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Jellinger PS, Handelsman Y, Rosenblit PD, Bloomgarden ZT, Fonseca VA, Garber AJ, Grunberger G, Guerin CK, Bell DSH, Mechanick JI, Pessah-Pollack R, Wyne K, Smith D, Brinton EA, Fazio S, Davidson M. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF DYSLIPIDEMIA AND PREVENTION OF CARDIOVASCULAR DISEASE. Endocr Pract 2019; 23:1-87. [PMID: 28437620 DOI: 10.4158/ep171764.appgl] [Citation(s) in RCA: 620] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these guidelines is mandated by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs). METHODS Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. RESULTS The Executive Summary of this document contains 87 recommendations of which 45 are Grade A (51.7%), 18 are Grade B (20.7%), 15 are Grade C (17.2%), and 9 (10.3%) are Grade D. These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world medical care. The evidence base presented in the subsequent Appendix provides relevant supporting information for Executive Summary Recommendations. This update contains 695 citations of which 203 (29.2 %) are EL 1 (strong), 137 (19.7%) are EL 2 (intermediate), 119 (17.1%) are EL 3 (weak), and 236 (34.0%) are EL 4 (no clinical evidence). CONCLUSION This CPG is a practical tool that endocrinologists, other health care professionals, health-related organizations, and regulatory bodies can use to reduce the risks and consequences of dyslipidemia. It provides guidance on screening, risk assessment, and treatment recommendations for a range of individuals with various lipid disorders. The recommendations emphasize the importance of treating low-density lipoprotein cholesterol (LDL-C) in some individuals to lower goals than previously endorsed and support the measurement of coronary artery calcium scores and inflammatory markers to help stratify risk. Special consideration is given to individuals with diabetes, familial hypercholesterolemia, women, and youth with dyslipidemia. Both clinical and cost-effectiveness data are provided to support treatment decisions. ABBREVIATIONS 4S = Scandinavian Simvastatin Survival Study A1C = glycated hemoglobin AACE = American Association of Clinical Endocrinologists AAP = American Academy of Pediatrics ACC = American College of Cardiology ACE = American College of Endocrinology ACS = acute coronary syndrome ADMIT = Arterial Disease Multiple Intervention Trial ADVENT = Assessment of Diabetes Control and Evaluation of the Efficacy of Niaspan Trial AFCAPS/TexCAPS = Air Force/Texas Coronary Atherosclerosis Prevention Study AHA = American Heart Association AHRQ = Agency for Healthcare Research and Quality AIM-HIGH = Atherothrombosis Intervention in Metabolic Syndrome With Low HDL/High Triglycerides trial ASCVD = atherosclerotic cardiovascular disease ATP = Adult Treatment Panel apo = apolipoprotein BEL = best evidence level BIP = Bezafibrate Infarction Prevention trial BMI = body mass index CABG = coronary artery bypass graft CAC = coronary artery calcification CARDS = Collaborative Atorvastatin Diabetes Study CDP = Coronary Drug Project trial CI = confidence interval CIMT = carotid intimal media thickness CKD = chronic kidney disease CPG(s) = clinical practice guideline(s) CRP = C-reactive protein CTT = Cholesterol Treatment Trialists CV = cerebrovascular CVA = cerebrovascular accident EL = evidence level FH = familial hypercholesterolemia FIELD = Secondary Endpoints from the Fenofibrate Intervention and Event Lowering in Diabetes trial FOURIER = Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects With Elevated Risk trial HATS = HDL-Atherosclerosis Treatment Study HDL-C = high-density lipoprotein cholesterol HeFH = heterozygous familial hypercholesterolemia HHS = Helsinki Heart Study HIV = human immunodeficiency virus HoFH = homozygous familial hypercholesterolemia HPS = Heart Protection Study HPS2-THRIVE = Treatment of HDL to Reduce the Incidence of Vascular Events trial HR = hazard ratio HRT = hormone replacement therapy hsCRP = high-sensitivity CRP IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial IRAS = Insulin Resistance Atherosclerosis Study JUPITER = Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin LDL-C = low-density lipoprotein cholesterol Lp-PLA2 = lipoprotein-associated phospholipase A2 MACE = major cardiovascular events MESA = Multi-Ethnic Study of Atherosclerosis MetS = metabolic syndrome MI = myocardial infarction MRFIT = Multiple Risk Factor Intervention Trial NCEP = National Cholesterol Education Program NHLBI = National Heart, Lung, and Blood Institute PCOS = polycystic ovary syndrome PCSK9 = proprotein convertase subtilisin/kexin type 9 Post CABG = Post Coronary Artery Bypass Graft trial PROSPER = Prospective Study of Pravastatin in the Elderly at Risk trial QALY = quality-adjusted life-year ROC = receiver-operator characteristic SOC = standard of care SHARP = Study of Heart and Renal Protection T1DM = type 1 diabetes mellitus T2DM = type 2 diabetes mellitus TG = triglycerides TNT = Treating to New Targets trial VA-HIT = Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial VLDL-C = very low-density lipoprotein cholesterol WHI = Women's Health Initiative.
