Drug therapy for hypercholesterolemia in patients with cardiovascular disease: factors limiting achievement of lipid goals

Real-World Effectiveness of Lipid-Lowering Therapy in Male and Female Outpatients with Coronary Heart Disease: Relation to Pre-Treatment Low-Density Lipoprotein-Cholesterol, Pre-Treatment Coronary Heart Disease Risk, and other Factors

Background

Determinants of the real-world effectiveness of lipid-lowering therapy have been rarely assessed in an unselected observational coronary heart disease (CHD) community cohort over time.

Design

Randomly drawn patients (n = 605) from randomly drawn practices (n = 62) were retrospectively followed for a median of 3.6 years (1998-2002) on lipid-lowering therapy (98% statins).

Methods

Coronary heart disease population-averaged estimates and variances accounting for repeated measurements within patients were obtained using generalized estimating equations.

Results

Post-treatment low-density lipoprotein-cholesterol (LDL-C) was 124 mg/dl in men and 141 mg/dl in women and was independently associated (all P<0.05) with pre-treatment LDL-C (+ 3.7 mg/dl per 10 mg/dl increment), female sex (+ 14.0 mg/dl), coronary bypass (-9.5 mg/dl), drug-treated diabetes mellitus (-6.8 mg/dl), and era 2002/2001 versus 1999/2000 (- 6.4 mg/dl) in age-adjusted multivariate analyses. Holding pre-treatment LDL-C constant post-treatment LDL-C was associated with pre-treatment Framingham CHD risk in men (- 13.9 mg/dl per doubling of risk), whereas LDL-C control in women resembled that in low-risk men. The likelihood of attaining LDL-C < 100 mg/dl was 0.28 in men and 0.17 in women and was likewise associated with the above factors.

Conclusion

Low-density lipoprotein-cholesterol control remained low despite lipid-lowering therapy across a wide range of pre-treatment LDL-C and pre-treatment CHD risk. Low-density lipoprotein-cholesterol control in women was inferior to that in men, a finding that warrants attention and clarification. Eur J Cardiovasc Prev Rehabil 12:37-45 © 2005 The European Society of Cardiology

Effects of Policosanol and Ticlopidine in Patients with Intermittent Claudication: A Double-Blinded Pilot Comparative Study

Policosanol is a cholesterol-lowering drug with concomitant antiplatelet effects. The present study was undertaken to compare the effects of policosanol and ticlopidine in patients with moderately severe intermittent claudication (IC). The study had a 4-week baseline step, followed by a 20-week double-blinded, randomized treatment period. Twenty-eight eligible patients were randomized to policosanol 10 mg or ticlopidine 250 mg tablets twice daily (bid). Walking distances in a treadmill (constant speed 3.2 km/hr, slope 10°, temperature 25°C) were assessed before and after 20 weeks of treatment. Both groups were similar at baseline. Compared with baseline, policosanol significantly increased (p<0.01) mean values of initial (ICD) and absolute (ACD) claudication distances from 162.1 to 273.2 m and from 255.8 to 401.0 m, respectively. Ticlopidine also raised significantly (p<0.01) ICD (166.2 to 266.3 m) and ACD (252.9 to 386.4 m). Comparisons between groups did not show significant differences. Policosanol, but not ticlopidine, significantly (p<0.05), but modestly, increased the ankle/arm pressure ratio. After 10 weeks, policosanol significantly (p<0.001) lowered low-density lipoprotein-cholesterol (LDL-C), total cholesterol (TC) (p<0.01), and TC/HDL-C and raised (p<0.05) high-density lipoprotein-cholesterol (HDL-C). At study completion, policosanol lowered (p<0.001) LDL-C (30.2%), TC (16.9%), and TC/HDL-C (33.9%), increased (p<0.01) HDL-C (+31.7%), and left triglycerides unchanged. Ticlopidine did not affect the lipid profile variable. Policosanol induced modest, but significant, reductions (p<0.01) of fibrinogen levels compared with baseline and ticlopidine. Treatments were well tolerated and did not impair safety indicators. Three ticlopidine patients (21.4%) withdrew from the trial, only 1 owing to a serious adverse experience (AE) (unstable angina). Three other ticlopidine patients experienced mild AE (headache, diarrhea, and acidity). It is concluded that policosanol (10 mg bid) can be as effective as ticlopidine (250 mg bid) for improving walking distances of claudicant patients, and it could be advantageous for the global risk of these individuals owing to its cholesterol-lowering effects. This study is, however, just a pilot comparison, so that further studies in larger sample sizes are needed for definitive conclusions of the comparative effects of both drugs on patients with IC.

