Effect of advanced access scheduling on chronic health care in a Canadian practice

OBJECTIVE

To determine the effect of advanced access scheduling (AAS) on the care of patients with chronic disease within a Canadian family practice.

DESIGN

Chart abstraction.

SETTING

A single family physician's practice in Brantford, Ont.

PARTICIPANTS

Patient charts were reviewed for all patients with a history of hypertension, type 2 diabetes mellitus, or coronary artery disease during the years before and after implementation of AAS.

MAIN OUTCOME MEASURES

The following information was extracted for each study patient: total number of appointments, number of appointments specific to chronic disease management, number of appointments for non-chronic disease, blood pressure (BP), and laboratory markers, including hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein levels.

RESULTS

For the year before and the year after implementation of AAS, the mean number of visits per patient was 4.3. The mean number of appointments for chronic disease management decreased significantly from 2.6 to 2.2 (P = .024), and the mean number of visits for non-chronic disease increased significantly from 1.7 to 2.1 (P = .001). The number of times clinical parameters of BP, HbA(1c), and low-density lipoprotein were measured decreased; however, there were no significant changes in actual BP or HbA(1c) levels.

CONCLUSION

Following a 1-year period using AAS, use of the family health practice by patients with chronic disease was unchanged overall; however, AAS allowed for an increase in visits for non-chronic health conditions without significantly affecting the clinical parameters of BP or HbA(1c).

HDL subfractions analysis: a new laboratory diagnostic assay for patients with cardiovascular diseases and dyslipoproteinemia

OBJECTIVE

The HDL family forms a protective part of plasma lipoproteins. It consists of large HDL, intermediate HDL, and small HDL subclasses. The large HDL and intermediate HDL subclasses are considered anti-atherogenic parts of the HDL family. The atherogenicity of the small HDL subclass is currently the subject of much discussion. In the patient group with the diagnosis of cardiovascular disease (arterial hypertension, coronary heart disease) and in individuals with a non-atherogenic hypercholesterolemia, a type of lipoprotein profile (either a non-atherogenic phenotype A, or an atherogenic phenotype B) was identified, and a concentration of small dense LDL (sdLDL) was analyzed. The aim of this study was to identify the major representative of the HDL subclasses in the individuals with cardiovascular diseases, who had an atherogenic lipoprotein phenotype B, and in the individuals with the diagnosis of non-atherogenic hyper-betalipoproteinemia LDL1,2, who had a non-atherogenic lipoprotein phenotype A.

METHODS

Identification of the specific lipoprotein phenotype and a quantitative analysis of small dense LDL was performed by an electrophoresis method on polyacrylamide gel (PAG), using the Lipoprint LDL system. For a quantitative analysis of HDL subclasses, i.e., large HDL, intermediatete HDL, and small HDL, in subjects with newly diagnosed cardiovascular diseases (arterial hypertension and coronary heart disease), and in subjects with a non-atherogenic hypercholesterolemia (hyper-betalipoproteinemia LDL1,2), we used an innovative electrophoresis method on polyacrylamide gel (PAG), the Lipoprint HDL system. With regard to lipids, total cholesterol and triglycerides in plasma were analyzed by an enzymatic CHOD PAP method. A control group consisted of a group of healthy normolipidemic volunteers without signs of clinically manifested impairment of the cardiovascular system.

RESULTS

In the patient group with the diagnosis of arterial hypertension (p<0.0002) and coronary heart disease (p<0.0001), (both are classified as cardiovascular diseases), the large HDL subclass was significantly decreased and the small HDL subclass was increased (p<0.0001). The concentration of the intermediate HDL subclass did not differ from that of the control group. These results were in accordance with an atherogenic lipoprotein phenotype B in individuals with the diagnosis of cardiovascular diseases, where, using a Lipoprint LDL analysis, a high concentration of atherogenic small dense LDL (p<0.0001) was found. Thus, it seems that the small HDL subclass represents an atherogenic part of the HDL family. Conversely, an increased concentration of total HDL (p<0.0001), large HDL (p<0.005), and intermediate HDL subclasses (p<0.0001) was found in a group of subjects with a non-atherogenic hyper-betalipoproteinemia LDL1,2.The concentration of the small HDL subclass did not differ from that of the control group. In this non-atherogenic lipoprotein profile, only traces of atherogenic small dense LDL were identified.

CONCLUSIONS

The advantages of this new method includes: (i) Identification of ten HDL subfractions with Lipoprint HDL analysis (large HDL1-3, intermediate HDL 4-7, and small HDL 8-10) . (ii) Discovery of a high concentration of small HDL in plasma lipoproteins in patients with cardovascular diseases with an atherogenic lipoprotein phenotype B, confirms that the atherogenic subclass of HDL family is attributable to small HDL. (iii) Presence of a low concentration of small HDL in non-atherogenic hypercholesterolemia also confirms the atherogenic characteristics of the small HDL subclass per se. (iv) Presence of small dense LDL is definitive to diagnose an atherogenic lipoprotein profile. It is valid for hyperlipidemia and for normolipidemia as well.

Atherogenic dyslipidemia as evidenced by the lipid triad: prevalence and associated risk in statin-treated patients in ambulatory care

OBJECTIVE

The prevalence of atherogenic dyslipidaemia (AD) can be assessed using the lipid triad (low high-density lipoprotein cholesterol [HDL-C] < 35 mg/dl, high triglyceride (TG) levels (≥ 200 mg/dl) and a high total cholesterol HDL-C ratio (TC/HDL-C>5). The aim of the present analysis was (1) to describe the prevalence of the lipid triad, (2) to quantify the associated cardiovascular risk on the basis of the PROCAM score, and (3) to calculate the additional risk reduction that can be obtained by adding nicotinic acid (NA) to a pre-existing statin therapy (model based on the outcomes of a previous randomized controlled study).

METHODS

Descriptive post-hoc analysis of the German 4E registry in 24,500 patients receiving statins for primary cardiovascular prevention in ambulatory care.

RESULTS

The sample comprised 24,500 patients in primary prevention, who had an overall 10-year risk of 16.2%. The prevalence of patients with lipid triad was 24.0%. The mean estimated risk reduction in the total sample (calculated on the basis of a mean LDL-C decrease by 24.3% and other lipid parameter changes) achieved after 6-week statin treatment was 46.6%, the estimated additional relative risk reduction by NA 45.1% (total effect compared to baseline about 70%). In the lipid triad group, the additional relative risk reduction by NA treatment was 42.9%. Relative treatment effects were consistent, irrespective of age and gender. Limitations of this analysis include the use of the TC/HDL-C ratio instead of the direct small dense LDL-C measurements, and the unknown variations of effect size of NA induced lipid reduction when used in combination with statins.

CONCLUSIONS

Our model calculations indicate that the residual risk which persists after statin treatment could be substantially lowered if besides LDL-C also HDL-C and TG would be addressed, e.g. by adding NA to statin therapy. Definitive prospective studies are needed to confirm this hypothesis.

The 2009 2nd Italian Consensus Conference on LDL-apheresis

The '2009 2nd Italian Consensus Conference on LDL-apheresis' was held in Rome, Italy, 15 May 2009. The latest scientific evidence and the information processed in more than two decades of LDL-apheresis application require new guidelines. Experts were invited by the Consensus Panel to give a scientific specific contribution in their clinical area of specialty. The experts of interdisciplinary affiliation participated in the extension of 'The new guidelines and recommendations for the indications and the appropriate use of LDL-apheresis'. The summary statement describing the frame and the lines of action of the scientific event and a supplementary document inherent to the Consensus available online at http://ees.elsevier.com/nmcd/ are reported.

[Metabolic syndrome may be better at predicting the prognosis of coronary artery disease than other traditional cardiovascular risk factors]

OBJECTIVE

The prevalence of cardiovascular risk factors is growing. People with metabolic syndrome (MS) plus five cardiovascular risk factors are at a higher risk of developing coronary artery disease (CAD). The effect of metabolic syndrome on outcomes in patients with preexisting CAD has not been well studied. The present study was conducted to assess the prevalence, characteristics and long-term prognosis of CAD with metabolic syndrome and to determine which factor is the most influential prognostic factor of CAD.

METHODS

The DESIRE (drug-eluting stent impact on revascularization) registry represented a database of 2368 CAD patients between July 2003 and September 2004. The median long-term follow-up was 3.5 years (293 -1855 days). Metabolic syndrome was based on the modified version of Adult Treatment Panel (ATP) III Definition of Metabolic Syndrome in 2005 using body mass index (BMI) instead of waist circumference. We tested the utility of MS and its components to predict the incidence of major adverse cardiac and cerebral events (MACCE) in a large cohort of patients undergoing revascularization.