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Goulart AC, Lotufo PA, Santos IS, Bittencourt MS, Santos RD, Blaha MJ, Jones S, Toth PP, Kulkarni K, Benseñor IM. The relationship between migraine and lipid sub-fractions among individuals without cardiovascular disease: A cross-sectional evaluation in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Cephalalgia 2017; 38:528-542. [DOI: 10.1177/0333102417699181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Recent studies have explored the relationship between dyslipidemia and migraine in a cardiovascular context. Thus, we aimed to evaluate the possible association between lipids, lipoprotein subfractions and migraine according to aura symptoms in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Methods 1,560 women and 1,595 men, without CVD or lipid disorders requiring medication, underwent a baseline clinical assessment. Total-cholesterol and its sub-fractions (LDL, VLDL and HDL subclass cholesterol); triglycerides and triglyceride-rich lipoprotein cholesterol [TRL-C (VLDL1+2-C VLDL3-C + IDL-C)] were determined by vertical auto profile (VAP). We also calculated logarithmic LDL density ratio [LLDR = ln ((LDL3-C + LDL4-C)/(LDL1-C + LDL2-C))], T-Chol/HDL-C and triglycerides/HDL-C ratios. Odds ratios (OR) with 95% confidence intervals (CI) were obtained to evaluate the relationship between lipids tertiles and migraine for both sexes. Results Main findings revealed positive associations between migraine without aura (MO) and the highest tertiles of VLDL-C (OR, 1.61; 95%CI, 1.07–2.40) and TRL-C (OR, 1.55; 95% CI, 1.03–2.34) in women. In men, the highest tertile of VLDL3-C (OR, 3.87; 95%CI, 1.23–12.19) was positively associated with MO, as well. Conclusions In middle-aged participants without CVD or lipid disorders requiring medication, the worst lipid profile was determined by the highest levels of TRL-C and their cholesterol-rich remnants in migraineurs without aura for both sexes.
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Affiliation(s)
| | - Paulo A Lotufo
- Hospital Universitário, University of São Paulo, São Paulo, Brazil
- Center for Clinical and Epidemiological Research, University of São Paulo, Medical School, Sao Paulo, Brazil
| | - Itamar S Santos
- Hospital Universitário, University of São Paulo, São Paulo, Brazil
- Center for Clinical and Epidemiological Research, University of São Paulo, Medical School, Sao Paulo, Brazil
| | | | - Raul D Santos
- Lipid Clinic Heart Institute (InCor) University of Sao Paulo, Medical School Hospital, Sao Paulo, Brazil
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, USA
| | - Steven Jones
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, USA
| | - Peter P Toth
- Department of Preventive Cardiology, CGH Medical Center, Sterling, IL, USA
| | | | - Isabela M Benseñor
- Hospital Universitário, University of São Paulo, São Paulo, Brazil
- Center for Clinical and Epidemiological Research, University of São Paulo, Medical School, Sao Paulo, Brazil
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Abstract
The common clustering of glucose intolerance, insulin resistance, abdominal adiposity, elevated blood pressure, and low HDL cholesterol is referred to as metabolic syndrome. Individuals with this syndrome have an increased risk of developing cardiovascular disease (CVD). The World Health Organisation and the National Cholesterol Education Programme’s Adult Treatment Panel III (NCEP-ATP III) have outlined specific diagnostic criteria for the diagnosis of the metabolic syndrome to help in the Identification of this syndrome in clinical practice. While the WHO criteria were specifically developed for use in research, the NCEP criteria are useful in clinical diagnosis of the metabolic syndrome. The metabolic syndrome is amenable to lifestyle modifications such as increased physical activity, weight loss, and possibly intake of low-glycemic foods. Drug therapy may be used to treat individual components of the syndrome such as elevated blood pressure and dyslipidemia. To control elevated glucose levels (when there is failure of lifestyle modification), medications such as metformin, thiazolidinedione derivatives and alpha glucosidase inhibitors may be used.
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Affiliation(s)
- Dorairaj Prabhakaran
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
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Tabibi H, Imani H, Atabak S, Najafi I, Hedayati M, Rahmani L. Effects of Ginger on Serum Lipids and Lipoproteins in Peritoneal Dialysis Patients: A Randomized Controlled Trial. Perit Dial Int 2016; 36:140-5. [PMID: 26475844 PMCID: PMC4803358 DOI: 10.3747/pdi.2015.00006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/17/2015] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED ♦ BACKGROUND In peritoneal dialysis (PD) patients, one of the major risk factors for cardiovascular disease is lipid abnormalities. This study was designed to investigate the effects of ginger supplementation on serum lipids and lipoproteins in PD patients. ♦ METHODS In this randomized, double-blind, placebo-controlled trial, 36 PD patients were randomly assigned to either the ginger or the placebo group. The patients in the ginger group received 1,000 mg ginger daily for 10 weeks, while the placebo group received corresponding placebos. At baseline and at the end of week 10, 7 mL of blood were obtained from each patient after a 12- to 14-hour fast, and serum concentrations of triglyceride, total cholesterol, low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), and lipoprotein (a) [Lp (a)] were measured. ♦ RESULTS Serum triglyceride concentration decreased significantly up to 15% in the ginger group at the end of week 10 compared with baseline (p < 0.01), and the reduction was significant in comparison with the placebo group (p < 0.05). There were no significant differences between the 2 groups in mean changes of serum total cholesterol, LDL-C, HDL-C, and Lp (a). ♦ CONCLUSION This study indicates that daily administration of 1,000 mg ginger reduces serum triglyceride concentration, which is a risk factor for cardiovascular disease, in PD patients.