Antilipidemic Drug Therapy Today and in the Future

The armamentarium for the treatment of dyslipidemia today comprises six different modes of action with overall around 24 different drugs. The treatment of lipid disorders was revolutionized with the introduction of statins which have become the most important therapeutic option available today to reduce and prevent atherosclerosis and its detrimental consequences like cardiovascular diseases and stroke. With and optimized reduction of elevated LDL levels with statins, the risk for cardiovascular diseases (CVD) can be reduced by 30%, indicating a residual remaining risk of 70% for the development and progression of CVD notifying still a high medical need for more effective antilipidemic drugs. Consequently, the search for novel lipid-modifying drugs is still one of the most active areas in research and development in the pharmaceutical industry. Major focus lies on approaches to LDL-lowering drugs superior to statins with regard to efficacy, safety, and patient compliance and on approaches modifying plasma levels and functionality of HDL particles based on the clinically validated inverse relationship between high-plasma HDL levels and the risk for CVD. The available drugs today for the treatment of dyslipidemia are small organic molecules or nonabsorbable polymers for binding of bile acids to be applied orally. Besides small molecules for novel targets, biological drugs such as monoclonal antibodies, antisense or gene-silencing oligonucleotides, peptidomimetics, reconstituted synthetic HDL particles and therapeutic proteins are novel approaches in clinical development are which have to be applied by injection or infusion. The promising clinical results of several novel drug candidates, particularly for LDL cholesterol lowering with monoclonal antibodies raised against PCSK9, may indicate more than a decade after the statins, the entrance of new breakthrough therapies to treat lipid disorders.

Effects of policosanol on borderline to mildly elevated serum total cholesterol levels: a prospective, double-blind, placebo-controlled, parallel-group, comparative study

BACKGROUND

Hypercholesterolemia is a major risk factor for coronary heart disease. Clinical studies have shown that lowering elevated serum cholesterol levels, particularly low-density lipoprotein cholesterol (LDL-C), is beneficial for patients with borderline to mildly elevated serum total cholesterol (TC) levels (5.0-6.0 mmol/L). Policosanol is a cholesterol-lowering drug made from purified sugar cane wax. The therapeutic range of policosanol is 5 to 20 mg/d.

OBJECTIVE

This study investigated the efficacy and tolerability of policosanol 5 mg/d in patients with borderline to mildly elevated serum TC levels.

METHODS

This 14-week, single-center, prospective, double-blind, placebo-controlled, parallel-group, comparative study was conducted in men and women aged 25 to 75 years with a serum TC level ≥4.8 to <6.0 mmol/L. After a 6-week run-in period in which patients were placed on therapeutic lifestyle changes, in particular a cholesterol-lowering diet, patients were randomly assigned to receive policosanol 5-mg tablets or placebo tablets once daily with the evening meal for 8 weeks, and the diet was continued throughout the study. Lipid profile variables, safety indicators, adverse events (AEs), and compliance with study medications were assessed.