RESULTS

The presence of MACCE was predicted only by MS (OR = 1.319, 95% CI 1.020 - 1.706, P = 0.035) but not other cardiovascular risk factors, such as advance age, male, smoking, high LDL cholesterol and CAD family history. MS was present in 45.6% (high fasting glucose 44.5%; high triglyceride 45.0%; low HDL 50.8%; high blood pressure 61.4%; high BMI 60.7%).

CONCLUSION

Among the traditional cardiovascular risk factors, only metabolic syndrome has a primary predictive ability for MACCE in CAD patients.

Paraoxonase gene polymorphism in south-western Korean population

Paraoxonase (PON) has anti-atherogenic activity. Considering the important role of polymorphism in the genetic susceptibility to cardiovascular disease and the variability of its allele frequencies in different ethnic groups, the distribution of genotypes and allele frequencies of PON1M55L, PON1Q192R, PON2A148G, and PON2S311C polymorphisms was analyzed in a total 988 South-western Koreans and determined their effects on lipid parameters. The genotype distribution of PON1 at position 55 was LL=0.886, LM=0.114; and at position 192 was QQ=0.406, QR=0.594. The frequencies of the PON1 55L allele and the PON1 192R allele were similar to those seen in Chinese populations and Western populations, respectively. The genetic distribution of PON2 at position 148 was AA=0.619, AG=0.345, GG=0.035; and at position 311 was CC=0.035, SC=0.345, SS=0.619. The frequencies of the PON2 148G and 311S alleles were similar to those seen in Chinese populations. The concentrations of LDL and ApoB were significantly different between the PON2A148G (P<0.05) and PON2 S311C polymorphisms (P<0.01). PON polymorphisms and allele frequencies were described in Koreans living south-western part of Korea. These ethnic variations are considered important in the interpretation of diseases associated with PON polymorphisms.

Impact of adding a single allele in the 9p21 locus to traditional risk factors on reclassification of coronary heart disease risk and implications for lipid-modifying therapy in the Atherosclerosis Risk in Communities study

BACKGROUND

A single-nucleotide polymorphism on chromosome 9p21, rs10757274 (9p21 allele), has been shown to predict coronary heart disease (CHD) in whites. We evaluated whether adding the 9p21 allele to traditional risk factors (RFs) improved CHD risk prediction in whites from the Atherosclerosis Risk in Communities study and whether changes in risk prediction would modify lipid therapy recommendations.

METHODS AND RESULTS

Whites (n=9998) in the Atherosclerosis Risk in Communities study for whom the 9p21 genotype and traditional RF information was available were included. Using Cox proportional hazards models, the Atherosclerosis Risk in Communities Cardiovascular Risk Score, which is based on traditional RFs, was determined. A total of 1349 individuals (13.5%) developed incident CHD events during a period of 14.6 years. Adding the 9p21 allele to traditional RFs was associated with a hazard ratio of incident CHD of 1.2 per allele (P<0.000003) and a significant increase in the area under the curve of the receiver operating characteristic from 0.782 to 0.786 (95% CI, 0.001, 0.007). The 9p21 allele's greatest influence to the Atherosclerosis Risk in Communities Cardiovascular Risk Score was observed in the intermediate-low (>5% to 10% to 100 mg/dL.

CONCLUSIONS

Adding the 9p21 allele to traditional RFs in whites in the Atherosclerosis Risk in Communities study modestly improved CHD risk prediction in the intermediate categories.

Abnormalities in metabolism of low density lipoproteins associated with coronary heart disease

Low density lipoprotein (LDL) is probably the most atherogenic of all the lipoproteins. Several abnormalities in LDL metabolism seem to be associated with coronary heart disease (CHD) one of them being an elevation of plasma LDL concentration. Recent findings suggest that disorders in the metabolism of LDL could be associated with accelerated atherosclerosis even without elevated LDL levels such as increased flux of LDL and changes in the LDL composition. Elevation of plasma LDL levels can be caused by two factors, first, a decrease in the clearance of LDL and second, an overproduction of this lipoprotein. Catabolism of LDL is largely determined by the LDL receptors as clearly shown in patients with familial hypercholesterolemia (FH). In this inherited disease the patients do not have normal LDL receptors and their LDL levels are remarkably elevated. LDL production is also increased in these subjects. In the rest of the population LDL levels are regulated by both the LDL clearance and production rate. The latter also seems to be related to the LDL receptor activity. The conversion of the LDL precursor, very low density lipoprotein (VLDL) to LDL is the most important factor regulating LDL synthesis. When the LDL receptor activity is low a large fraction of VLDL apolipoprotein B (apoB), the major structural protein in VLDL, is converted to LDL, and LDL production is high. On the other hand, only a small part of VLDL apoB is converted to LDL resulting in low LDL synthesis rate in conditions with high LDL receptor activity. The relationships between production and clearance of LDL are, however, more complex. There are individuals who produce a large number of VLDL and LDL particles but maintain LDL concentrations at a normal level by clearing their LDL very effectively. These subjects obviously have another abnormality in lipoprotein metabolism namely an overproduction of apoB. This disorder has been observed in several conditions like obesity, adult-onset diabetes mellitus, several patients with familial combined hyperlipidemia and some normolipidemic subjects with premature coronary heart disease. In all these conditions increased transport of LDL can be associated with coronary artery disease even in the absence of hypercholesterolemia. This raises the possibility that increased flux of LDL could itself be atherogenic possibly by overloading reverse cholesterol transport. Finally, there is some evidence that LDL particle composition may be important in the process of atherogenesis. High LDL apoB but normal LDL cholesterol levels, hyperapobetalipoproteinemia, has been associated with premature coronary heart disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Cytokine profile of peripheral blood in type 2 diabetes mellitus patients with diabetic retinopathy

To evaluate the usefulness of cytokine levels of peripheral blood in diabetic retinopathy (DR), demographic and biochemical parameters including low-density lipoprotein (LDL) diameter as well as cytokine profiles were analyzed in 74 patients with type 2 diabetes mellitus (DM), with DR (n=46) or without DR (n=28). DM duration was longer in the patients with DR than without (p<0.001). Serum glucose (p=0.005) and total cholesterol (p=0.029) levels were higher in DM patients with DR than DM patients without DR. Plasma LDL diameter, interleukin-6 (IL-6), and interleukin-8 (IL-8) showed significant differences among the different degrees of DR severity in analysis of variance (ANOVA) with no definite trend. The risk of DR in DM patients was decreased by an increase of interleukin-10 (IL-10) level [odds ratio (OR)=0.152; confidence interval (CI): 0.028-0.817]. Plasma LDL diameter was smaller and IL-6 and tumor necrosis factor-alpha (TNF-alpha) levels were higher in DM patients with proliferative diabetic retinopathy (PDR) compared to those with non-proliferative diabetic retinopathy (NPDR) (p<0.05). We found that higher IL-10 levels were related to lower risk of DR in DM patients. Levels of IL-6 and TNF-alpha as well as LDL diameter may be helpful in the prediction of PDR in DM patients with DR.

Safety and efficacy of Atorvastatin-induced very low-density lipoprotein cholesterol levels in Patients with coronary heart disease (a post hoc analysis of the treating to new targets [TNT] study)

High-dose statin therapy has been demonstrated to provide incremental benefit when low-density lipoprotein (LDL) cholesterol concentrations are lowered well below recommended target levels. This secondary analysis of the Treating to New Targets (TNT) study was conducted to investigate whether the attainment of very low LDL cholesterol levels was associated with a further reduction in major cardiovascular events compared with higher LDL cholesterol concentrations and whether any incremental benefit was achieved without additional safety risk. Patients with coronary heart disease and LDL cholesterol levels <130 mg/dl (3.4 mmol/L) were randomized to therapy with atorvastatin 10 mg/day (n = 5,006) or 80 mg/day (n = 4,995). The primary end point was the occurrence of a first major cardiovascular event. Clinical outcomes and safety data were compared across on-treatment LDL cholesterol quintiles. There was a highly significant reduction in the rate of major cardiovascular events with descending achieved levels of on-treatment LDL cholesterol (p <0.0001 for trend across LDL cholesterol). Analysis of individual components of the primary end point demonstrated similar results. Death from any cause and from noncardiovascular causes was lowest in patients with the lowest on-treatment LDL cholesterol levels. Cardiovascular deaths were also reduced with lower levels of on-treatment LDL cholesterol. There were no clinically important differences in adverse event rates across quintiles. Specifically, no increase in muscle complaints, suicide, hemorrhagic stroke, or cancer deaths was observed at the lowest LDL cholesterol levels. In conclusion, the present analysis adds support to the concept that for patients with established atherosclerotic cardiovascular disease, a further risk reduction without sacrifice of safety can be achieved by reducing LDL cholesterol to very low levels.

