The first Lipid Master Class 'A case-based approach to advanced lipid management'
The PACE Lipid Master Class was held in Amsterdam, The Netherlands on May 22 and 23 2015, in collaboration with Medpace ‘FH Clinician’, an initiative bringing HoFH investigators together from around the world. This Lipid Master Class was a unique opportunity to be updated on current options for optimal management of high cardiovascular risk patients and the status of development of novel lipid-modifying agents. Leaders in the field of clinical management of dyslipidaemia summarised the state-of-the-art as well as upcoming therapeutic strategies. There was ample opportunity to exchange and discuss clinical experiences.
We here give a brief impression of what was discussed during the Lipid Master Class. Follow the links to watch brief videos in which the speakers summarise their messages.
After a brief introduction by prof John Kastelein (AMC Amsterdam, The Netherlands), prof. Erik Stroes (AMC Amsterdam, The Netherlands) set out to discuss challenges in lipid management. He considered the need for new approaches and outlined which novel agents targeting lipid moieties appear most promising based on current data.
Prof. Kausik Ray (Imperial College, London, United Kingdom) considered how to identify patients at high CV risk. While trials give insight into relative risk reduction, he stressed that we need to learn to look at the absolute risk of a specific patient visiting clinical practice. This includes modifiable and non-modifiable risk factors. He discussed the value of various risk markers beyond LDL-c and how these may help to identify patients at high CV risk who may benefit from additional treatment.
After these new insights were discussed over dinner, the Lipid Master Class continued the next morning, with an interactive session in which dr. Kees Hovingh (AMC Amsterdam, The Netherlands) discussed the epidemiology of familial hypercholesterolaemia, pointing out that it is more common than previously thought. Using some illustrative clinical cases, he outlined how patients can be screened for FH, and how they should be managed and why.
Prof. Frederick Raal (University of Witwatersrand, Johannesburg, South Africa) continued with an overview of treatment challenges in homozygous familial hypercholesterolaemia (HoFH); a condition in which patients have extremely high CV risk. The currently available treatment options are often inadequate to protect HoFH patients, but fortunately there are drugs under development that shed a brighter light on the future of this patient group.
Dr. Kees Hovingh then outlined the recent advances that have been made in the molecular screening of homozygous and heterozygous FH (HeFH). Even Next Generation Sequencing is already being used as a diagnostic tool in the first laboratory. Screening efforts may yield new mutations underlying severe FH phenotypes in patients who currently do not have a molecular diagnosis. This will impact the quality of future screening further. Combining molecular with lipid data was found to be the most cost-effective screening approach.
In a case-oriented talk, prof. Erik Stroes considered how to manage patients who may be statin-intolerant; and how to distinguish true from perceived side-effects of statins. There are other targets of statins aside from LDL that may induce muscle problems, so various factors that may induce statin-attributed muscle symptoms (SAMS, a common reason for non-adherence) were discussed. Since statin discontinuation increases CV morbidity and mortality, it is important to keep patients on the maximally tolerated dose, and to stress the importance of adherence.
Dr. Rob Hegele (University of Western Ontario, London, ONT, Canada) elaborated on a clinical case of combined hyperlipidaemia (CHL). He emphasised that, although CHL may often be familial, in that it clusters in families, this does not imply that it is monogenic. In fact, CHL commonly has a polygenic origin; where a combination of SNPs that unfavourably alter lipid levels add up to cause the clinical picture of combined hyperlipidaemia. The specific array of lipid-modifying SNPs in an individual determines the clinical picture, which explains the phenotypic variation of CHL. Clinical management in CHL should be focussed on global CVD risk.
Dr. Kausik Ray summarised what different guidelines say about lipid management. First he considered which are the best lipid measurements that should guide treatment. He continued with when to initiate therapy, based on these lipid parameters, with a preference for non-HDL as a marker for atherogenic risk. Based on an overview of which guidelines appropriately implemented the available evidence, he discouraged people to use the ACC/AHA 2013 guidelines.
Dr. Evan Stein (University of Cincinnati, OH, USA) concluded the master class with an invitation for investigators to become involved in FH research. With assistance of Medpace, those interested can become established investigators, which will benefit their own experiences and careers, but most importantly, the patients.