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Affiliation(s)
- Hadi Tabibi
- Department of Clinical Nutrition & Dietetics, Faculty of Nutrition and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Hossein Imani
- Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Shahnaz Atabak
- Department of Nephrology, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Iraj Najafi
- Department of Nephrology, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Mehdi Hedayati
- Cellular and Molecular Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Islamic Republic of Iran
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Jellinger PS, Smith DA, Mehta AE, Ganda O, Handelsman Y, Rodbard HW, Shepherd MD, Seibel JA. American Association of Clinical Endocrinologists' Guidelines for Management of Dyslipidemia and Prevention of Atherosclerosis. Endocr Pract 2012; 18 Suppl 1:1-78. [PMID: 22522068 DOI: 10.4158/ep.18.s1.1] [Citation(s) in RCA: 296] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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McAna JF, Goldfarb NI, Couto J, Henry MA, Piefer G, Rapier GM. Improved Cardiac Management with a Disease Management Program Incorporating Comprehensive Lipid Profiling. Popul Health Manag 2012; 15:46-51. [DOI: 10.1089/pop.2011.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John F. McAna
- Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Neil I. Goldfarb
- Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph Couto
- Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Gary Piefer
- WellMed Medical Management, Inc., San Antonio, Texas
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Kooshki A, Taleban FA, Tabibi H, Hedayati M. Effects of Omega-3 Fatty Acids on Serum Lipids, Lipoprotein (a), and Hematologic Factors in Hemodialysis Patients. Ren Fail 2011; 33:892-8. [DOI: 10.3109/0886022x.2011.605536] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
A family history of coronary heart disease (CHD) is an accepted risk factor for cardiovascular events and is independent of common CHD risk factors. Advances in the understanding of genetic influences on CHD risk provide the opportunity to apply this knowledge and improve patient care. Utility of inherited cardiovascular risk testing exists by utilizing both phenotypes and genotypes and includes improved CHD risk prediction, selection of the most appropriate treatment, prediction of outcome, and family counseling. The major impediment to widespread clinical adoption of this concept involves un-reimbursed staff time, educational needs, access to a standardized and efficient assessment mechanism, and privacy issues. The link between CHD and inheritance is indisputable and the evidence strong and consistent. For clinicians, the question is how to utilize this information, in an efficient manner, in order to improve patient care and detection of high-risk family members.
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Affiliation(s)
- H Robert Superko
- Center for Genomics and Human Health, Saint Joseph's Translational Research Institute, Atlanta, Georgia, USA.
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9
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SHAKERI A, TABIBI H, HEDAYATI M. Effects of l-carnitine supplement on serum inflammatory cytokines, C-reactive protein, lipoprotein (a), and oxidative stress in hemodialysis patients with Lp (a) hyperlipoproteinemia. Hemodial Int 2010; 14:498-504. [DOI: 10.1111/j.1542-4758.2010.00476.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tabibi H, Imani H, Hedayati M, Atabak S, Rahmani L. Effects of Soy Consumption on Serum Lipids and Apoproteins in Peritoneal Dialysis Patients: A Randomized Controlled Trial. Perit Dial Int 2009; 30:611-8. [DOI: 10.3747/pdi.2009.00161] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Lipid abnormalities, particularly high serum concentration of lipoprotein(a) [Lp(a)], are one of the major risk factors for cardiovascular disease (CVD) in peritoneal dialysis (PD) patients. The present study was designed to investigate the effects of soy consumption on serum lipids and apoproteins, especially Lp(a), in PD patients. Methods This study was a randomized clinical trial in which 40 PD patients (20 males, 20 females) were randomly assigned to either the soy or the control group. Patients in the soy group received 28 g/day textured soy flour (containing 14 g of soy protein) for 8 weeks, whereas patients in the control group received their usual diet, without any soy. At baseline and the end of week 8 of the study, 5 mL of blood was collected from each patient after a 12- to 14-hour fast and serum triglyceride, total cholesterol, low density lipoprotein-cholesterol (LDL-C), high density lipoprote-incholesterol (HDL-C), apoprotein B100 (apo B100), apoprotein AI (apo AI), and Lp(a) were measured. Results In the present study, serum Lp(a) concentrations were above the normal range in 86% of the PD patients. Mean serum Lp(a) concentration was reduced significantly, by 41%, in the soy group at the end of week 8 compared to baseline ( p < 0.01); the reduction was also significant compared to the control group ( p < 0.05). During the study, mean serum Lp(a) concentration did not change significantly in the control group. There were no significant differences between the two groups in mean changes in serum triglyceride, total cholesterol, HDL-C, LDL-C, apo B100, or apoAI. Conclusion The results of our study indicate that soy consumption reduces serum Lp(a) concentration, which is a risk factor for cardiovascular disease in peritoneal dialysis patients.