Anodic porous alumina as mechanical stability enhancer for LDL-cholesterol sensitive electrodes

In this work, to improve the mechanical stability of electrodes based on P450scc for LDL-cholesterol detection and measure, anodic porous alumina (APA) was used. This inorganic matrix, which pores can be tuned in diameter modifying the synthesis parameters, was realized with cavities 275 nm wide and 160 microm deep (as demonstrated with AFM and SEM measurement), to allow the immobilization of P450scc macromolecules preserving their electronic sensitivity to its native substrate, cholesterol. Even if the sensitivity of the APA+P450scc system was slightly reduced with respect to the pure P450scc system, the readout was stable for a much longer period of time, and the measures remained reproducible inside a proper confidentiality band, as demonstrated with several cyclic voltammetry measures. To optimize the adhesion of P450scc to APA, a layer of poly-L-lysine, a poly-cathion, was successfully implemented as intermediate organic structure.

Human serum albumin levels and cardiovascular risk factors in elderly Japanese-American men: the Honolulu Heart Program

The objective of this study is to investigate the relationship between lowlevels of human serum albumin (HSA) and the incidence of coronary heart disease (CHD) in a cohort of elderly Japanese-American men. Using data from the Honolulu Heart Program's fourth examination (1991-1993), HSA levels of 998 Japanese American men aged 71-93 years was compared with plasma levels of fibrinogen, total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, diastolic BP, BMI, and fasting blood glucose. HSA was significantly negatively associated with age and fibrinogen, and significantly positively associated with total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, diastolic BP, BMI and fasting blood glucose. After adjusting for age, tertiles of HSA were significantly positively associated with total cholesterol, HDL cholesterol and triglycerides, and significantly negatively associated with fibrinogen. Using multivariate stepwise regression, significant correlations were seen between HSA and fibrinogen, cholesterol, age, HDL cholesterol and triglycerides, and a borderline correlation was seen with systolic blood pressure. However, the model R-square for all variables was only 0.10. In conclusion, HSA levels are significantly associated with several traditional cardiovascular risk factors, particularly serum lipid levels.

Care management dosage

BACKGROUND

The care of patients with complex illnesses requires careful management, but systems of care management (CM) vary in their structure and effectiveness.

OBJECTIVE

To create a framework identifying components of broad-based CM interventions and validate the framework, including using this framework to evaluate the contribution of varying components on outcomes of patients with chronic illness.

DESIGN

We create the framework using retrospective information about CM activities and services over 12 months and categorize it using cluster and factor analysis. We then validate this framework through content and criterion techniques. Content validity is assessed through a Delphi study and criterion validity through relationship of the dosage measures and patterns of care to process and outcomes measures.

PARTICIPANTS

Patients with diabetes and/or cardiovascular disease receiving CM services in a model known as Care Management Plus implemented in primary care.

RESULTS

Six factors of CM activity were identified, including a single dosage summary measure and 5 separate patterns of care. Of these, the overall dosage summary measure, face-to-face time, duration of follow-up, and breadth of services were all related to improved processes for hemoglobin A1c and LDL testing and control. Brief intense patterns of care and high face-to-face care manager time were also related to improved outcomes.

CONCLUSIONS

Using this framework, we isolate components of a CM intervention directly related to improved process of care or patient outcomes. Current efforts to structure CM to include face-to-face time and multiple diseases are discussed.

Comparative study of LDL-cholesterol levels in Thai patients by the direct method and using the Friedewald formula

In this study, low-density lipoprotein cholesterol (LDL-C) levels by direct measurement and estimation using the Friedewald formula, were compared among 1,016 Thai patients. The study assessed blood samples from out-patients sent to the Clinical Chemistry Laboratory, Department of Clinical Pathology, Rajvithi Hospital, Ministry of Public Health, for measurement of total cholesterol (TC), LDL-C, high-density lipoprotein cholesterol (HDL-C) and triglyceride (TG) levels, January 2004-December 2005. Patients' ages ranged 8-89 years, 573 (56.4%) were females. Linear regression analysis showed the two methods had highly significant correlation coefficients (p<0.001). Upon comparing the two methods, at TG levels of 151-200 mg/dl, bias was 18.3 mg/dl; and for TG levels of 201-300 mg/dl, bias was lower at 11.4 mg/dl; for TG levels of 301-400 mg/dl, bias increased to 20.9 mg/dl. The direct assay meets currently established analytical performance targets and may be useful for the diagnosis and management of hyperlipidemic patients. The Friedewald formula did not give a homogeneous performance when estimating LDL-C levels in samples with different TG levels.

The effect of intensified lipid-lowering therapy on long-term prognosis in patients with peripheral arterial disease

BACKGROUND

The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are associated with improved outcome in patients with peripheral arterial disease. Statins may also have beneficial properties beyond their lipid-lowering effect.

METHODS

A prospective, observational cohort study was conducted at a university hospital from 1990 to 2005 to examine whether higher doses of statins and lower low-density lipoprotein (LDL) cholesterol levels are both independently associated with improved outcome in peripheral arterial disease. Enrolled were 1374 consecutive patients (age, 61 +/- 10 years, 73% male) with peripheral arterial disease (ankle-brachial index <or=0.90). They were screened for clinical risk factors, statin therapy, and LDL cholesterol levels. Serial LDL cholesterol levels were measured at 6 months and yearly after enrollment. The mean follow-up time was 6.4 +/- 3.6 years, and no patients were lost to follow-up. The primary end points were all-cause and cardiac mortality. The secondary end point was the progression to kidney failure.

RESULTS

Overall mortality, cardiac death, and progression to kidney failure occurred in 29%, 20%, and 5% of patients, respectively. Multivariate analysis revealed that higher doses of statins (per 10% increase) and lower 6-month LDL cholesterol levels (per 10 mg/dL decrease) were both independently associated with lower all-cause mortality (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.62 to 0.80; and HR, 0.96; 95% CI, 0.93 to 0.98, respectively) and cardiac death (HR, 0.76; 95% CI, 0.67 to 0.86; and HR, 0.95; 95% CI, 0.92 to 0.98, respectively). Higher high-density lipoprotein cholesterol levels also correlated significantly with lower all-cause and cardiac mortality. Higher doses of statins (per 10% increase) were associated with less progression to kidney failure (HR, 0.69; 95% CI, 0.54 to 0.89).

CONCLUSIONS

Higher doses of statins and lower LDL cholesterol levels are both independently associated with improved outcome in patients with peripheral arterial disease. These results support the view that statins have beneficial effects beyond their lipid-lowering properties and should be considered in all patients with PAD, irrespective of LDL cholesterol levels.

Efficacy and safety of extended-release fluvastatin in Turkish patients with hypercholesterolaemia: TULIPS (Turkish Lipid Study)

OBJECTIVE

The efficacy and safety of extended-release fluvastatin (fluvastatin XL), 80 mg once daily, was assessed in Turkish patients with primary hypercholesterolaemia (low-density lipoprotein cholesterol (LDL-C) 3.37-5.70 mmol/l and triglyceride (TG) < 4.52 mmol/l).

RESEARCH DESIGN

In this open-label, prospective, multi-centre study, 154 patients were given fluvastatin XL 80 mg once daily and lipid levels were assessed after 2 and 12 weeks.

RESULTS

Fluvastatin XL 80 mg once daily significantly reduced LDL-C levels by 38.8 and 38.1% at weeks 2 (n = 140) and 12 (n = 116), respectively (p < 0.001 vs. baseline). Treatment with fluvastatin XL for 2 and 12 weeks significantly reduced total cholesterol levels by 30.2 and 27.4%, respectively (p < 0.001 vs. baseline) and reduced TG levels by 14.9 and 7.5%, respectively (p < 0.001 vs. baseline). Following stratification by risk factors for coronary heart disease (CHD) according to the National Cholesterol Education Program Adult Treatment Panel III guidelines, 87.3% of patients with > or = 2 risk factors, and 67.4% of patients with existing CHD or CHD risk equivalents achieved target LDL-C levels (< 3.37 mmol/l and < 2.59 mmol/l, respectively) with fluvastatin XL. Fluvastatin XL reduced high-density lipoprotein cholesterol by 8.9 and 4.7% at weeks 2 and 12 weeks, respectively. fluvastatin XL 80 mg once daily was generally well-tolerated.

CONCLUSIONS

This open-label study indicates fluvastatin XL 80 mg once daily is an effective and well-tolerated lipid-lowering therapy for the reduction of CHD risk in Turkish patients.

Longitudinal lipid screening and use of lipid-lowering medications in pediatric type 1 diabetes

OBJECTIVE

Because cardiovascular disease (CVD) is the leading cause of death in patients with type 1 diabetes (T1D) and dyslipidemia is an important CVD risk factor, we investigated dyslipidemia and its treatment in children with T1D.

