment of LDL-C

Park JE et al. Eur J Cardiovasc Prevent Rehabil 2011; epub ahead of print.
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https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019

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 The global CVD crisis

www.who.int/global_hearts 2017 11
https://www.acc.org/latest-in-cardiology/articles/2017/05/31/17/42/the-global-burden-of-cardiovascular-disease Last accessed June 29th 2019
Cannon B. Nature 2013; 493: S2 – S3

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American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 2017
 ASCVD Risk Categories and LDL-C Treatment Goals
Treatment goals
Risk category Risk factors/10-year risk LDL-C Non-HDL-C Apo B
(mg/dL) (mg/dL) (mg/dL)
– Progressive ASCVD including unstable angina in individuals after
achieving an LDL-C <70 mg/dL
Extreme risk – Established clinical cardiovascular disease in individuals with DM, <55 <80 <70
stage 3 or 4 CKD, or HeFH
– History of premature ASCVD (<55 male, <65 female)
– Established or recent hospitalization for ACS, coronary, carotid or
peripheral vascular disease, 10-year risk >20%
Very high risk – DM or stage 3 or 4 CKD with 1 or more risk factor(s) <70 <100 <80

– HeFH
– ≥2 risk factors and 10-year risk 10%-20%
High risk – DM or stage 3 or 4 CKD with no other risk factors
<100 <130 <90

Moderate risk ≤2 risk factors and 10-year risk <10% <100 <130 <90
Low risk 0 risk factors <130 <160 NR

Abbreviations: ACS, acute coronary syndrome; apo, apolipoprotein; ASCVD, atherosclerotic cardiovascular disease; CKD, chronic kidney disease; DM, diabetes mellitus;
HeFH, heterozygous familial hypercholesterolemia; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NR, not recommended.

Barter PJ, et al. J Intern Med. 2006;259:247-258; Boekholdt SM, et al. J Am Coll Cardiol. 2014;64(5):485-494; Brunzell JD, et al. Diabetes Care.
2008;31:811-822; Cannon CP, et al. N Engl J Med. 2015;372(25):2387-2397; Grundy SM, et al. Circulation. 2004;110:227-239; Heart Protection Study
Collaborative Group. Lancet. 2002;360:7-22; Jellinger P, Handelsman Y, Rosenblit P, et al. Endocr Practice. 2017;23(4):479-497; Lloyd-Jones DM, et al.
Am J Cardiol. 2004;94:20-24; McClelland RL, et al. J Am Coll Cardiol. 2015;66(15):1643-1653; NHLBI. NIH Publication No. 02-5215. 2002; Ridker PM, J
Am Coll Cardiol. 2005;45:1644-1648; Ridker PM, et al. JAMA. 2007;297(6):611-619; Sever PS, et al. Lancet. 2003;361:1149-1158; Shepherd J, et al.
Lancet. 2002;360:1623-1630; Smith SC Jr, et al. Circulation. 2006;113:2363-2372; Stevens RJ, et al. Clin Sci. 2001;101(6):671-679; Stone NJ. Am J
Med. 1996;101:4A40S-48S; Weiner DE, et al. J Am Soc Nephrol. 2004;15(5):1307-1315.
Heart SCORE (Systematic Coronary Risk Estimation)

European Heart Journal (2019) 00, 178 1 mmol/L = 38.67 mg/dL 15

 Factors modifying heart SCORE
• Social deprivation and
psychosocial stress set the scene
for increased risk. For those at
moderate risk, other factors—
including metabolic factors such
as increased ApoB, Lp(a), TGs, or
C-reactive protein; the presence
of albuminuria; the presence of
atherosclerotic plaque in the
carotid or femoral arteries; or the
coronary artery calcium (CAC)
score—may improve risk
classification

European Heart Journal (2019) 00, 178 16

 Risk categories

aTarget organ damage is defined as microalbuminuria, retinopathy, or neuropathy

European Heart Journal (2019) 00, 178 17
Intervention strategies as a function of total
cardiovascular risk & untreated LDL-C levels

European
18 Heart Journal (2019) 00, 178
Recommendations for treatment goals for LDL-C

d Theterm ‘baseline’ refers to the LDL-C level in a person not taking any LDL-C-lowering medication.
In people who are taking LDL-C-lowering medication(s), the projected baseline (untreated) LDL-C levels should be estimated, based on the average LDL-C-lowering efficacy of the given medication or combination of medications.

European Heart Journal (2019) 00, 178 19

Treatment goal for LDL-C

European Heart Journal (2019) 00, 178 20

Treatment algorithm for pharmacological LDL-C lowering

European Heart Journal (2019) 00, 178 21

Recommendations for the treatment of dyslipidaemias
in metabolic syndrome & DM

European Heart Journal (2019) 00, 178 22

Challenges in dyslipidemia management

American Heart Association. 2015. Cardiovascular Disease and Diabetes. International Diabetes Federation IDF Diabetes Atlas. 8th Edition, 2017
 Patients(%) reporting statin non-adherence behaviors
in the last 12 months by statin PDC (proportion of days covered) level

Note: Weighted for sampling proportions; p<0.05

Fung V, GraetzI, Reed M, Jaffe MG (2018) Patient-reported adherence to statin therapy, barriers to adherence, and perceptions of cardiovascular risk. PLoS ONE 13(2): 24
e0191817.
Doubling statin dose

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 Statin intolerance
• 20% of individuals with a clinical indication for statin therapy are unable to take a daily statin because of some
degree of intolerance, and 40–75% of patients discontinue their statin therapy within 1–2 years after
initiation

Toth PP, et al. Management of Statin Intolerance in 2018: Still More Questions than Answers. Am J Cardiovasc Drugs (2018) 18:157–
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Further improvement from what NLA
proposed

Rosenson RS, et al. Cardiovasc Drugs Ther (2017) 31:179–186

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How to apply in clinical practice
CASE
Medical History:
Patient : M.K. Type 2 Diabetes Mellitus with
microalbuminuria
Profile : 43 years old male
BMI : 29.7 kg/m2 Previous MI last month
BP : 140/75 mm Hg Heavy smoker • During anamnesis, what other questions would you
HR : 65 bpm like to ask? Why?
• Is there any other lab tests would you order? Why?
Current medication: Lab results: • Would you change his current medication? Why?
Chinese herbal medicine
TC : 210 mg/dl
LDL :135 mg/dl
He comes to your clinic for follow up HDL : 38 mg/dl
TG : 500 mg/dl

How would you manage this patient?

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