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Affiliation(s)
| | - Hossein Imani
- Faculty of Nutrition Sciences and Food Technology, Iran
| | - Mehdi Hedayati
- National Nutrition and Food Technology Research Institute; Prevention & Treatment of Obesity Research Center, Iran
| | - Shahnaz Atabak
- Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences & Health Services; Department of Nephrology, Iran
| | - Leila Rahmani
- Shahid Modares Hospital, Shahid Beheshti University of Medical Sciences & Health Services, Tehran, Iran
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Wu SC, Shiang JC, Lin SL, Wu TL, Huang WC, Chiou KR, Liu CP. Efficacy and safety of statins in hypercholesterolemia with emphasis on lipoproteins. Heart Vessels 2006; 20:217-23. [PMID: 16160904 DOI: 10.1007/s00380-005-0836-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2004] [Accepted: 03/25/2005] [Indexed: 10/25/2022]
Abstract
Information of the effect of statin on lipoproteins such as apolipoprotein (apo) A-I, lipoprotein (a) [Lp (a)], or apolipoprotein B levels is limited. This investigation was a crossover study designed to evaluate the efficacy and safety of atorvastatin and simvastatin in patients with hyperlipidemia. Sixty-six patients were involved in the study. Group I consisted of 32 patients, who were first treated with atorvastatin (10 mg) then switched to simvastatin (10 mg). Group II consisted of 34 patients, who were first treated with simvastatin then switched to atorvastatin. Each regimen was used for 3 months (phase I), stopped for 2 months, and then restarted for another 3 months (phase II). Both statins effectively reduced total cholesterol, low-density lipoprotein cholesterol (LDL-C), apo B, and Lp (a) (P < 0.001 in all comparisons). A significant increase in the high-density lipoprotein cholesterol (HDL-C) was noted after both statin treatments (P < 0.05 in all comparisons). Both statins caused an increase in the apo A-I levels, and the extent of changes in apo A-I revealed no difference between the two drugs. Compared to the simvastatin group, there were more patients in the atorvastatin group achieving the National Cholesterol Education Program ATP-III LDL-C goal (P < 0.05) and European LDL-C goal (P < 0.001). Both treatments were well tolerated; no patient was withdrawn from the study. This study demonstrates that both statins can effectively improve lipid profiles in patients with hyperlipidemia. Atorvastatin is more effective in helping patients reach the ATP-III and European LDL-C goals than simvastatin at the same dosage.
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Affiliation(s)
- San-Chiang Wu
- Department of Human Resource Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
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van Wissen S, Smilde TJ, Trip MD, de Boo T, Kastelein JJP, Stalenhoef AFH. Long term statin treatment reduces lipoprotein(a) concentrations in heterozygous familial hypercholesterolaemia. Heart 2003; 89:893-6. [PMID: 12860867 PMCID: PMC1767793 DOI: 10.1136/heart.89.8.893] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Raised plasma lipoprotein(a) (Lp(a)) is associated with increased risk of cardiovascular disease. It is unknown whether increased Lp(a) is an additional risk factor for coronary artery disease in familial hypercholesterolaemia (FH) or whether statin treatment can reduce Lp(a) concentrations in the long term. OBJECTIVE To investigate Lp(a) concentrations in relation to statin treatment and the progression of atherosclerosis in a large cohort of FH patients. DESIGN A two year, randomised, double blind trial (the ASAP trial). PATIENTS 325 heterozygous FH patients. INTERVENTION Treatment with 80 mg atorvastatin or 40 mg simvastatin. MAIN OUTCOME MEASURE Change in Lp(a) concentrations and intima-media thickness of carotid artery segments at one year and two years. RESULTS At baseline, median Lp(a) concentrations were 327 mg/l and 531 mg/l in the atorvastatin and simvastatin arms, respectively (p = 0.03). In the atorvastatin arm, Lp(a) concentrations decreased to 243 mg/l after one year (p < 0.001) and to 263 mg/l after two years (p < 0.001). In the simvastatin arm, Lp(a) concentrations decreased to 437 mg/l after one year (p < 0.001) and to 417 mg/l after two years (p < 0.001). The difference in Lp(a) reduction between the two treatment arms was significant after one year (p = 0.004), but not after two years (p = 0.086). Lp(a) concentrations at baseline were not related to cardiovascular events at baseline. There was no correlation between baseline Lp(a) concentrations and low density lipoprotein cholesterol concentrations or intima-media thickness at baseline. Change in Lp(a) concentrations was not correlated with change in intima-media thickness after one or two years. CONCLUSIONS Long term statin treatment significantly lowers Lp(a) in FH patients. However, this reduction was unrelated to changes in intima-media thickness and casts doubt on the importance of Lp(a) in the progression of atherosclerotic disease in these patients.
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Affiliation(s)
- S van Wissen
- Department of Vascular Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
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van Oostrom AJHHM, Sijmonsma TP, Verseyden C, Jansen EHJM, de Koning EJP, Rabelink TJ, Castro Cabezas M. Postprandial recruitment of neutrophils may contribute to endothelial dysfunction. J Lipid Res 2003; 44:576-83. [PMID: 12562833 DOI: 10.1194/jlr.m200419-jlr200] [Citation(s) in RCA: 183] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Atherosclerosis is a low-grade inflammatory disease involving leukocytes, lipids, and glucose leading to endothelial dysfunction. Since activation of neutrophils by triglycerides and glucose has been described in vitro, we hypothesized that the postprandial phase is an inflammatory state affecting leukocytes, possibly contributing to endothelial dysfunction. We measured postprandial blood leukocyte counts, cytokines, hydroperoxides (HPOs), and flow-mediated vasodilation (FMD) in eight healthy males (age 23 +/- 2 years) after a FAT (50 g/m2) and GLUCOSE challenge (37.5 g/m2), a combination of both (MIXED test), and after WATER. All tests, except WATER, resulted in significantly impaired FMD (10% reduction) between t = 1 h and t = 3 h, accompanied by a significant increase of neutrophils (59% after FAT and 28% after GLUCOSE and MIXED), total plasma HPOs (15 to 31% increase), and plasma interleukin-8 (IL-8) (50-130% increase). WATER did not affect FMD, neutrophils, HPOs, or IL-8. Lymphocytes increased gradually in all tests (40-70% increase at t = 10 h compared with t = 0; P < 0.005), paralleling a gradual 3- to 5-fold interleukin-6 increase. Monocyte and erythrocyte counts did not change in any test. In conclusion, the neutrophil increment during postprandial lipemia and glycemia with concomitant IL-8 and HPO increases may contribute to endothelial dysfunction. Lymphocyte increment is a nonspecific diurnal process. Postprandial intravascular inflammatory changes may be relevant for the pathogenesis of atherosclerosis.
