2016 Consensus statement on prevention of atherosclerotic cardiovascular disease in the Hong Kong population

Worldwide Increasing Use of Nonfasting Rather Than Fasting Lipid Profiles

BACKGROUND

Historically, lipids and lipoproteins were measured in the fasting state for cardiovascular risk prediction; however, since 2009 use of nonfasting lipid profiles has increased substantially worldwide. For patients, nonfasting lipid profiles are convenient and avoid any risk of hypoglycemia. For laboratories, blood sampling in the morning and extra visits for patients who have not fasted are avoided. For patients, clinicians, hospitals, and society, nonfasting sampling allows same-day visits with first blood sampling followed by a short wait for test results before clinical consultation. Therefore, nonfasting compared to fasting lipid profiles will save money and time and may improve patient compliance with cardiovascular prevention programs.

CONTENT

We report on the progression of endorsement and implementation of nonfasting lipid profiles for cardiovascular risk prediction worldwide and summarize the recommendations from major medical societies and health authorities in different countries. We also describe practical advantages and disadvantages for using nonfasting lipid profiles. Further, we include a description of why fasting has been the standard historically, the barriers against implementation of nonfasting lipid profiles, and finally we suggest the optimal content of a nonfasting lipid profile.

SUMMARY

Lipid, lipoprotein, and apolipoprotein concentrations vary minimally in response to normal food intake and nonfasting lipid profiles are equal or superior to fasting profiles for cardiovascular risk prediction. Major guidelines and consensus statements in Europe, the United States, Canada, Brazil, Japan, India, and Australia now endorse use of nonfasting lipid profiles in some or all patients; however, there are still gaps in endorsement and implementation of nonfasting lipid profiles worldwide.

Asian Pacific Society of Cardiology Consensus Recommendations on Dyslipidaemia

The prevalence of dyslipidaemia has been increasing in the Asia-Pacific region and this is attributed to dietary changes and decreasing physical activity. While there has been substantial progress in dyslipidaemia therapy, its management in the region is hindered by limitations in awareness, adherence and healthcare costs. The Asian Pacific Society of Cardiology (APSC) developed these consensus recommendations to address the need for a unified approach to managing dyslipidaemia. These recommendations are intended to guide general cardiologists and internists in the assessment and treatment of dyslipidaemia and are hoped to pave the way for improving screening, early diagnosis and treatment. The APSC expert panel reviewed and appraised the evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed, which were then put to an online vote. The resulting consensus recommendations tackle contemporary issues in the management of dyslipidaemia, familial hypercholesterolaemia and lipoprotein(a) in the Asia-Pacific region.

Determining propensity for sub-optimal low-density lipoprotein cholesterol response to statins and future risk of cardiovascular disease

BACKGROUND

Variability in low-density lipoprotein cholesterol (LDL-C) response to statins is underappreciated. We characterised patients by their statin response (SR), baseline risk of cardiovascular disease (CVD) and 10-year CVD outcomes.

METHODS AND RESULTS

A multivariable model was developed using 183,213 United Kingdom (UK) patients without CVD to predict probability of sub-optimal SR, defined by guidelines as <40% reduction in LDL-C. We externally validated the model in a Hong Kong (HK) cohort (n = 170,904). Patients were stratified into four groups by predicted SR and 10-year CVD risk score: [SR1] optimal SR & low risk; [SR2] sub-optimal SR & low risk; [SR3] optimal SR & high risk; [SR4] sub-optimal SR & high risk; and 10-year hazard ratios (HR) determined for first major adverse cardiovascular event (MACE). Our SR model included 12 characteristics, with an area under the curve of 0.70 (95% confidence interval [CI] 0.70-0.71; UK) and 0.68 (95% CI 0.67-0.68; HK). HRs for MACE in predicted sub-optimal SR with low CVD risk groups (SR2 to SR1) were 1.39 (95% CI 1.35-1.43, p<0.001; UK) and 1.14 (95% CI 1.11-1.17, p<0.001; HK). In both cohorts, patients with predicted sub-optimal SR with high CVD risk (SR4 to SR3) had elevated risk of MACE (UK HR 1.36, 95% CI 1.32-1.40, p<0.001: HK HR 1.25, 95% CI 1.21-1.28, p<0.001).

CONCLUSIONS

Patients with sub-optimal response to statins experienced significantly more MACE, regardless of baseline CVD risk. To enhance cholesterol management for primary prevention, statin response should be considered alongside risk assessment.

Current Knowledge and Behavior towards Salt Reduction among Hong Kong Citizens: A Cross-Sectional Survey

Excessive dietary salt intake is prevalent in the Hong Kong community. Over the last decade, the Hong Kong Special Administrative Region Government has been actively promoting community participation to reduce salt intake. The aim of this study was to investigate the current knowledge levels and behaviors relating to dietary salt intake among Hong Kong adults. This cross-sectional survey involved 426 adults in Hong Kong. The findings of this study identified areas of knowledge deficit in the recommended upper limit of daily salt intake for an adult set by World Health Organization (n = 295, 69.2%) indicated a lack of awareness that the overconsumption of salt could cause coronary heart disease (n = 233, 54.7%). Disengagement with salt reduction behavior, such as rarely/never checking the sodium or salt content listed on the food label (n = 252, 59.2%) and rarely/never purchasing food labelled with low salt or no salt content (n = 292, 68.9%), was reported. Excessive salt intake in dietary habits remains an under-recognized non-communicable disease threat by Hong Kong citizens, indicating ineffective responsive risk communication. There is a need to refine existing salt reduction initiatives to aid in making appropriate decisions regarding dietary salt intake among Hong Kong citizens.

Systematic review of clinical guidelines for lipid lowering in the secondary prevention of cardiovascular disease events

BACKGROUND

The WHO recommends that those with established cardiovascular disease should be treated with lipid-lowering therapy, but there is no specific guidance regarding lipid monitoring. Unnecessary general practitioner visits may be a burden for patients and increase healthcare costs. A systematic review of the current guidelines was performed to reveal gaps in the evidence base for optimal lipid monitoring approaches.

METHODS

For this systematic review, a search of Medline, Cumulative Index to Nursing and Allied Health Literature and Turning Research Into Practice databases was conducted for relevant guidelines published in the 10 years prior to 31 December 2019. Recommendations surrounding the frequency of testing, lipid-lowering therapies and target cholesterol values were compared qualitatively. Each guideline was assessed using the 2009 Appraisal of Guidelines for Research and Evaluation II tool.

RESULTS

Twenty-two guidelines were included. All recommended statins as the primary lipid-lowering therapy, with a high level of supporting evidence. Considerable variation was found in the recommendations for cholesterol targets. Seventeen guidelines provided at least one cholesterol target, which for low-density lipoprotein (LDL) cholesterol ranged between 1.0 and 2.6 mmol/L, although the most frequently recommended was <1.8 mmol/L (n=12). For long-term follow-up, many recommended reviewing patients annually (n=9), although there was some variation in recommendations for the interval of between 3 and 12 months. Supporting evidence for any approach was limited, often being derived from clinical opinion.

CONCLUSIONS

Further research is required to provide an evidence base for optimal lipid monitoring of the on-statin secondary prevention population.