RESULTS

One hundred patients (71 women, 29 men; mean [SD] age, 52 [10] years) entered the study after the dietary run-in period. After 8 weeks of treatment, the mean (SD) serum LDL-C level decreased significantly in the policosanol group (P<0.001 vs baseline and placebo) from 3.57 (0.30) mmol/L to 2.86 (0.41) mmol/L (change, -19.9%). Significantly more patients in the policosanol group (42 patients [84%]) achieved a ≥15% decrease in serum LDL-C than in the placebo group (2 patients [4%]) (P<0.001). Also in the policosanol group, the mean (SD) serum TC level decreased significantly, from 5.20 (0.22) mmol/L to 4.56 (0.44) mmol/L (P<0.001 vs baseline and placebo) (change, -12.3%); the mean (SD) triglyceride (TG) level decreased significantly, from 1.59 (0.57) mmol/L to 1.48 (0.57) mmol/L (P<0.01 vs baseline; P<0.05 vs placebo) (change, -6.9%); and the mean (SD) high-density lipoprotein cholesterol (HDL-C) level increased significantly from 1.05 (0.18) mmol/L to 1.16 (0.21) mmol/L (P<0.001 vs baseline and placebo) (change, +10.5%). The percentage changes were significantly different between the policosanol and placebo groups for serum LDL-C, TC, and HDL-C levels (P<0.001, P<0.001, and P<0.05, respectively), but not for TG. In the placebo group, changes in lipid profile variables from baseline were not significant. Policosanol did not significantly impair any safety indicator and was well tolerated. Three patients (3%) (1 patient [2%] in the policosanol group; 2 patients [4%] in the placebo group) withdrew from the trial, none because of AEs. Two patients (1 patient [2%] each in the policosanol and placebo groups) withdrew from the study because of an unwillingness to return for follow-up; 1 patient (2%) in the placebo group had a change of address and could not be followed up. Overall, 4 patients (4%) (1 patient [2%] in the policosanol group; 3 [6%], placebo) reported AEs; all were mild. Of the patients who received placebo and reported AEs, all 3 (6%) experienced heartburn, and 1 (2%) also experienced dry skin, while the policosanol-treated patient (2%) who reported an AE experienced headache.

CONCLUSIONS

In this study of patients with borderline to mildly elevated serum TC levels, based on the criterion that ≥70% of policosanol-treated patients reached the LDL-C goal of a decrease ≥15% from baseline whenever this proportion was different with respect to placebo, 8 weeks of treatment with policosanol 5 mg/d was effective. The decreased LDL-C, TC, and TG levels, increased HDL-C level, and good tolerability found with this treatment support its use in such patients.

Combination therapy with ezetimibe and simvastatin to achieve aggressive LDL reduction

A low-density lipoprotein (LDL) cholesterol goal of less than 100 mg/dl is recommended for patients at moderate to high risk of cardiovascular disease with an optional LDL goal of less than 70 mg/dl for patients at a very high risk of cardiovascular disease. Most patients will require reductions in LDL of more than 50% in order to achieve these more aggressive goals. Only a few agents will lower LDL by at least 50%. This review will focus on the efficacy and safety ezetimibe/simvastatin coadministered as a therapy with enhanced LDL-lowering efficacy, while minimizing the adverse effects of statins in a wide range of patients. Ezetimibe 10 mg/simvastatin 80 mg lowers LDL by approximately 60% and has been demonstrated to be superior to the highest doses of atorvastatin and rosuvastatin for lowering LDL and raising high-density lipoprotein.

Effects of D-003 on the Lipid Profile of Patients with Type II Hypercholesterolaemia : A Phase II Clinical Study

BACKGROUND

D-003 is a cholesterol-lowering agent that is isolated and purified from sugarcane wax and has concomitant antiplatelet effects.

OBJECTIVE

To evaluate lipid profile responses to different doses of D-003 in patients with type II hypercholesterolaemia.

STUDY DESIGN

An 8-week, double-blind, placebo-controlled, parallel-group clinical study.

METHODS

After concluding a 5-week diet-only baseline period, 55 patients were randomly allocated to receive either placebo or D-003 at 5, 10, 20 or 40mg once daily with their evening meal for 8 weeks. An interim check-up was performed at week 4. The primary efficacy variable was the reduction of serum low-density lipoprotein-cholesterol (LDL-C) from baseline compared with placebo. Drug safety and tolerability were assessed on the basis of changes in physical, haematological and blood biochemical indicators and on questioning about adverse experiences (AEs).