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Affiliation(s)
- A J H H M van Oostrom
- Department of Vascular Medicine, University Medical Center, Utrecht, The Netherlands
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Hirany, MS SV, Rainwater, PhD DL, Devaraj, PhD S, Othman, PhD Y, Jialal, MD, PhD I, Kutscher, MS P. Comparison of Low-Density Lipoprotein Size by Polyacrylamide Tube Gel Electrophoresis and Polyacrylamide Gradient Gel Electrophoresis. Am J Clin Pathol 2003. [DOI: 10.1309/h4e6-ktyu-fff2-3hfn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Superko HR, Chronos NA. Hypercholesterolemia and Dyslipidemia: Issues for the Clinician. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2003; 5:35-50. [PMID: 12686017 DOI: 10.1007/s11936-003-0013-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The current state of the art in the diagnosis and treatment of lipoprotein disorders has progressed beyond the standard "lipid profile," which includes total low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol, along with fasting triglycerides. Incorporating aspects of the atherogenic lipoprotein profile (ALP) (ALP and LDL subclass distribution), HDL subclass distribution, apolipoprotein E isoforms, lipoprotein (a), homocysteine, and high-sensitivity C-reactive protein provides the clinician with the tools to create a more detailed, accurate, and personalized diagnosis of disorders contributing to coronary artery disease in their patients. Sophisticated laboratory tests are available to clinicians through technology transfer programs as exemplified by the Lawrence Berkeley National Laboratory/Berkeley HeartLab, Berkeley, CA, collaboration and allow clinicians access to research quality laboratory tools. This has significant clinical relevance because the presence of these disorders guides treatment that is specific to the disorder(s). Appropriate treatment has been shown to have significantly greater clinical benefit in patient subgroups exhibiting the disorder the therapy is most likely to correct. A single drug or lifestyle therapy plan is no longer appropriate for all patients. The treatment must match the individual disorder(s).
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Affiliation(s)
- H. Robert Superko
- American Cardiovascular Research Institute, 5665 Peachtree Dunwoody Road, Suite 225, Atlanta, GA 30342, USA.
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Superko HR, Nejedly M, Garrett B. Small LDL and its clinical importance as a new CAD risk factor: a female case study. PROGRESS IN CARDIOVASCULAR NURSING 2003; 17:167-73. [PMID: 12417832 DOI: 10.1111/j.0889-7204.2002.01453.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The underlying metabolic cause of coronary heart disease in many patients is not high blood cholesterol. In fact, the Framingham study has reported that 80% of individuals who go on to have coronary artery disease have the same total blood cholesterol values as those who do not go on to have a cardiovascular event. The most common metabolic contributor to coronary artery disease is the atherogenic lipoprotein profile, characterized by an abundance of highly atherogenic small, dense low-density lipoprotein particles and a deficiency of the high-density lipoprotein (HDL) subtype most associated with coronary artery disease protection (HDL(2b)). This trait is present in 50% of men with coronary artery disease and is not reflected by total or low-density lipoprotein cholesterol values. While fasting triglycerides tend to he higher, and HDL cholesterol lower in patients with the atherogenic lipoprotein profile, the majority have triglyceride and HDL cholesterol values generally accepted to be in the "normal" range. An abundance of basic science and clinical trial evidence convincingly indicates that the presence of an atherogenic lipoprotein profile signifies a three-fold increased risk for a cardiovascular event and rapid arteriographic progression, but it also identifies a group of patients who respond particularly well to specific therapeutic interventions. Often the most effective interventions are the least expensive.
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Affiliation(s)
- H Robert Superko
- Advanced Cardiovascular Prevention Program, American Cardiovascular Research Institute, Atlanta, GA 30342, USA.
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Otvos JD, Shalaurova I, Freedman DS, Rosenson RS. Effects of pravastatin treatment on lipoprotein subclass profiles and particle size in the PLAC-I trial. Atherosclerosis 2002; 160:41-8. [PMID: 11755921 DOI: 10.1016/s0021-9150(01)00544-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lipoprotein subclass analyses may facilitate coronary heart disease (CHD) risk stratification and provide insight into the cardioprotective benefits of statins (3-hydroxymethylglutaryl-coenzyme A reductase inhibitors). This study evaluated the influence of pravastatin on lipoprotein subclass profiles to determine whether subjects with predominantly large LDL (LDL size >20.5 nm) or small LDL (LDL size < or =20.5 nm) at baseline differ in responsiveness to drug treatment. Frozen plasma specimens were analyzed from a subset of participants in the Pravastatin Limitation of Atherosclerosis in the Coronaries (PLAC-I) trial at baseline and after treatment for 6 months with pravastatin (n=154) or placebo (n=138). Lipids were measured by standard chemical methods and lipoprotein subclasses by nuclear magnetic resonance (NMR) spectroscopy. Pravastatin-induced changes in lipid levels were similar in subjects with large or small LDL at baseline. Levels of the most abundant LDL subclass were preferentially lowered by pravastatin, resulting in an increase in average LDL size for those with a predominance of small LDL. High-risk CHD subjects with small LDL particles gain at least as much pharmacological benefit from pravastatin as those with large LDL, as evidenced by reductions in the numbers of total and small LDL particles, and increases in average LDL and HDL particle size.