STUDY DESIGN

Subjects had T1D (n = 360), repeated lipid measurements (n = 1095; mean, 3.04 +/- 0.94; range, 2 to 11), and were seen between 1994 and 2004. Total cholesterol (TC), high-density lipoprotein cholesterol (HDL), and non-HDL cholesterol (non-HDL) were categorized on the basis of published guidelines. Age, diabetes duration, sex, body mass index, HbA1c, and lipid-lowering medication use were recorded. Predictors of TC, HDL, and non-HDL were determined.

RESULTS

Sustained abnormalities existed for TC > or = 200 mg/dL (16.9%); HDL < 35 mg/dL (3.3%); and non-HDL > or = 130 mg/dL (27.8%), > or = 160 mg/dL (10.6%), and > or = 190 mg/dL (3.3%). Lipid-lowering medications were started on 23 patients. In mixed model longitudinal data analyses, HbA1c was significantly related to TC and non-HDL. Body mass index z-score was inversely related to HDL.

CONCLUSIONS

In this retrospective, longitudinal study of pediatric patients with T1D with repeated lipid measurements, sustained abnormal levels for TC, HDL, and non-HDL were present. Prospective longitudinal data for dyslipidemia in youth with T1D are needed.

Westgard multirule for calculated laboratory tests

BACKGROUND

In clinical laboratories, many test results such as low-density lipoprotein (LDL)-cholesterol can be calculated using the results of specifically measured tests. However, quality control programs deal only with measured tests and there is no adequate quality assessment procedure for calculated tests. I aimed to apply the Westgard multirule to calculated tests as a part of routine quality procedures.

METHODS

I prepared a Levey-Jennings chart for calculated tests and all their measured components (Equation chart) and then applied the Westgard multirule to these tests.

RESULTS

Applying the Westgard multirule to calculated LDL-cholesterol (and other calculated tests) was simple, and increased the reliability of the results of the calculated tests.

CONCLUSIONS

Checking the reliability of only measured tests by quality control procedures before reporting patient results may be inadequate. Applying the Westgard multirule to calculated tests as part of total quality management will increase the reliability of test results.

Comparative performance of two point-of-care analysers for lipid testing

The aim of this study was to compare the analytical performance of the Cholestech LDX and CardioChek PA lipid point-of-care devices to a CDC-certified laboratory. Inter-assay imprecision (n=10) for blood samples from 2 patients with different lipid profiles was 3.0% for total cholesterol, 2.6% for triglyceride, 5.2% for HDL cholesterol and 6.2% for calculated LDL cholesterol on the Cholestech, and 4.4% for total cholesterol, 4.8% for triglyceride, 7.0% for HDL cholesterol and 7.4% for calculated LDL cholesterol on the Cardiochek. In a patient comparison study (n=100), correlation coefficients (r) between the POCT and laboratory methods were greater than 0,90 for all tests for the Cholestech and greater than 0.84 for all tests for the Cardiochek. The mean difference (bias) between the results obtained on the Cholestech LDX and the laboratory method was not statistically significant; however the mean difference between the CardioChek and the laboratory method was statistically significant for total, HDL and LDL cholesterol (one way analysis of variance with Scheffe post-hoc test). The Cholestech LDX met the NCEP goal for total error for all analytes except LDL cholesterol. The CardioChek PA system met the NCEP total error goal for triglyceride but not the other lipid analytes. We conclude that the Cholestech LDX device is a suitable POCT device for cardiovascular risk assessment in the primary care setting, while the CardioChek device requires more study and refinement.

Evaluation of lipids, lipoproteins and apolipoproteins concentrations in cord blood serum of newborns from rural and urban environments

The purpose of the present study was to check the influence of rural and urban environments on some of the parameters of lipids metabolism in the cord blood serum in healthy newborns, as well as the evaluation of the concentration of lipids, lipoproteins and apolipoproteins in the cord blood serum with relation to risk factors of atherosclerosis in the family of the studied newborns. The study included 75 newborns (37 from rural areas and 38 from urban areas). Newborns weight and length were recorded at birth. On the basis of the family history taken from the mothers, the atherosclerosis risk factors were established in the families of the studied newborns. In all of the studied newborns, concentration of triglycerides, total cholesterol and LDL, VLDL and HDL cholesterol as well as of apolipoproteins (apo-Al, apo-B) in the cord blood serum sampled soon after birth were performed. No statistically significant differences between the mean levels of triglycerides, total cholesterol and cholesterol of fractions: LDL, VLDL, HDL and apolipoproteins (apo-AI, apo-B) in the cord blood serum in the newborns from rural and urban areas were found. However, when analysing the concentration of parameters of lipid metabolism in cord blood serum in newborns with regard to gender, higher concentrations of total cholesterol, LDL cholesterol and apo-AI in female newborns from rural areas, and higher HDL cholesterol and apo-AI in female newborns from urban regions were confirmed. When analysing the concentration of lipids and lipoproteins in cord blood serum in newborns from families with risk factors confirmed as compared to the families without that risk, both in the rural and urban regions no significant differences were confirmed. The studies have not proved any significant differences between the levels of lipids, lipoproteins and apolipoproteins in the cord blood serum in newborns from rural and urban areas.

Utilization of calculated low density lipoprotein cholesterol and measured low density lipoprotein cholesterol in Siriraj Hospital

A study to determine the utilization of calculated low density lipoprotein (c-LDL) cholesterol and measured low density lipoprotein (m-LDL) cholesterol was conducted. The test results of total cholesterol, triglyceride, HDL-cholesterol and m-LDL-cholesterol from the same individuals aged > or = 18 years who had the tests done at the Department of Clinical Pathology, Faculty of Medicine Siriraj Hospital during January to December 2004 were retrieved. The c-LDL-cholesterol level was computed using Friedewald formula. There were two data sets i.e. the m-LDL-cholesterol cut-off level derivation data set (784 subjects) and the m-LDL-cholesterol cut-off level validation data set (800 subjects). The study results revealed: 1) 2.6% of the subjects had blood triglyceride > 400 mg/dl hence c-LDL-cholesterol could not be computed, 2) the correlation between c-LDL-cholesterol levels and m-LDL-cholesterol levels from both data sets was very good (r > 0. 95, p < 0. 001), 3) the m-LDL-cholesterol levels were usually higher than c-LDL-cholesterol levels, 4) the m-LDL-cholesterol cut-off level derivation data set showed that m-LDL-cholesterol < 87, > 143, > 188, > 233 and > 254 mg/dl were highly correlated with c-LDL-cholesterol < 100, > or = 100, > or = 130, > or = 160 and > or = 190 mg/dl respectively, 5) an application of m-LDL-cholesterol cut-off levels derived from the m-LDL-cholesterol cut-off level derivation data set to the m-LDL-cholesterol cut-off level validation data set showed that m-LDL-cholesterol < 87, > 143, > 188, > 233 and > 254 mg/dl had accuracy in predicting c-LDL-cholesterol < 100, > or = 100, > or = 130, > or = 160 and > or = 190 mg/dl of 100%, 99. 7%, 100%, 100% and 100% respectively, 6) the use of m-LDL-cholesterol levels as a guide for initiating lipid-lowering agents based on cut-off values of c-LDL-cholesterol levels led to an overuse of lipid-lowering agents in 3.6% to 42.9% of the patients and 7) Nomogram for transforming m-LDL-cholesterol to c-LDL-cholesterol was developed as well as a formula for transforming m-LDL-cholesterol to c-LDL-cholesterol (c-LDL-cholesterol = 0.89 x m-LDL-cholesterol). Therefore, m-LDL-cholesterol assay has a very limited use in managing individuals with suspected or known dyslipidemia. The use of m-LDL-cholesterol level as a guide for management of abnormal LDL-cholesterol conditions leads to an overuse of lipid lowering medications and an enormous expense of m-LDL-cholesterol assay.

Low-density lipoprotein cholesterol goal attainment among high-risk patients: Does a combined intervention targeting patients and providers work?

BACKGROUND

Physicians are aware of the National Cholesterol Education Program guidelines; however, most patients fail to attain cholesterol goals.

OBJECTIVE

To determine whether a combined program of patient education and provider awareness could improve the National Cholesterol Education Program goal attainment among patients at high risk for cardiovascular events.

METHODS

One hundred seven high-risk patients with cardiovascular disease were educated in a single 15-minute session regarding their cholesterol levels, risk factors, and medication adherence. Those with scores of 2 or lower on the Morisky questionnaire were classified as low-adherence patients, and those with scores of 3 or higher were classified as high-adherence patients. Seven physicians were provided this information and were requested to evaluate the dyslipidemia management of these patients. Lipid levels were reevaluated 8 to 12 weeks after the intervention.