RESULTS

After 8 weeks of therapy, D-003 significantly lowered (p < 0.0001 vs baseline and placebo) serum LDL-C in a dose-related manner, with reductions of 20.5-26.1% from the lowest to the highest dose investigated. At study completion, 43 of 44 (97.7%) randomised patients treated with D-003 reached LDL-C reductions >15% compared with baseline, while 30 of 44 patients (68.2%) reached LDL-C targets according to their individual global coronary risk status. Decreases in total cholesterol (TC) and the ratios of TC/high-density lipoprotein-cholesterol (HDL-C) and LDL-C/HDL-C were also significant (p < 0.0001) and dose related. Changes in LDL-C, TC and both ratios were significant from the interim check-up. D-003 significantly increased HDL-C values (11.7-16.7%), but the increase was not dose related. No significant changes in lipid profile variables were observed with placebo. D-003 was well tolerated. The treatment did not affect any physical, haematological or blood safety indicators. All included patients completed the study. Four patients reported mild AEs during the study: headache (one patient treated with placebo and one treated with D-003 20 mg/day), insomnia (one patient treated with D-003 5 mg/day) and polyuria (one patient treated with D-003 40 mg/day).

CONCLUSIONS

D-003 was effective in dose dependently reducing LDL-C in patients with type II hypercholesterolaemia, as documented by average percentage reductions and the percentage of patients achieving decreases >15% from baseline and LDL-C goals. The treatment was well tolerated by patients and did not affect any safety indicator. Further studies corroborating these results and exploring the effect of lower doses of D-003 and a longer treatment duration must be carried out, however, before definitive conclusions can be reached. These results encourage continuing clinical investigation on this drug.

COACH trial: a randomized controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers: rationale and design

BACKGROUND

Despite well-publicized guidelines on the appropriate management of cardiovascular disease (CVD) and type 2 diabetes, implementation of risk-reducing practices remains poor. This paper describes the rationale and design of a randomized controlled clinical trial evaluating the effectiveness of a comprehensive program of CVD risk reduction delivered by nurse practitioner (NP)/community health worker (CHW) teams versus enhanced usual care in improving the proportion of patients in urban community health centers who achieve goal levels recommended by national guidelines for lipids, blood pressure, HbA1c and prescription of appropriate medications.

METHODS

The COACH (Community Outreach and Cardiovascular Health) trial is a randomized controlled trial in which patients at federally-qualified community health centers were randomly assigned to one of two groups: comprehensive intensive management of CVD risk factors for one year by a NP/CHW team or an enhanced usual care control group.

RESULTS

A total of 3899 patients were assessed for eligibility and 525 were randomized. Groups were comparable at baseline on sociodemographic and clinical characteristics with the exception of statistically significant differences in total cholesterol and hemoglobin A1c.

CONCLUSIONS

This study is a novel amalgam of multilevel interdisciplinary strategies to translate highly efficacious therapies to low-income federally-funded health centers that care for patients who carry a disproportionate burden of CVD, type 2 diabetes and uncontrolled CVD risk factors. The impact of such a community clinic-based intervention is potentially enormous.

Emerging options in the treatment of dyslipidemias: a bright future?

INTRODUCTION

Hypercholesterolemia is a major risk factor for cardiovascular disease (CVD). Low-density lipoprotein cholesterol (LDL-C) reduction has been demonstrated to decrease CVD-related morbidity and mortality. However, several patients do not reach LDL-C target levels with the currently available lipid lowering agents, particularly statins. Lipid and non-lipid parameters other than LDL-C may account for the residual CVD risk after adequate LDL-C lowering with statins.

AREAS COVERED

This review focuses on the efficacy and safety of emerging drugs aiming at high-density lipoprotein cholesterol (HDL-C) elevation (i.e., recombinant or plasma-derived wild-type apolipoprotein (apo) A-I, apo A-I mimetic peptides, reconstituted mutant HDL, partially delipidated HDL and cholesterol ester transfer protein inhibitors), microsomal triglyceride transfer protein inhibitors and antisense oligonucleotides.

EXPERT OPINION

Several lipid modifying agents in development may potently reduce the residual CVD risk. Ongoing and future studies with clinical outcomes will clarify their efficacy in clinical practice.

