Accepted Manuscript
2016 Canadian Cardiovascular Society Guidelines for the management ofDyslipidemia for the Prevention of Cardiovascular Disease in the Adult
Todd J. Anderson, MD, Jean Grgoire, MD, Glen J. Pearson, PharmD, Arden R.Barry, PharmD, Patrick Couture, MD, Martin Dawes, MD, Gordon A. Francis, MD,Jacques Genest, Jr., MD, Steven Grover, MD, Milan Gupta, MD, Robert A. Hegele,MD, David C. Lau, MD, PhD, Lawrence A. Leiter, MD, Eva Lonn, MD, G.B JohnMancini, MD, Ruth McPherson, MD, PhD, Daniel Ngui, MD, Paul Poirier, MD, PhD,John L. Sievenpiper, MD, PhD, James A. Stone, MD, PhD, George Thanassoulis,MD, Richard Ward, MD
PII: S0828-282X(16)30732-2
DOI: 10.1016/j.cjca.2016.07.510
Reference: CJCA 2223
To appear in: Canadian Journal of Cardiology
Received Date: 28 June 2016
Revised Date: 13 July 2016
Accepted Date: 13 July 2016
Please cite this article as: Anderson TJ, Grgoire J, Pearson GJ, Barry AR, Couture P, DawesM, Francis GA, Genest Jr J, Grover S, Gupta M, Hegele RA, Lau DC, Leiter LA, Lonn E, ManciniGBJ, McPherson R, Ngui D, Poirier P, Sievenpiper JL, Stone JA, Thanassoulis G, Ward R, 2016Canadian Cardiovascular Society Guidelines for the management of Dyslipidemia for the Preventionof Cardiovascular Disease in the Adult, Canadian Journal of Cardiology (2016), doi: 10.1016/j.cjca.2016.07.510.
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http://dx.doi.org/10.1016/j.cjca.2016.07.510
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2016 Canadian Cardiovascular Society GUIDELINES FOR THE MANAGEMENT OF DYSLIPIDEMIA FOR THE PREVENTION OF CARDIOVASCULAR
DISEASE IN THE ADULT
Todd J. Anderson MD*, Jean Grgoire MD*, Glen J. Pearson PharmD*, Arden R. Barry
PharmD, Patrick Couture MD, Martin Dawes MD, Gordon A. Francis MD, Jacques Genest Jr
MD, Steven Grover MD, Milan Gupta MD, Robert A. Hegele MD, David C. Lau MD, PhD,
Lawrence A. Leiter MD, Eva Lonn MD, G.B John Mancini MD, Ruth McPherson MD, PhD,
Daniel Ngui MD, Paul Poirier MD, PhD, John L. Sievenpiper MD, PhD, James A. Stone MD,
PhD, George Thanassoulis MD, Richard Ward MD.
*equal contribution
Short title: 2016 CCS Dyslipidemia Guidelines
Address for correspondence: Todd J. Anderson, Libin Cardiovascular Institute, Cumming
School of Medicine, University of Calgary
1403-29th St NW Calgary, Alberta, T2N 2T9
Email: [email protected]
Telephone: 403 944-1033
Fascimile: 403 944-1592
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BRIEF SUMMARY
The 2016 Canadian Cardiovascular Society Dyslipidemia guidelines provide guidance to
clinicians for the assessment of risk and appropriate treatment of dyslipidemia for the prevention
of cardiovascular disease. The focus is on shared decision making between the clinician and
patient. We now recommend non-fasting determination of lipids and expanded definitions of
subjects who will benefit from statin therapy. There is also new information on the use of health
behavior modifications and non-statin medications.
