Lipid,

Atherosclerosis and
Primary Cardiovascular Disease Prevention

Anggoro Budi Hartopo

Department of Cardiology and Vascular Medicine
Faculty of Medicine Universitas Gadjah Mada-Yogyakarta
Cardiovascular disease (CVD) prevention :
q a coordinated set of actions,
q at the population level or targeted at an
individual,
q aim to eliminate or minimize the impact of CVDs
and their related disabilities.
Prevention should be delivered:
q at the general population: healthy lifestyle behaviour

q at the individual level (moderate to high risk of CVD or

established CVD) : tackling unhealthy lifestyles (e.g. poor-quality
diet, physical inactivity, smoking)
 Primordial prevention healthy
Primary prevention risk factor
Secondary prevention post CVD
event
Primordial prevention
Prevention of having risk factors :
Governments law
Social rules
School curricullum, etc.
Primary prevention
Control the risk factors
Secondary prevention
Prevent/retard to suffer a relapse & reduce
CVD mortality
 What are CVDs ???
Atherosclerotic cardiovascular disease (ASCVD)
v coronary heart disease (CHD),
v cerebrovascular disease / stroke,
v peripheral arterial disease,
v aneurysms abdominal aorta
all of presumed atherosclerotic origin
 What are CVDs ???
SURROGATE MEASURES include: carotid intimal
medial thickness (IMT), coronary calcium,
angiographic stenosis, brachial ultrasound flow
mediated dilatation (FMD)

Hard endpoints: clinical event of myocardial

infarction, ACS, CHD death, and stroke
Atherosclerosis
specific form of arteriosclerosis (thickening &
hardening of arterial walls) affecting primarily the
intima of large and medium-sized muscular arteries
and is characterized by the presence of fibrofatty
plaques or atheromas.

Fatty streak Complicated

Simple Plaque
Plaque
LUMEN

INTIMA
Development of Atherosclerotic
Plaques
Fatty streak
Normal

Lipid-rich plaque

Foam cells

Fibrous cap

Lipid core
Thrombus

Ross R. Nature. 1993;362:801-809.

Concept of cardiovascular risk
factors

Age, sex, hypertension, hyperlipidemia, smoking, diabetes,

(family history), (obesity)

Kannel et al, Ann Intern Med 1961

Developing estimated risk score
Tsunami of Cardiovascular Disease Targets Indonesia
 Serangan Jantung & Stroke merupakan penyebab
kematian utama di Indonesia 1,2

Tingginya angka
kematian di
Indonesia akibat
Penyakit
Jantung
Stroke Koroner Tingginya kadar
merupakan mencapai 26%.1 kolesterol LDL
penyebab dan tekanan darah
kematian merupakan 2
faktor risiko utama
utama di
serangan Jantung &
Indonesia. 2 Stroke.3

1. Hasil Survei Kesehatan Rumah Tangga Nasional (SKRTN) DEPKES tahun 2001
2. Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan RI. Riset Kesehatan Dasar. 2013.
http://www.depkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf
3. The atlas of heart disease and stroke. World Health Organization website. http://www.who.int/cardiovascular_diseases/resources/atlas/en/.
Need for optimization of treatment dyslipidemia
to maximize benefit and improve outcome
 Kelas Rekomendasi
(Class of recommendations)
KELAS SARAN
DEFINISI
REKOMENDASI PENGGUNAAN KATA
Kelas I Terbukti dan/atau persetujuan umum bahwa Direkomendasikan /
pemberian terapi atau prosedur bermanfaat, Diindikasikan
berguna, efektif
Kelas II Ada pertentangan bukti dan/atau perbedaan
opini mengenai kegunaan/efikasi terapi atau
prosedur
Kelas IIa Tingkat bukti/opini lebih besar ke Harus
kegunaan/efikasi dipertimbangkan
Kelas IIb Kegunaan/efikasi kurang didukung bukti/opini Dapat
dipertimbangkan
Kelas III Terbukti/persetujuan umum bahwa pemberian Tidak
terapi atau prosedur tidak memiliki direkomendasikan
kegunaan/manfaat; dan pada beberapa kasus
mungin berbahaya
Tingkat Bukti
(Level of Evidence)
Data didapat dari banyak penelitian klinis acak (RCT
Level of Evidence A
Randomized Clinical Trials) atau meta-analisis

Data didapat dari satu penelitian klinis acak (RCT

Level of Evidence B Randomized Clinical Trials) atau penelitian klinis tanpa
acak (non-randomized studies) yang besar

Konsensus atau opini ahli dan/atau studi kecil, studi

Level of Evidence C
retrospektif, dan studi registri
When to start risk calculation ?
When and how to start intervention
Statin profile
Triglycerides and CVD risk
The role of TGs as a risk factor for CVD has been strongly
debated.

Recent data favour the role of TG-rich lipoproteins as a

risk factor for CVD.

EAS consensus :
q mild to moderate hyperTG: TGs 1.7 mmol/L
(150 mg/dL) - 10 mmol/L (880 mg/dL)
q severe hyperTG : TGs .10 mmol/L (880 mg/dL)
 New 2013 ACC/AHA Guidelines identify 4 Statin benefit groups: Shift
from a target-based approach to a drug and dose-based approach

Group 1 Group 2

Clinical ASCVD LDL-C 190 mg/dL

CHD, stroke, and
peripheral arterial disease,
all of presumed
atherosclerotic origin

Group 3 Group 4

Diabetes mellitus ASCVD risk 7.5%

+ age of 4075 years No diabetes

+ LDL-C 70189 mg/dL + age of 4075 years
ASCVD, atherosclerotic cardiovascular disease (1.84.9 mmol/L) + LDL-C 70189 mg/dL
CHD, coronary heart disease (1.84.9 mmol/L)
LDL-C, low-density lipoprotein-cholesterol

Stone NJ, et al. J Am Coll Cardiol 2013 Nov 7. Epub ahead of print
Thank you