Session 4: CVD, diabetes and cancer A dietary portfolio for management and prevention of heart disease

CHD is the leading cause of worldwide mortality. The prevalence of heart disease has been linked to the adoption of a sedentary lifestyle and the increased dietary dependence on saturated fats from animal sources and the intake of refined foods. Elevated blood cholesterol level is one of the major risk factors for CHD. While cholesterol-lowering drug therapy (statins) has been effective in reducing the risk of heart disease, there are those individuals who are unwilling or because of muscle pains or raised levels of liver or muscle enzymes are unable to take cholesterol-lowering medication. Fortunately, there is evidence linking a number of dietary components to CHD risk reduction. The strength of this evidence has prompted various regulatory bodies to advocate diet as the first line of defence for primary prevention of heart disease. It was therefore decided to combine four dietary components that have been shown to lower blood cholesterol concentrations (nuts, plant sterols, viscous fibre and vegetable protein) in a dietary portfolio in order to determine whether the combined effect is additive. In a metabolically-controlled setting this dietary portfolio has proved to be as effective as a starting dose of a first-generation statin cholesterol-lowering medication in reducing the risk of CHD. The dietary portfolio has also been shown to be effective in sustaining a clinically-significant effect in the long term under a ‘real-world’ scenario. However, success of the diet depends on compliance and despite the accessibility of the foods adherence has been found to vary greatly. Overall, the evidence supports the beneficial role of the dietary portfolio in reducing blood cholesterol levels and CHD risk.

Low-dose combination therapy with colesevelam hydrochloride and lovastatin effectively decreases low-density lipoprotein cholesterol in patients with primary hypercholesterolemia

BACKGROUND

Colesevelam hydrochloride is a novel, lipid-lowering agent that binds bile acids with high affinity. A multicenter, randomized, double-blind, placebo-controlled, parallel-design study was conducted to assess the efficacy and tolerability of combination low-dose colesevelam and lovastatin treatment in patients with primary hypercholesterolemia.

HYPOTHESIS

Combination therapy with low doses of colesevelam and lovastatin decreases low density (LDL) cholesterol with minimal adverse events.

METHODS

Following a 4- to 6-week dietary lead in, 135 patients were randomized into five groups for a 4-week treatment period: placebo, colesevelam 2.3 g at dinner, lovastatin 10 mg at dinner, the combination of colesevelam and lovastatin given at dinner (dosed together), and combination treatment with colesevelam given at dinner and lovastatin administered at bedtime (dosed apart).

RESULTS

Combination colesevelam and lovastatin treatment decreased LDL cholesterol by 34% (60 mg/dl, p < 0.0001) and 32% (53 mg/dl, p < 0.0001) when colesevelam and lovastatin were dosed together or dosed apart, respectively. Both combination therapies were superior to either agent alone (p < 0.05). Decreases in LDL cholesterol exceeded the combined decreases observed for colesevelam alone (13 mg/dl, 7%) and lovastatin alone (39 mg/dl, 22%). Both combination treatments reduced total cholesterol by 21% (p < 0.0001) and apolipoprotein B by 24% (p < 0.0001). Neither combination treatment significantly altered high-density lipoprotein cholesterol or triglycerides. Adverse side effects were not significantly different among randomized groups.

CONCLUSIONS

Combination colesevelam and lovastatin was efficacious and well tolerated, resulting in additive decreases in LDL cholesterol levels whether or not both agents were administered simultaneously.

Colesevelam hydrochloride in clinical practice: a new approach in the treatment of hypercholesterolaemia

OBJECTIVE

Hypercholesterolaemia is a major risk factor for atherosclerosis and coronary heart disease. Treatment with lipid lowering agents reduces the risk of vascular events. Colesevelam is a novel bile acid sequestrant (BAS) indicated for the treatment of hypercholesterolaemia, either as monotherapy or in combination with statins.

SCOPE

This article reviews the efficacy, tolerability and safety of colesevelam in clinical practice. The literature search was based on a PubMed search up to January 2008.

FINDINGS

Colesevelam, used alone or in combination with other hypolipidaemic agents (statins, ezetimibe and fenofibrate), has an overall favourable effect on lipid profile. Specifically, colesevelam reduces total and low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B levels and increases high-density lipoprotein cholesterol and apolipoprotein AI. However, colesevelam may slightly raise triglyceride levels. Colesevelam can improve glycaemic control in diabetic patients. Moreover, it may have anti-inflammatory properties, as it can reduce high sensitivity C-reactive protein concentration. Colesevelam almost lacks the intense side effects of previously used BASs, thus resulting in better patient compliance. However, the dose regimen consisting of up to 7 tablets/day and high cost may limit its use.