RESULTS

At the start of the study, 38 (35.5%) of the 107 patients were at target low-density lipoprotein cholesterol (LDL-C) levels, and 64 of the 107 patients (59.8%) were at target levels after the intervention. High-adherence patients decreased their LDL-C levels from a mean of 118.6 mg/dL (3.07 mmol/L) to 98.6 mg/dL (2.55 mmol/L); low-adherence patients increased their LDL-C levels after the intervention from 134.5 mg/dL (3.48 mmol/L) to 142.1 mg/dL (3.68 mmol/L). A comparison between the LDL-C goal achievers vs nonachievers revealed a significant difference in adherence (P = .001). Among the goal achievers, significant decreases in preintervention vs postintervention total cholesterol levels (P = .001) and LDL-C levels (P = .001) were also noted.

CONCLUSION

This study demonstrates that an intervention simultaneously targeting patients and providers is successful in improving goal attainment among high-risk patients.

Partners in lowering cholesterol: comparison of a multidisciplinary educational program, monetary incentives, or usual care in the treatment of dyslipidemia identified among employees

OBJECTIVE

We sought to assess whether either a low-cost educational intervention or small monetary incentive is more effective than usual care in lowering low-density lipoprotein (LDL) cholesterol among employees.

METHODS

Employees with an LDL-C >130 mg/dL were eligible. After receiving on-line educational materials, subjects were assigned to three groups: group 1 received dollar 100 if they reduced their LDL-C by 15% within 6 months, group 2 participated in a multi-disciplinary educational program, and group 3 received no further intervention.

RESULTS

In total, 171 employees participated. Baseline mean LDL-C was 156 mg/dL. Approximately 6 months after randomization, mean LDL-C was reduced 17.9 mg/dL (11.3%) in group 1, 17.9 mg/dL (11.5%) in group 2, and 5.5 mg/dL (3.5%) in group 3. Reductions in groups 1 and 2 were statistically superior to group 3 (P = 0.02).

CONCLUSIONS

Both an employer directed low-cost educational program and small monetary incentives similarly lowered LDL-C compared with usual care.

Lipid profile of healthy adult Nigerians in Port Harcourt, Nigeria

BACKGROUND

Hyperlipidaemia is a major cardiovascular risk factor for coronary artery disease, atherosclerosis, hypertension and stroke. It is thought that serum cholesterol levels are low in Nigerians as shown by results of a population survey done over twenty years ago. In addition the last national non communicable disease survey recorded a low prevalence of Hyperlipidaemia (4.0%) in Nigeria. With increasing urbanisation and socioeconomic improvement, changing population dynamics is expected to influence disease pattern and noncommunicable diseases are expected to rise. Thus there is a need to screen healthy adults for their lipid pattern in Port Harcourt a city with high population dynamics where such studies have not been previously reported.

METHOD

A prospective descriptive population survey was carried out among healthy adults residing in Port Harcourt. A total of ninety two adults were screened after obtaining informed consent. Weight, height, blood pressure, fasting blood sugar and fasting lipid profile were measured. Results were analysed using simple statistical methods.

RESULTS

A total of ninety two subjects were recruited into the study. Fourty seven (51.1%) of the subjects were males while fourty five (48.9%) were females. The age range of subjects was 24-59 years with mean of 38.84 +/- 8.36 years. The mean BMI was 28.76 +/- 5.91 Kg/m2. There was no significant statistical difference between the mean BMI for males and females. The mean fasting blood sugar, mean total cholesterol and mean LDL cholesterol were 4.45 +/- 0.89 mmol/L, 4.76 +/- 1.06 mmol/L and 3.65 +/- 0.89 mmol/L. The mean total triglyceride was 1.02 +/- 0.30 mmol/L while the mean HDL was 0.90 +/- 0.25 mmol/L. There was an increase in total cholesterol with increasing age and an increase in total cholesterol and LDL cholesterol with increasing social class. Subjects with total cholesterol above 6.5 mmol/L constituted 31.52% of study subjects. Subjects with BMI between 25-29 Kg/m2 made up 43.48% of subjects while 33.69% of subjects had BMI above 30 Kg/m2.

CONCLUSION

A high mean total and LDL cholesterol values were observed among healthy adults in Port Harcourt. The prevalence of obesity was also found to be high. There is a need for public health action to address these findings especially as high serum cholesterol levels have a direct correlation with coronary artery disease. Further large scale urban survey of non communicable diseases in the country is therefore necessary at this time.

LDL particle size, fat distribution and insulin resistance in obese children

BACKGROUND

The importance of small dense low-density lipoprotein (sdLDL) cholesterol in coronary heart disease has been demonstrated in many studies. Body fat accumulation, especially abdominal adiposity, is one of the important factors modifying the expression of sdLDL in adults.

OBJECTIVE

To determine the prevalence of sdLDL in obese children, and to investigate its relationship with anthropometric and metabolic variables.

SUBJECTS

A total of 30 obese children (22 males, 8 females) aged 12.6+/-0.6 years (mean+/-s.e.), who presented to our outpatient clinic with obesity.

METHODS

LDL peak particle diameter was determined using gel electrophoresis. LDL subclasses were classified into sdLDL (pattern B; diameter<25.5 nm) and non-sdLDL (pattern A; diameter>or=25.5 nm). Anthropometric and metabolic variables were also determined to identify factors modifying LDL particle size.

RESULTS

sdLDL was detected in 11 children (40.0%). In children with sdLDL, waist/height ratio was significantly higher (P=0.0466), and they had significantly higher triglyceride (TG) (P=0.0035) and lower high-density lipoprotein cholesterol (HDLC) levels (P=0.036). Peak LDL diameter as a continuous variable was significantly correlated with HDLC and TG levels. In multiple regression analysis, body mass index and waist/height ratio were significant determinants of the peak LDL diameter variability.

CONCLUSIONS

We found a high prevalence of sdLDL in obese children, and a relationship of peak LDL diameter with abdominal fat accumulation, HDLC and TG levels. The presence of sdLDL might be an important risk factor for the metabolic syndrome.

Low-density lipoprotein cholesterol estimation by the Anandaraja's formula--confirmation

The number of the indirect methods for LDL-C estimation is growing. Our result support the reliability of new Anandaraja's formula for low-density lipoprotein estimation from total cholesterol and triglycerides.

Cholesterol-lowering effect of platycodin D in hypercholesterolemic ICR mice

This study investigates the in vivo hypocholesterolemic action of platycodin D and its in vitro evidence for the cholesterol-lowering properties. In order to examine the effects of platycodin D on hypercholesterolemia in male ICR mice, platycodin D with doses of 15, 30 or 50 mg/kg was orally administered for 8 weeks. Changes in body weight and daily food intake were measured regularly during the experimental period. Final contents of triglyceride and different types of cholesterol in the serum, livers and feces were determined. The effects of platycodin D on cholesterol metabolism were further investigated with several in vitro assays, including antioxidant effect on low density lipoprotein oxidation, inhibition of human acyl-coenzyme A:cholesterol acyltransferase (hACAT) and serum lipoprotein associated-phospholipase A(2) (Lp-PLA(2)), as well as the regulation of farnesoid X receptor. The formation of insoluble complex between platycodin D and cholesterol was also investigated. Following an eight week experimental period, the body weights of platycodin D-fed mice were less than those of control mice on a high cholesterol diet by 11.2+/-5% (P<0.01) with 15 mg/kg platycodin D, 11.7+/-5% (P<0.01) with 30 mg/kg platycodin D, and 23.4+/-7.9% (P<0.0001) with 50 mg/kg platycodin D, respectively. A decrease in daily food consumption was also noted in most of the treated animals. Triglyceride and cholesterol concentrations were decreased in serums and livers, but increased in feces. Some of the in vitro observations revealed that the hypocholesterolemic effect of platycodin D is partly associated with inhibition to hACAT activity and antagonism to the farnesoid X receptor as well as the formation of insoluble complex with between platycodin D and cholesterol. Both in vivo and in vitro results demonstrate a potential value of platycodin D as a novel cholesterol-lowering and anti-atherogenic candidate.

Increased targeting of cardiovascular risk factors in patients with chronic kidney disease does not improve atheroma burden or cardiovascular function

BACKGROUND

Although multiple risk factor intervention (MRFI) is recommended to reduce the increased morbidity and mortality of cardiovascular disease (CVD) in chronic kidney disease (CKD), its efficacy is unknown. We studied the efficacy of a MRFI program in CKD.

METHODS

This randomized controlled study of 200 patients with stage 4 or 5 CKD compared a physician-supervised, nurse-driven MRFI clinic (focused on dyslipidemia, hyperhomocysteinemia, blood pressure [BP], anemia, and hyperphosphatemia) with conventional care in CKD. One hundred eleven subjects completed 2 years of follow-up (median follow-up 674 days [interquartile range {IQR} 348-719 days]). Outcome measures were atheroma burden (carotid intimamedia thickness [IMT]) and endothelial function (brachial artery reactivity [BAR]).