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Affiliation(s)
- James D Otvos
- Department of Biochemistry, North Carolina State University, Raleigh, NC, USA
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18
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Abstract
Recently published data have greatly expanded the applicability of electron beam tomography (EBT) and electron beam angiography (EBA). The prognostic power of coronary artery calcium scoring for cardiac events and associated obstructive disease far surpasses that of conventional risk factors, and will increasingly be incorporated into risk assessment and treatment guidelines. EBT leads to the identification of treatable, non-low-density lipoprotein metabolic disorders that contribute to plaque formation, and to appropriate selection of stress test candidates. Change in calcium score can be used to assess the efficacy of lipid therapy and will serve as a surrogate marker in drug studies. EBA provides effective, noninvasive visualization of native coronary arteries and bypass grafts.
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Affiliation(s)
- H S Hecht
- Department of Preventive Cardiology and Electron Beam Tomography, Heart & Vascular Institute, 111 Madison Avenue, Morristown, NJ 07960, USA.
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19
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Superko HR, Hecht HS. Metabolic disorders contribute to subclinical coronary atherosclerosis in patients with coronary calcification. Am J Cardiol 2001; 88:260-4. [PMID: 11472704 DOI: 10.1016/s0002-9149(01)01637-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This investigation determined the prevalence of low-density lipoprotein (LDL) subclass distribution abnormalities, elevated lipoprotein(a) (Lp(a)), and elevated total plasma homocysteine in asymptomatic subjects with subclinical coronary artery disease determined by electron beam tomography (EBT). Fifty-five percent of subjects were classified as higher risk patients and 45% as lower risk patients, employing the National Cholesterol Education Program (NCEP) lipid criteria. EBT was performed in 296 consecutive asymptomatic subjects, and blood was analyzed for total, LDL, and high-density lipoprotein (HDL) cholesterol, triglycerides, LDL subclass distribution by S(3) gradient gel electrophoresis, Lp(a), and total homocysteine. Disorders of LDL subclass distribution were the most common disorder with 60.6% of the population expressing a distribution in the small regions IIIa + IIIb of >20%; and this was more common in the NCEP higher risk group (LDL cholesterol > or =130 and/or HDL cholesterol <35 mg/dl) (p <0.0004). A Lp(a) value >25 mg/dl was found significantly more often in the NCEP higher (36.9%) compared with lower (14.3%) risk group (p <0.001). None of the laboratory measurements correlated with the calcium score or calcium score percentile rank, with the exception of a weak correlation of mean LDL peak particle diameter and calcium percentile (r = 0.14, p = 0.02). Determination of metabolic disorders in addition to LDL cholesterol and HDL cholesterol increased the diagnostic yield from 55.1%, based on NCEP lipid criteria, to 84.1% with the addition of LDL subclass distribution, Lp(a), and total homocysteine. We conclude that: (1) disorders of LDL subclass distribution and elevated Lp(a) occur frequently in NCEP higher risk patients with subclinical coronary artery disease and are the only identifiable disorders in lower NCEP risk patients; and (2) electron beam tomographic evaluation and determination of LDL subclass distribution and Lp(a) should be considered for incorporation into primary prevention guidelines.
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Affiliation(s)
- H R Superko
- Berkeley HeartLab, University of California, Berkeley, California 94010, USA.
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20
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Leander K, Hallqvist J, Reuterwall C, Ahlbom A, de Faire U. Family history of coronary heart disease, a strong risk factor for myocardial infarction interacting with other cardiovascular risk factors: results from the Stockholm Heart Epidemiology Program (SHEEP). Epidemiology 2001; 12:215-21. [PMID: 11246583 DOI: 10.1097/00001648-200103000-00014] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We explored the relation between family history of coronary heart disease and the risk of myocardial infarction in a case-control study of subjects, 45 to 70 years of age, living in Stockholm, Sweden. Our cases comprised 1091 male and 531 female first-time acute myocardial infarction patients who had survived at least 28 days after their infarction. Referents were randomly selected from the population from which the cases were derived. The adjusted odds ratio (OR) of myocardial infarction was 2.0 (95% confidence interval [CI] = 1.6-2.6) for men reporting > or = 1 affected parent or sibling, compared with men with no family history of coronary heart disease, and 3.4 (95% CI = 2.1-5.9) for those reporting > or = 2 affected parents or siblings. The corresponding OR for women were 2.1 (95% CI = 1.5-3.0) and 4.4 (95% CI = 2.4-8.1). We found evidence for synergistic interactions in women exposed to family history of coronary heart disease in combination with current smoking and with a high quotient between low-density lipoprotein and high-density lipoprotein cholesterol (>4.0), respectively, which yielded adjusted synergy index scores of 2.9 (95% CI = 1.2-7.2) and 3.8 (95% CI = 1.5-9.7), respectively. Similarly, in men we found evidence for interaction for the co-exposure of family history of coronary heart disease and diabetes mellitus. Our study shows that family history of coronary heart disease is not only a strong risk factor for myocardial infarction in both sexes, but that its effect is synergistic with other cardiovascular risk factors as well.