CONCLUSIONS

Colesevelam is a safe alternative for those intolerant to other lipid lowering medication. This BAS also provides an option for patients who do not reach their LDL-C goal despite treatment with a statin.

Cholesterol goal attainment in patients with coronary heart disease and elevated coronary risk: results of the Hong Kong hospital audit study

OBJECTIVE

We sought to determine 1) long-term lipid-lowering treatment patterns; 2) cholesterol goal attainment rates and possible determinants of goal achievement; and 3) effects of cholesterol goal attainment on coronary events in hospitalized Hong Kong patients.

METHODS

In this retrospective cohort analysis, records of two public Hong Kong hospitals were reviewed for 196 adults (69% with coronary heart disease (CHD) or CHD-risk equivalent) who received at least one lipid-lowering therapy during hospitalization. Low-density lipoprotein cholesterol (LDL-C) targets were <2.6 mmol/l (<100 mg/dL) for patients with CHD or CHD risk equivalents and <3.37 mmol/l (<130 mg/dL) for those without.

RESULTS

Most participants were initiated on regimens of low to midequipotency doses and never had their regimens adjusted to higher potency. Approximately 44% of patients not at LDL-C at baseline failed to achieve goal during a median follow-up of 1.9 years. Patients with higher coronary risk and/or LDL-C levels at baseline were less likely than their lower-risk counterparts to achieve goal; for each 1-mmol/l (38.7-mg/dL) increase in LDL-C at baseline, the likelihood of attaining goal declined by 64%. Patients achieving cholesterol goal had significantly longer cardiovascular event-free times.

CONCLUSIONS

A total of 44% of Hong Kong patients not at LDL-C goals at baseline did not achieve them over 1.9 years. More effective and well-tolerated therapies, including adjunctive regimens (e.g., ezetimibe-statin, niacin-statin), may be necessary to enhance LDL-C goal achievement and increase event-free time.

Effects of D-003, a mixture of high-molecular-weight sugar cane wax acids, on lipid peroxidation markers in older individuals: A randomized, double-blind, placebo-controlled study

BACKGROUND

Aging is associated with increased lipid peroxidation (LP). D-003, a mixture of long-chain aliphatic primary acids purified from sugar cane wax, has been found to inhibit LP in experimental models and in healthy subjects.

OBJECTIVES

The aim of this study was to assess the effects of D-003 on LP markers and the lipid profile of older individuals.

METHODS

This randomized, double-blind, placebo-controlled study was conducted at the Plaza Veterans' House, Havana City, Cuba. Male and female patients aged ≥60 years with total cholesterol values of <6.1 mmol/L were eligible for inclusion in the study. After a 3-week lead-in and baseline assessment period, patients were randomized to receive PO D-003 5 mg/d, D-003 10 mg/d, or placebo for 8 weeks. The effect on copper-induced LP of low-density lipoprotein (LDL) particles was the primary variable, and the effects on plasma total antioxidant status (TAS), plasma malondialdehyde (MDA) concentration, plasma antioxidant enzyme (superoxide dismutase and glutathione peroxidase) activities, and the lipid profile were secondary variables. A clinical examination was performed at each visit (baseline, weeks 4 and 8). A clinical examination, LP, and blood tests (lipid profile, hematologic, and blood biochemistry safety indicators) were performed at baseline and after 8 weeks of treatment. Compliance and adverse events (AEs) were assessed at weeks 4 and 8. A 2-tailed P < 0.05 was considered statistically significant for comparisons of both continuous and categoric variables.