RESULTS

The MRFI group showed significant improvements, compared with usual care, in serum low-density lipoprotein cholesterol (-30.9 mg/dL vs -12.7 mg/dL, P = .001), homocysteine (-6.95 vs -0.67 micromol/L, P < .001), systolic BP (-6.9 vs -0.2 mm Hg, P = .049), and diastolic BP (-4.8 vs -1.0 mm of Hg, P = .043). No significant changes were seen in serum phosphate or hemoglobin level. Despite observed improvements in risk factors, no differences from baseline were demonstrated for IMT (-0.00 vs -0.01 mm, P = .533) or BAR (0.09% vs 0.22%, P = .834). Forty-two patients reached a composite end point of CVD death, acute coronary syndrome, revascularization, nonfatal stroke, and amputation and this was similar between groups (23 vs 19 events, P = .475).

CONCLUSIONS

A MRFI program was not associated with improvement in vascular structure or function in stage 4 or 5 patients with CKD.

Comparison of two methods (precipitation manual and fully automated enzymatic) for the analysis of HDL and LDL cholesterol

OBJECTIVE

To compare accuracy and throughput time for the measurement of HDL and LDL cholesterol by manual precipitation and fully automated enzymatic methods.

METHODS

Fifty, serum samples collected over a 4 months period (February - May 2004) were analyzed for HDL and LDL cholesterol by two different methods i.e. precipitation manual and automatic enzymatic method in the section of chemical pathology, Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi Pakistan.

RESULTS

The mean standard deviation for HDL Cholesterol by precipitation method and automated method were 43.12 +/- 8.97mg/dl and 43.86 +/- 10.34mg/dl respectively (p-value = 0.301). The mean standard deviation for LDL cholesterol by precipitation method and automated method were 111.76 +/- 25.57mg/dl and 111.8 +/- 28.41mg/dl respectively (p-value = 0.981). The calculated "t" and "F" value for HDL-C was 0.0172 and 0.75 respectively, and calculated "t" and "F" values for LDL-C were 0.047 and 0.809 respectively. Average time for manual method was 45 minutes and automation 20 minutes.

CONCLUSION

Both the precipitation (manual) method and the automated method provide reliable, precise and accurate results. In both the methods "t" and "F" values were less than critical. Automated method provide high throughput and are less labor intensive. The choice of method can depend on laboratory facilities and workload

Lipoprotein profiles in plasma and interstitial fluid analyzed with an automated gel-filtration system

BACKGROUND

High-quality methods for lipoprotein characterization are warranted in studies on various metabolic diseases.

MATERIALS AND METHODS

An automated system for size-exclusion chromatography (SEC) of lipoproteins using commercially available components is described. Cholesterol or triglyceride content in separated lipoproteins from plasma and interstitial fluid (IF) was continuously determined on-line using microlitre sample volumes.

RESULTS

The lipoprotein assay showed a good concordance with the classic ultra-centrifugation/precipitation technique using fresh or frozen samples. Determination of lipoproteins in IF obtained from vacuum-induced skin blisters from 18 healthy subjects revealed that very low density lipoprotein (VLDL), low density lipoprotein (LDL) and high density lipoprotein (HDL) cholesterol levels were 18%, 19% and 25%, respectively, of concomitant plasma concentrations. The size-exclusion chromatography (SEC) system also allows for triglyceride determination on-line and it could be shown that the system is advantageous for an accurate determination of triglycerides in conditions when there are high levels of glycerol, e.g. in mice and in patients with hyperglycerolaemia (pseudo-hypertriglyceridaemia).

CONCLUSIONS

The described system should be of value in studies where detailed lipoprotein analysis is warranted and particularly when significant sample series with small volumes are available. Our data also suggest that there is a 4-5.5-fold concentration gradient between plasma and IF for the three major plasma lipoproteins.

Adzuki resistant starch lowered serum cholesterol and hepatic 3-hydroxy-3-methylglutaryl-CoA mRNA levels and increased hepatic LDL-receptor and cholesterol 7alpha-hydroxylase mRNA levels in rats fed a cholesterol diet

We examined the effects of adzuki bean resistant starch on serum cholesterol and hepatic mRNA in rats fed a cholesterol diet. The mRNA coded for key regulatory proteins of cholesterol metabolism. The control rats were fed 15 % cornstarch (basal diet, BD). The experimental rats were fed BD plus a 0.5 % cholesterol diet (CD), or a 15 % adzuki resistant starch plus 0.5 % cholesterol diet (ACD) for 4 weeks. The serum total cholesterol and VLDL + intermediate density lipoprotein + LDL-cholesterol levels in the ACD group were significantly lower than those in the CD group throughout the feeding period. The total hepatic cholesterol concentrations in the CD and ACD groups were not significantly different. The faecal total bile acid concentration in the ACD group was significantly higher than that in the BD and CD groups. Total SCFA and acetic acid concentrations in the ACD group were significantly higher than those in the CD group but there were no significant differences in the concentrations between the ACD and BD groups. The hepatic LDL-receptor mRNA and cholesterol 7alpha-hydroxylase mRNA levels in the ACD group were significantly higher than those in the CD group and the hepatic 3-hydroxy-3-methylglutaryl (HMG)-CoA reductase mRNA level in the ACD group was significantly lower than in the CD group. The results suggest that adzuki resistant starch has a serum cholesterol-lowering function via enhancement of the hepatic LDL-receptor mRNA and cholesterol 7alpha-hydroxylase mRNA levels and faecal bile acid excretion, and a decrease in the hepatic HMG-CoA reductase mRNA level, when it is added to a cholesterol diet.

Missed opportunity in the treatment of hyperlipidemia in patients with coronary heart disease: the primary care setting

BACKGROUND

Multiple clinical trials have established the benefits of controlling hyperlipidemia in patients with coronary heart disease (CHD). Nonetheless, many patients still remain untreated or not at goal low-density lipoprotein (LDL). There is limited data concerning the control of this risk factor in CHD patients in the primary care outpatient setting.

METHODS

We evaluated the treatment of hyperlipidemia in the main primary care clinics of an academic, urban hospital. We identified 147 patients in a one-month period with a diagnosis of CHD and assessed the frequency of lipid-lowering therapy as well as the number of patients with LDL values that were at goal according to the National Cholesterol Education Program (NCEP) guidelines.

RESULTS

A large proportion of patients were minorities and of low income, with 91.8% being African-American and 54.4% female. Although the frequency of statin therapy was relatively high (74.8%), only 55 patients (45.8%) were at goal LDL: < 100 mg/dl. The mean dose of statin prescribed (primarily simvastatin) was 33.3 +/- 17.1 mg. Only seven patients (6.5%) were on the maximum statin dose of 80 mg.

CONCLUSIONS

These data show that while the frequency of lipid-lowering therapy in CHD patients in the primary care outpatient setting is relatively high, there remains a treatment gap. Specific areas for improvement are the initiation of higher doses of statins and more aggressive statin titration. The primary care outpatient setting may represent an ideal opportunity to improve control of hyperlipidemia in CHD patients.

Ultra-Endurance Exercise and Oxidative Damage

At least 30 minutes of moderate-intensity physical activity accumulated on most, preferably all days is considered the minimum level necessary to reduce the risk of developing cardiovascular disease. Despite an unclear explanation, some epidemiological data paradoxically suggest that a very high volume of exercise is associated with a decrease in cardiovascular health. Although ultra-endurance exercise training has been shown to increase antioxidant defences (and therefore confer a protective effect against oxidative stress), an increase in oxidative stress may contribute to the development of atherosclerosis via oxidative modification of low-density lipoprotein (LDL). Research has also shown that ultra-endurance exercise is associated with acute cardiac dysfunction and injury, and these may also be related to an increase in free radical production. Longitudinal studies are needed to assess whether antioxidant defences are adequate to prevent LDL oxidation that may occur as a result of increased free radical production during very high volumes of exercise. In addition, this work will assist in understanding the accrued effect of repeated ultra-endurance exercise-induced myocardial damage.

Detection of electronegative low density lipoprotein (LDL-) in plasma and atherosclerotic lesions by monoclonal antibody-based immunoassays

OBJECTIVES

To produce a monoclonal antibody (MAb) against electronegative LDL (LDL-) for detecting this modified lipoprotein in blood plasma and tissues.

DESIGN AND METHODS

LDL- was isolated from human blood plasma and used as an antigen for immunization of Balb/c mice. Lymphocytes of immunized mice were fused with myeloma cells (SP2/0) to obtain the hybridomas. LDL- was detected in blood plasma and atherosclerotic lesions of humans and rabbits by MAb-based ELISA and immunohistochemistry, respectively.