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AFFILIATIONS
Todd J. Anderson MD, Libin Cardiovascular Institute, Cumming School of Medicine, University
of Calgary, Calgary, Alberta
Jean Grgoire MD, Institut de Cardiologie de Montral, Universit de Montral, Montral,
Qubec
Glen J. Pearson PharmD, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton,
Alberta
Arden Barry PharmD, Chilliwack General Hospital, Chilliwack, British Columbia
Patrick Couture MD, Centre Hospitalier de lUniversit Laval, Laval, Qubec
Martin Dawes MD, University of British Columbia, Vancouver, British Columbia
Gordon A. Francis MD, St. Pauls Hospital, University of British Columbia, Vancouver, British
Columbia
Jacques Genest Jr MD, McGill University Health Centre, Montral, Qubec
Steven Grover MD, Montral General Hospital and McGill University, Montral, Qubec
Milan Gupta MD, McMaster University, Hamilton, Ontario and St. Michaels Hospital, University
of Toronto, Toronto, Ontario
Robert A. Hegele MD, Robarts Research Institute, London, Ontario
David C. Lau MD, PhD, Julia MacFarlane Diabetes Research Centre, Libin Cardiovascular
Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta
Lawrence A. Leiter MD, St. Michaels Hospital, University of Toronto, Toronto, Ontario
Eva Lonn MD, Population Health Research Institute, McMaster University, Hamilton, Ontario
G.B John Mancini MD, University of British Columbia, Vancouver, British Columbia
Ruth McPherson MD, PhD, University of Ottawa Heart Institute, Ottawa, Ontario
Daniel Ngui MD, University of British Columbia, Vancouver, British Columbia
Paul Poirier MD, PhD, Institut Universitaire de cardiologie et de Pneumologie de Qubec,
Qubec City, Qubec
John Sievenpiper MD, PhD, St. Michaels Hospital, University of Toronto, Toronto, Ontario
James A. Stone MD, PhD, Libin Cardiovascular Institute, Cumming School of Medicine,
University of Calgary, Calgary, Alberta
George Thanassoulis MD, McGill University Health Centre, Montral, Qubec
Richard Ward MD, Cumming School of Medicine, University of Calgary and Alberta Health
Services, Calgary, Alberta
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ABSTRACT
Since the publication of the 2012 guidelines new literature has emerged to inform decision
making. The 2016 guidelines primary panel selected a number of clinically relevant questions
and has produced updated recommendations, based on important new findings. In subjects with
clinical atherosclerosis, abdominal aortic aneurysm, most subjects with diabetes or chronic
kidney disease and those with low-density lipoprotein (LDL) cholesterol 5 mmol/L, statin
therapy is recommended. For all others, there is an emphasis on risk assessment linked to lipid
determination to optimize decision making. We have recommended non-fasting lipid
determination as a suitable alternative to fasting levels. Risk assessment and lipid determination
should be considered in individuals over 40 years of age or in those at increased risk regardless
of age. Pharmacotherapy is generally not indicated for those at low Framingham Risk Score
(FRS) 20%). Despite the controversy, we continue
to advocate for LDL-C targets for subjects who are started on therapy. Detailed
recommendations are also presented for health behavior modification which is indicated in all
subjects. Finally, recommendation for the use of non-statin medications is provided. Shared
decision making is vital as there are many areas where clinical trials do not fully inform practice.
The guidelines are meant to be a platform for meaningful conversation between patient and
care provider so that individual decisions can be made for risk screening, assessment and
treatment.
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INTRODUCTION AND PROCESS:
The 2012 Canadian Cardiovascular Society (CCS) Dyslipidemia Guidelines have been updated
to reflect new clinical trial and epidemiologic evidence. The primary panel posed a number of
PICO (population, intervention, comparator, outcomes) questions to create recommendations
based on detailed literature review. The PICO format is a common standard used for guidelines
implementation, aiding clinicians in determining if the recommendations apply to their own
patients with outcomes relevant to their practice. Using the Grading of Recommendations,
Assessment, Development, and Evaluation (GRADE) standards, individual studies and
composite literature was reviewed for quality and bias. We have included both strong and
conditional recommendations within the main manuscript. The literature review and results of
voting on each PICO question are included in the Supplement. For recommendations to go
forward a 2/3 voting majority was required. Individuals with conflicts of interest were recused
from voting. We have introduced a recommendation for non-fasting lipid determination and
retained the concept of LDL-C targets of treatment. Global risk assessment is discussed
recognizing there are several approaches in a primary prevention setting. The overall goal of the
process was to produce a document based on the best available evidence that would allow
clinicians and patients to make collaborative treatment decisions (Table 1). These guidelines
are not absolute, but are meant to launch one on one discussion between practitioner and
patient. As dyslipidemia is an important risk factor for cardiovascular disease, these guidelines
will allow appropriate risk assessment, treatment and
