HOW LOW SHOULD YOU TARGET LDL-C? SCIENTIFIC PLANNING

HOW LOW SHOULD YOU TARGET LDL-C? SCIENTIFIC PLANNING

HOW LOW SHOULD YOU TARGET LDL-C? SCIENTIFIC PLANNING COMMITTEE (SPC) Anthony D. D'Urzo MD, MSc, BPHE, CCFP Daniel Ngui, BSc, PT, MD, FCFP Associate Professor, University of Toronto Department of Family and Community Medicine Department of Family and Community Medicine Toronto, Ontario Toronto, Ontario Marla Shapiro, C.M., MDCM, CCFP, MHSc, FRCPC, FCFP, NCMP Professor, University of Toronto Department of Family and Community Medicine University Health Network North York General, Mount Sinai Toronto, Ontario

Associate Professor, University of Toronto DISCLOSURE OF COMMERCIAL SUPPORT This program has received financial support from [organization name] in the form of an educational grant. This program has received in-kind support from [organization name] in the form of [describe support here e.g. logistical support]. Potential for conflict(s) of interest: [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [insert generic and brand name here] FACULTY/PRESENTER Robert P. Giugliano MD, SM, FACC, FAHA Senior Investigator, TIMI Study Group Physician, Cardiovascular Medicine Brigham and Women's Hospital Associate Professor Harvard Medical School FACULTY/PRESENTER DISCLOSURE

Faculty [SPEAKERS NAME] Relationships with commercial interests: Grants/Research Support: PharmaCorp ABC Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd. Consulting Fees: MedX Group Inc. Other: Employee of XXY Hospital Group MITIGATING POTENTIAL BIAS All content has been reviewed by a physician steering committee and the College of Family Physicians Canada All data has been sourced from evidence that is clinically accepted All support used in justification of patient care recommendations conform to generally accepted standards LEARNING OBJECTIVES By participating in this educational program, health care providers will be able to: 1. UNDERSTAND The burden of acute exacerbations in patients with COPD 2. OPTIMALLY

Manage acute exacerbations of COPD (AECOPD) 3. APPLY Mon-pharmacologic and pharmacologic approaches to prevent future AECOPD 4. INCORPORATE Guideline recommendations into clinical practice to manage comorbidities and assess inhaler techniques of COPD patients PATIENT PROFILE 65-year-old female, 1 ppd smoker x 45 yrs, quit 5 years ago Progressive SOBOE for several years COPD confirmed by spirometry FEV1 50% of predicted at last visit

PMHx: Hypertension Diabetes 2 or 3 episodes of severe bronchitis every year over past 5 years Treated with antibiotics CURRENT MEDICATIONS Perindopril erbumine 4 mg + indapamide 1.25 mg qd, metformin, daily ASA Ipratropium bromide MDI 2 puffs bid Salbutamol 2 puffs PRN GOALS OF COPD MANAGEMENT Goals of treatment of stable COPD Relieve symptoms

Improve exercise tolerance Improve Health Status Prevent disease progression Prevent and treat exacerbation Reduce mortality REDUCE SYMPTOMS REDUCE RISK Global Strategy for the Diagnosis MaPoC, Global Initiative for Chronic Obsctructive Lung Disease (GOLD) 2017. http://goldcopd.org. ASSOCIATION OF DISEASE SEVERITY WITH THE FREQUENCY AND SEVERITY OF EXACERBATIONS 50 47 40 33 33 30

22 20 10 0 18 7 GOLD 2 GOLD 3 Hospitalized for exacerbation in yr 1 Hurst JR et al. N Engl J Med 2010; 363:11281138 GOLD 4 Frequent exacerbations MORTALITY INCREASES WITH THE FREQUENCY AND SEVERITY OF AECOPD Severity of Exacerbations 1.0 1.0

0.8 0.8 p<0.0002 0.6 p<0.0001 0.4 p=0.069 0.2 0.0 0 10 20 30 40 50

60 Time (months) Probability of surviving Probability of surviving Frequency of Exacerbations NS 0.6 p=0.005 p<0.000 1 p<0.000 1 0.4 NS 0.2 0.0 0 10

20 30 40 Time (months) 50 60 Patients with no acute exacerbations of COPD No acute exacerbations of COPD Patients with readmissions Patients with 1-2 acute exacerbations of COPD requiring hospital management Patients with 3 acute exacerbations of COPD Patients with acute exacerbations of COPD requiring emergency service visits without admission Patients with acute exacerbations of COPD requiring hospital admission

Soler-Cataluna JJ,et al. Thorax 2005;60:925 931 PREVALENCE OF CO-MORBIDITIES IN CANADIAN COPD PATIENTS 82% of patients had co-morbidities Depression Diabetes Osteoporosis Ischemic Heart Disease Hypertension 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Hernandez et al. Can Respir J 2013; 20:97-105. Number of Comorbidities % of Patients No co-morbidities 18% One co-morbidity

22% Two co-morbidities 24% Three co-morbidities 16% Four or more 20% Mean Number of Co-morbidities: 2.7

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