RESULTS

LDL- concentrations were higher (P < 0.05) in the blood plasma of hypercholesterolemic subjects (HC, 248 +/- 77 mg/dL of total cholesterol) than in normolipidemic subjects (NL, 173 +/- 82 mg/dL of total cholesterol) and rabbits (HC, 250 +/- 15 mg/dL of cholesterol versus NL, 81 +/- 12 mg/dL of cholesterol). Moreover, LDL- was detected in the atherosclerotic lesions of humans and rabbits.

CONCLUSION

These MAb-based immunoassays are adequate to detect LDL- in biological samples and represent an important tool for investigating the role of LDL- in atherosclerosis.

Effect of red mold rice supplements on serum and meat cholesterol levels of broilers chicken

Monacolin K is a secondary metabolite produced by Monascus species. It was found that it is able to decrease cholesterol levels. In this study, red mold rice (RMR) was added to the diet of Arbor Acres broiler chickens, and the cholesterol level in meat, as well as the concentration of triglyceride, the high-density lipoprotein cholesterol (HDL-C), and the low-density lipoprotein cholesterol (LDL-C) in the serum were evaluated. Four-week-old broilers are studied and divided into four groups in that each group contains 15 subjects. A 3-week experimental feeding trial was conducted in which three groups of broilers were fed 2.0, 5.0, and 8.0% of RMR (RMR groups) within their diet, respectively, and the result was compared to the control group. The results indicated that for each RMR group, the cholesterol content was significantly lower than that of the control group; in addition, their meat products contain higher level of unsaturated fatty acids. Triglyceride and cholesterol concentration in serum was also found to be considerably lower in RMR groups when compared to control group. Finally, in RMR groups, HDL-C/LDL-C and HDL-C/cholesterol ratios were all higher than those of the control group. In short, the results demonstrated that the cholesterol levels could be lowered by adding RMR to the diet of chickens.

Influence of dietary carbohydrate and fat on LDL and HDL particle distributions

Variations in the size and density distributions of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) particles have been related to risk for cardiovascular disease. In particular, increased levels of small, dense LDL particles, together with reduced levels of large HDL and increases in small HDL, are integral features of the atherogenic dyslipidemia found in patients with insulin resistance, obesity, and metabolic syndrome. Increased dietary carbohydrates, particularly simple sugars and starches with high glycemic index, can increase levels of small, dense LDL and HDL, primarily by mechanisms that involve increasing plasma triglyceride concentrations. Low-carbohydrate diets may have the opposite effects. Diets with differing fatty acid composition can also influence LDL and HDL particle distributions.

Antiobese and hypolipidemic effects of platycodin saponins in diet-induced obese rats: evidences for lipase inhibition and calorie intake restriction

OBJECTIVE

To investigate how and to what extent platycodin saponin (PS) from Platycodi Radix exerts a favorable influence on obesity and hyperlipidemia.

DESIGN

Sprague-Dawley rats were fed with a high fat (HF) diet for 4 weeks and then the animals were treated with 35 or 70 mg / kg of PS for another 4 weeks. Changes in body weight and daily calorie intake were measured regularly during the experimental period and the degree of linear correlation for the above two variables was further analyzed. The in vitro lipase inhibition of each PS compound and the in vivo fecal lipid excretion were examined in hope of revealing their relationship. The concentrations of hepatic triglyceride and cholesterol in serum.

RESULTS

The body weight reduction (13+/-4% vs HF control, P<0.05) by PS administration was highly correlated to the food intake restriction (Pearson's linear coefficient r=0.752, P<0.005). The in vitro inhibition of lipase by each isolated compound and mixture of PS were virtually identical. Consequently, the fecal TG excretion was increased by 2.1-3.2 folds depending on the dose of PS. The serum TG and LDL-cholesterol concentrations were decreased without noticeable changes in HDL-cholesterol levels. Concomitantly, the contents of the hepatic TG, cholesterol, and the liver surface fat pads were decreased in ubiquity, but no noticeable biochemical abnormalities or histological tissue damages were observed.

CONCLUSIONS

The administration of PS produced profound effects on the control of obesity and lipid metabolism, which resulted in LDL-cholesterol reduction. PS also caused a remarkable reduction in calorie intake, which was highly correlated to the body weight loss. These results suggest that PS has a greater role in anti-obesity, hypolipidemia, and liver protection than previously thought. Hence, PS could be a potential therapeutic alternative in the treatment of obesity and hyperlipidemia.

Novel predictors of overt nephropathy in subjects with type 1 diabetes. A nested case control study from the Pittsburgh Epidemiology of Diabetes Complications cohort

BACKGROUND

Predictors of diabetic nephropathy are only partly known and traditional risk factors do not adequately explain disease risk. We thus examined novel risk factors for overt nephropathy (ON) in type 1 diabetes.

METHODS

The EDC is a prospective study of childhood-onset type 1 diabetes. When first seen (1986-1988), mean age was 28 and diabetes duration 19 years. In the subsequent 10 years, 56 of 485 subjects without ON in 1986-88 developed ON. An age, duration (+/-3 years), and sex-matched control was identified for 47 cases. Forty-two matched pairs had available stored plasma samples obtained prior to ON onset in cases, and complete standard risk factor data.

RESULTS

Cases had a higher baseline albumin excretion rate (AER), HbA1, pulse rate, non-HDL cholesterol, fibrinogen, small LDL and lower eGDR and LDL particle size compared to controls (all P values<0.05). Multiple measures of immune complexes were increased in cases (P<0.05), whereas borderline elevations were seen for total antioxidant reserve (P=0.06) and retinol (P=0.08). Multivariably, other than AER, LDL particle size and IgG-IC were predictive beyond the standard predictors.

CONCLUSION

Besides AER, the immunecomplexes and lipoprotein subclasses may provide additional information in the assessment of ON risk in type 1 diabetes.

Effect of renal transplantation on endothelial function in haemodialysis patients

BACKGROUND

Haemodialysis patients (HD) have been characterized by a high incidence and prevalence of atherosclerotic cardiovascular disease. Based on the traditional cardiovascular risk factors in this population, we cannot explain this high incidence and prevalence. One of the mechanisms contributing to cardiovascular risk in HD patients may be to uraemic toxins. Cardiovascular risk factors and uraemic toxins themselves may cause endothelial dysfunction, which may play a pivotal role in the development and progression of atherosclerosis in this population. We hypothesized that elimination of uraemic toxins in response to renal transplantation (RTx) can improve endothelial function as assessed by flow-mediated dilatation of brachial artery in haemodialysis (HD) patients.

METHODS

Endothelial function measured by flow-mediated dilatation of the brachial artery (FMD) and glyceryltrinitrate-induced dilatation of the brachial artery (NMD) were assessed twice, during haemodialysis treatment and after RTx in 30 chronic haemodialysis patients. All patients were characterized by absence of known atherosclerotic disease and traditional cardiovascular risk factors. We also studied age- and gender-matched 20 normotensive healthy controls.

RESULTS

FMD values significantly improved after RTx (6.69+/-3.1% vs 10.50+/-3.0%, P<0.001) in HD patients. FMD of patients both during haemodialysis and after RTx was lower than in healthy controls (6.69+/-3.1%, 10.50+/-3.0% vs 14.02+/-2.3%, P<0.001 and P<0.01, respectively). There was no change in NMD values after RTx in HD patients (16.27+/-1.9% vs 16.30+/-1.8%, P>0.05). Also, NMD values in all patients were similar to healthy control values.

CONCLUSIONS

There is an improvement of endothelial function as assessed by FMD of the brachial artery after RTx in HD patients. This may be attributed to the elimination of uraemic toxins by successful RTx.

Lipid-modifying therapy and attainment of cholesterol goals in Europe: the Return on Expenditure Achieved for Lipid Therapy (REALITY) study

BACKGROUND

Few studies have been conducted in actual clinical practice settings to evaluate the ways in which dyslipidemia is managed using lipid-modifying therapies.

OBJECTIVE

To determine lipid-modifying therapy practices and their effects on low-density lipoprotein cholesterol (LDL-C) and/or total cholesterol (TC) goal attainment in Europeans based on prevailing guidelines at the time of therapy in each country.

METHODS

Retrospective cohort analysis involving 58,223 patients initiated on lipid-modifying therapies in 10 European countries, with a median patient follow-up on lipid-modifying therapy of 15.3 months. Data on prescriptions of lipid-modifying therapies, laboratory data including LDL-C and TC, achievement of cholesterol goals for LDL-C and/or TC, and hospitalizations were obtained from healthcare administrative databases and/or patient chart reviews.