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Affiliation(s)
- K Leander
- Division of Cardiovascular Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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21
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Moriarty PM, Gibson CA. Low-density lipoprotein apheresis in the treatment of atherosclerosis and other potential uses. Curr Atheroscler Rep 2001; 3:156-62. [PMID: 11177660 DOI: 10.1007/s11883-001-0052-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This review concerns the clinical impact of low-density lipoprotein (LDL) apheresis for patients with refractory hypercholesterolemia. We examine and provide examples of investigations that have demonstrated the clinical benefits of LDL apheresis. In addition to benefits derived from the stabilization or regression of arterial lesions, we highlight other possible mechanisms related to clinical improvement. We also discuss the potential advantages of lipid apheresis for the treatment of patient populations other than those characterized by severe hypercholesterolemia and premature coronary heart disease.
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Affiliation(s)
- P M Moriarty
- Lipid, Atherosclerosis, and Metabolic Clinic, University of Kansas Medical Center, 1336 KU Hospital, 3901 Rainbow Boulevard, Kansas City, KS 66160-7374, USA.
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22
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Després JP, Lemieux I, Dagenais GR, Cantin B, Lamarche B. HDL-cholesterol as a marker of coronary heart disease risk: the Québec cardiovascular study. Atherosclerosis 2000; 153:263-72. [PMID: 11164415 DOI: 10.1016/s0021-9150(00)00603-1] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Primary as well as secondary prevention trials have shown the relevance of lowering LDL-cholesterol to reduce coronary heart disease (CHD) risk. However, although the association between LDL-cholesterol and CHD is well recognized, there is a considerable overlap in the distribution of plasma LDL-cholesterol levels between CHD patients and healthy subjects. The objective of the present review article is to use data from the Quebec cardiovascular study to demonstrate that in men, a low HDL-cholesterol may be even more of a risk factor and a target for therapy than a high LDL-cholesterol. METHODS AND RESULTS Results of the Quebec cardiovascular study, a prospective study of 2103 middle-aged men followed for a period of 5 years, have confirmed results of previous studies in showing that plasma HDL-cholesterol concentration was an independent predictor of a first ischemic heart disease (IHD) event which included typical effort angina, coronary insufficiency, nonfatal myocardial infarction and coronary death. In addition, a reduced plasma HDL-cholesterol concentration was found to have a greater impact than raised LDL-cholesterol on the atherogenic index (total cholesterol/HDL-cholesterol ratio), this ratio being the best variable of the traditional lipid profile for the prediction of IHD events in the Quebec cardiovascular study. However, a low HDL-cholesterol concentration is not often observed as an isolated disorder but also includes hypertriglyceridemia, elevated apo B concentration, and an increased proportion of small, dense LDL particles. These abnormalities are features of an insulin resistant-hyperinsulinemic state resulting from abdominal obesity. CONCLUSIONS It is therefore recommended that we need to go beyond LDL-cholesterol measurement lowering therapy for the optimal management of CHD risk. Raising plasma HDL-cholesterol through weight loss and a healthy diet, by an increased physical activity and, if required, by proper pharmacotherapy is therefore a legitimate therapeutic target for the optimal prevention of CHD in a large proportion of high risk patients.
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Affiliation(s)
- J P Després
- Québec Heart Institute, Laval Hospital Research Center, Sainte-Foy, Canada.
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23
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Beery TA. THE EVOLVING ROLE OF GENETICS IN THE DIAGNOSIS AND MANAGEMENT OF HEART DISEASE. Nurs Clin North Am 2000. [DOI: 10.1016/s0029-6465(22)02650-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Abstract
Disorders of low-density lipoprotein (LDL) and high- density lipoprotein (HDL) subclass distribution are more common contributors to coronary artery disease (CAD) than is elevated low-density lipoprotein cholesterol (LDLC). Recent research has emphasized the importance of LDL and HDL subclass distribution in patient management and response to treatments. Laboratory determination of LDL and HDL subclass distribution involves analytic ultracentrifugation or polyacrylalmide gradient gel electrophoresis. If subclass distribution is to be used for patient management, research quality control and standards are necessary in order to assure that the patient's values accurately reflect the metabolic disorder. The importance of this topic for patient care has been recognized by the medical insurance industry. Investigations employing electron beam computed tomography in asymptomatic individuals has revealed that 50% with established CAD have normal lipids by National Cholesterol Education Program (NCEP) criteria. However, a large proportion of other metabolic contributors to CAD are not revealed by routine blood tests.