RESULTS

Across Europe, statin monotherapy was the initial lipid-modifying treatment in 51,786 (89.3%) of 58,009 patients with available data. In addition, 38,853 (89.5%) of 43,410 patients with available follow-up statin potency data were initiated on statin regimens of medium or lower equipotency. Low-equipotency regimens include atorvastatin 5 mg, simvastatin 10 mg, and pravastatin 20 mg, whereas medium-equipotency regimens include atorvastatin 10 mg, simvastatin 20 mg, and pravastatin 40 mg. Regimens were adjusted to higher equipotency via either up-titration or switches to combination regimens in 16.2% of patients. On average, 40.5% of patients across Europe who were not initially at guideline recommended cholesterol goals (either LDL-C or TC) and had follow-up data attained recommended cholesterol levels, including <30% of patients in Spain, Italy, or Hungary. In many countries, the likelihood of goal attainment was inversely associated with baseline cardiovascular risk and/or LDL-C levels.

CONCLUSIONS

Lipid management strategies in Europe during the study period were dominated by statin monotherapy. Even after prolonged follow-up on lipid-modifying therapy, approximately 60% of Europeans studied did not achieve guideline recommended cholesterol goals. Future emphasis must be placed on subsequent lipid panel monitoring, as well as the use of more efficacious, well-tolerated lipid-modifying therapies such as dual cholesterol inhibitors to enable more European patients to attain their recommended cholesterol goals.

Independent Effect of Cardiac Rehabilitation on Lipids in Coronary Artery Disease

PURPOSE

We evaluate the effects cardiac rehabilitation (CR) participation independent of using lipid-altering agents (LAAs) on low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, total cholesterol, and triglyceride. Measurements included absolute and relative change in lipids and increases in percent of patients achieving goals.

METHODS

Analysis of 766 patients who participated in CR between 2000 and 2003 was performed. On enrollment to CR, all were being treated with an LAA defined as HIviG-CoA reductase inhibitors, bile acid sequestrant, fibrate, and niacin, hormone replacement therapy. Preenrollment and postenrollment lipids were obtained. Analysis was performed on 2 cohorts, participants enrolled on an LAA with no change in medication (n = 13) and participants enrolled on an LAA with a change in medications (n = 153).

RESULTS

At completion of CR, 74.9% of patients on LAA at enrollment with no medication adjustments during the program were at Adult Treatment Panel III goal for low-density lipoprotein cholesterol compared with 68.5% at entry (P = .01), all other lipid parameters also significantly improved. Sixty-three percent who started CR on an LAA and had dose adjustment or an additional LAA added achieved low-density lipoprotein cholesterol goal compared with 43.1% at entry (P < .0001).

CONCLUSION

Participation in CR significantly potentiates the lipid-improving effects of pharmacological therapy and independently contributed to the percent of patients achieving all lipid levels at Adult Treatment Panel III goal.

Soy protein reduces hepatic lipotoxicity in hyperinsulinemic obese Zucker fa/fa rats

Hepatic steatosis is commonly present during the development of insulin resistance, and it is a clear sign of lipotoxicity attributable in part to an accelerated lipogenesis. There is evidence that a soy protein diet prevents the overexpression of hepatic sterol-regulatory element binding protein-1 (SREBP-1), decreasing lipid accumulation. Therefore, the aim of the present work was to study whether a soy protein diet may prevent the development of fatty liver through the regulation of transcription factors involved in lipid metabolism in hyperinsulinemic and hyperleptinemic Zucker obese fa/fa rats. Serum and hepatic cholesterol and triglyceride levels, as well as VLDL-triglyceride and LDL-cholesterol, were significantly lower in rats fed soy protein than in rats fed a casein diet for 160 days. The reduction in hepatic cholesterol was associated with a low expression of liver X receptor-alpha and its target genes, 7-alpha hydroxylase and ABCA1. Soy protein also decreased the expression of SREBP-1 and several of its target genes, FAS, stearoyl-CoA desaturase-1, and delta5 and delta6 desaturases, decreasing lipogenesis even in the presence of hyperinsulinemia. Reduction in SREBP-1 was not associated with the presence of soy isoflavones. Finally, soy protein reduced SREBP-1 expression in adipocytes, preventing hypertrophy, which also helps prevent the development of hepatic lipotoxicity.

Ambulatory hypercholesterolemia management in patients with atherosclerosis. Gender and race differences in processes and outcomes

OBJECTIVE

To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control.

DESIGN

Retrospective cohort study.

SETTING

Primary care clinics affiliated with an academic medical center.

PARTICIPANTS

Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)>130 mg/dl.

MEASUREMENTS AND MAIN RESULTS

The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C <130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C <130 mg/dl and gender.

CONCLUSIONS

In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.

Genetic polymorphisms affecting the phenotypic expression of familial hypercholesterolemia

The clinical expression of heterozygous familial hypercholesterolemia (FH) is highly variable even in patients carrying the same LDL receptor (LDL-R) gene mutation. This variability might be due to environmental factors as well as to modifying genes affecting lipoprotein metabolism. We investigated Apo E (2, 3, 4), MTP (-493G/T), Apo B (-516C/T), Apo A-V (-1131T/C), HL (-514C/T and -250G/A), FABP-2 (A54T), LPL (D9N, N291S, S447X) and ABCA1 (R219K) polymorphisms in 221 unrelated FH index cases and 349 FH relatives with defined LDL-R gene mutations. We found a significant and independent effect of the following polymorphisms on: (i) plasma LDL-C (Apo E, MTP and Apo B); (ii) plasma HDL-C (HL, FABP-2 and LPL S447X); (iii) plasma triglycerides (Apo E and Apo A-V). In subjects with coronary artery disease (CAD+), the prevalence of FABP-2 54TT genotype was higher (16.5% versus 5.2%) and that of ABCA1 219RK and KK genotypes lower (33.0% versus 51.5%) than in subjects with no CAD. Independent predictors of increased risk of CAD were male sex, age, arterial hypertension, LDL-C level and FABP-2 54TT genotype, and of decreased risk the 219RK and KK genotypes of ABCA1. These findings show that several common genetic variants influence the lipid phenotype and the CAD risk in FH heterozygotes.

Statins in atherosclerosis: lipid-lowering agents with antioxidant capabilities

Low-density lipoprotein (LDL) cholesterol is an established risk factor for coronary heart disease (CHD). In the presence of oxidative stress LDL particles can become oxidized to form a lipoprotein species that is particularly atherogenic. Indeed, oxidized LDL (oxLDL) is pro-inflammatory, it can cause endothelial dysfunction and it readily accumulates within the arterial wall. Several factors may influence the susceptibility of LDL to oxidation, including its size and composition, and the presence of endogenous antioxidant compounds, such as alpha-tocopherol. Individuals with type 2 diabetes or the metabolic syndrome have high levels of oxidative stress and consequently are at an increased risk for cardiovascular events. Reducing oxidative stress has been proposed as a potential approach to prevent CHD and antioxidant vitamins have been employed with encouraging results in experimental models of atherosclerosis. However, clinical trials have not demonstrated consistent beneficial effects of antioxidants on cardiovascular outcomes. Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) are the first-line choice for lowering total and LDL cholesterol levels and they have been proven to reduce the risk of CHD. Recent data suggest that these compounds, in addition to their lipid-lowering ability, can also reduce the production of reactive oxygen species and increase the resistance of LDL to oxidation. It may be that the ability of statins to limit the oxidation of LDL contributes to their effectiveness at preventing atherosclerotic disease.

A genome-wide scan of serum lipid levels in the Old Order Amish

Elevated serum low density lipoprotein cholesterol (LDL-C) and triglyceride (TG) and decreased high density lipoprotein cholesterol (HDL-C) levels are established risk factors for cardiovascular disease (CVD). To identify quantitative trait loci influencing lipid levels, we conducted genome-wide linkage analyses of total serum cholesterol (TSC), HDL-C, ln-transformed TG (LNTG) and LDL-C levels in 612 individuals from 28 families of the Amish Family Diabetes Study (AFDS). Subjects were genotyped for 373 microsatellite markers covering all 22 autosomes and the X chromosome at an average density of 9.7 centimorgans. All lipid traits exhibited moderate estimated heritability (h2 +/- S.E.): TSC, 0.63 +/- 0.11; HDL-C, 0.54 +/- 0.08; LNTG, 0.37 +/- 0.08; LDL-C, 0.62 +/- 0.10. The highest logarithm of the odds (LOD) score observed was 2.47 (P = 0.0003), at 3p25 for LDL-C. LOD scores exceeding 2.0 (P < 0.001) were also observed at 2p23 (LOD = 2.17) and 19p13 (LOD = 2.23) for LDL-C, and at 11q23 (LOD = 2.03) for LNTG. Three additional regions exhibited LOD scores greater than 1.5, corresponding to a P-value of <0.005. Many of the regions suggestively linked in this genome-wide scan contain genes encoding proteins with established roles in lipid metabolism, including apolipoproteins, peroxisome proliferater-activated receptor-gamma and the LDL receptor.