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Affiliation(s)
- H R Superko
- Lawrence Berkeley National Laboratory, University of California, Berkeley, CA 94720, USA. www.berkeleyheartlab.com
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25
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Abstract
Disorders of cholesterol and lipoprotein metabolism are at the heart of atherosclerosis and coronary artery disease (CAD). CAD, however, is a metabolic disorder that involves a complex interaction between genetic susceptibility and environmental conditions. Despite considerable success in the treatment of hypercholesterolemia, atherosclerosis remains the leading cause of death in most Western countries. Although cholesterol-lowering trials have revealed a 25% to 30% reduction in clinical events, most patients continue to have events even when treated successfully with cholesterol-lowering medications (Fig. 1). This less-than-optimal result is partly because atherosclerosis is a multifactorial disease. Although disorders of lipoprotein metabolism are found in more than 80% of patients with CAD, these disorders are very heterogeneous, and single-drug therapy aimed at one disorder should not be expected to improve the disease status in most patients. Metabolic treatment still requires identification and treatment of patients with high cholesterol levels, but the focus has shifted to identifying high-risk patients in groups previously thought to be low risk, or to identifying disorders coexistent with high cholesterol levels that are not corrected by standard cholesterol-lowering medications (Table 1). The ability to detect high-risk CAD traits, which are often inherited, and to predict response to treatment has substantially improved in the past few years. These improvements allow identification of metabolic subgroups of patients, which can alter risk prediction and response to specific treatments. Sophisticated laboratory methods permit physicians to apply this knowledge to patient care and to enter a new era of CAD risk factor detection and treatment. These advances allow for a more scientific approach than did the previously standard epidemiologic risk factors and routine blood lipid profiles. The current state-of-the-art method of diagnosing and treating lipoprotein disorders has progressed beyond the standard "lipid profile," which includes total, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol along with fasting triglyceride levels. Incorporating aspects of the atherogenic lipid profile (ALP), LDL subclass distribution, HDL subclass distribution, apo E isoforms, and lipoprotein (a) provides the interested clinician with the tools to create a more detailed and accurate diagnosis of lipoprotein disorders. Sophisticated laboratory tests are available to clinicians through technology transfer programs, as exemplified by the Lawrence Berkeley National Laboratory/Berkeley HeartLab collaboration, and allow clinicians access to research-quality laboratory tools. This has significant clinical relevance because the presence of these disorders guides treatment specific to the disorder(s). Appropriate treatment is more beneficial in subgroups exhibiting the disorder that the therapy is most likely to correct. A single drug or lifestyle therapy is no longer appropriate for all patients. The treatment must match the disorder.
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26
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Abstract
Interactions of genetic and environmental risk factors influence the susceptibility to coronary artery disease (CAD) and myocardial infarction. In myocardial infarction occurring at young age, genetics of this multifactorial disease may be the leading factor. A number of candidate genes have been implicated in the pathogenesis of CAD and myocardial infarction. Mutations in the DNA sequence (gene polymorphisms) have been identified that appear to play a crucial role in blood pressure regulation, lipid metabolism, endothelial function, in the pathophysiology of coagulation or thrombosis, or in interventional cardiology by interfering with restenosis development. Genetic polymorphisms seem to be clinically important because they not only potentiate the individual risk under certain circumstances, but they also determine safety and effectiveness of commonly prescribed drugs. Understanding the complexity and functional relevance of genetic risk factors will be useful in early detection and treatment of individuals that are exposed to higher risk for myocardial infarction. Thus it is important to include genetic risk factors in the concept of the classical risk factor theory. Potentially in future a genetic risk profile including relevant polymorphisms may be an essential part of the clinicians' knowledge in primary and secondary prevention of coronary artery disease.
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Affiliation(s)
- D H Walter
- Abteilung Kardiologie, Johann-Wolfgang-Goethe-Universität Frankfurt/Main.
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27
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Abstract
In only 50% of cases of coronary heart disease (CHD) is the cause attributable to the established risk factors of hypertension, cigarette smoking, and elevated total and low-density lipoprotein (LDL) cholesterol levels. This finding has led to research examining other markers for CHD that may have a causal link to the atherothrombotic process. Several of these "emerging" risk factors are reviewed in this article: lipoprotein(a); small dense LDL particle size; hyperhomocysteinemia; and inflammatory, infectious, and hemostatic factors. Evaluation of each of these factors includes a review of the epidemiologic evidence, examination of the pathologic mechanism(s) by which the factor might participate in atherothrombosis, and the clinical utility of screening. Finally, and most relevant for the practicing clinician, the following is addressed: Does evidence exist that selective modification of these risk factors is associated with net clinical benefit?
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Affiliation(s)
- S Hughes
- The Heart Group, Inc., Akron, Ohio, USA
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28
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Superko HR. Small, dense low-density lipoprotein subclass pattern B: issues for the clinician. Curr Atheroscler Rep 1999; 1:50-7. [PMID: 11122692 DOI: 10.1007/s11883-999-0050-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A large portion of coronary artery disease (CAD) can be attributed to disorders of lipoprotein metabolism. However, these disorders are a complex interaction of genetic susceptibility and environmental interaction. The most common disorder of lipoprotein metabolism contributing to CAD is the Small, Dense Low-Density Lipoprotein Pattern B disorder, also known as the Atherogenic Lipoprotein Profile (ALP), which consists of multiple metabolic disorders. This disorder is an independent risk factor for CAD and in patients with established CAD, identifies a subgroup with a twofold greater rate of arteriographic progression compared with CAD patients without this disorder. Treatment of the disorder is specific to lifestyle and some pharmacologic agents. The most effective treatments are often the least expensive.
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Affiliation(s)
- H R Superko
- Cholesterol, Genetics, and Heart Disease Institute, Berkeley HeartLab, Lawrence Berkeley National Laboratory, University of California, Berkeley, USA
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