RESULTS

Fifty-four patients aged ≥60 years were assessed for inclusion in the study, and 51 patients (40 women, 11 men; mean [SD] age, 67 [6] years) were included in the study. The lag phase of conjugated diene formation increased significantly and in a dose-dependent manner in the group treated with D-003 5 mg (24.7%; P < 0.01) and in the group treated with D-003 10 mg (29.3%; P < 0.01) compared with placebo. The maximal rate of conjugated diene propagation decreased significantly in the D-003 5- and 10-mg groups -22.7% and -25.8%, respectively; both, P < 0.05) compared with placebo. TAS increased significantly (17.7% and 23.0%, respectively; both, P < 0.01) in both active treatment groups compared with placebo. Plasma MDA concentration decreased significantly in the D-003 10-mg group (-28.6%; P < 0.05) but not in the D-003 5-mg group, compared with placebo. These changes were also significant compared with baseline. Antioxidant enzyme activities did not change in the active treatment groups compared with placebo or baseline. In the D-003 5- and 10-mg groups, significant decreases were found in LDL cholesterol concentration (-15.8% and -23.8%, respectively; both, P < 0.001) and total cholesterol concentration (-13.0% and -16.8%, both, P < 0.05) compared with placebo. High-density lipoprotein cholesterol concentration increased significantly in the D-003 5-mg group (5.7%; P < 0.05) and the D-003 10-mg group (18.2%; P < 0.001) compared with placebo. Changes in the lipid profile were also significant compared with baseline. In the placebo group, no variable changed significantly compared with baseline. D-003 was well tolerated at both dose levels, and no patient withdrew from the study. There were a total of 3 AEs reported: insomnia and acidity in 2 patients receiving placebo; and heartburn in 1 patient receiving D-003 5 mg.

CONCLUSIONS

D-003 5 and 10 mg/d administered to these older individuals (aged ≥60 years) for 8 weeks inhibited LP of LDL and increased TAS in a dose-dependent manner, while plasma MDA concentration decreased in the patients receiving D-003 10 mg/d only. D-003 was well tolerated at both doses.

Reaching target lipid levels in patients at high risk of cardiovascular event: the experience of a Canadian tertiary care lipid clinic

OBJECTIVES

To determine the proportion of high risk patients followed at a tertiary care lipid clinic who met recommended lipid targets and to identify predictors of reaching goal lipid levels.

RESEARCH DESIGN AND METHODS

A retrospective cohort study of 502 high risk patients followed between 1983 and 2003. Clinical and demographic data and fasting lipid profiles were extracted from each patient's first two clinic visits as well as the most recent visit.

RESULTS

All patients in this study were at high risk of cardiovascular events due to dyslipidemia. At "Visit 1", only 55 (11.0%) of patients were at target TC/HDL-C < 4.0, and 97 (19.3%) of patients met target LDL-C < 2.5 mmol/l. At "Visit 3", 229 (45.8%) patients reached TC/HDL-C target, and 216 (43.2%) patients were at LDL-C target. The mean change in lipid values between Visit 1 and Visit 3 was significant (p = 0.0002) for LDL-C and (p < 0.0001) for TC/HDL-C. The use of statins, niacin, or salmon oil were all significantly associated with reaching TC/HDL-C target and LDL-C target, as well male gender, diabetes mellitus and peripheral vascular disease were also associated with reaching LDL-C target. Increasing age and lower body mass index were associated with reaching goal TC/HDL-C.

CONCLUSIONS

The mean absolute changes in lipid values were significant and median lipid levels approached target levels in patients followed at specialized clinic, however the majority of high risk patients are not meeting goal lipid levels.

Lipid-modifying therapy and attainment of cholesterol goals in Hungary: the return on expenditure achieved for lipid therapy (REALITY) study

BACKGROUND AND OBJECTIVE

Cardiovascular disease is a leading cause of death in Eastern Europe. Few studies on cholesterol goal achievement have been conducted in Hungarian clinical settings. This study set out to evaluate lipid-modifying therapy practices and their effects on total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) goal attainment in Hungarian patients with coronary heart disease (CHD), CHD risk equivalents, or >or=2 coronary risk factors.

METHODS

This multicentre observational study involved patients receiving lipid-modifying therapy who were under the care of general practitioners (n = 300) or specialists (n = 140). Physician questionnaires were used to collect data on baseline patient characteristics, including laboratory parameters. Using validated cardiovascular risk assessment measures, patients were stratified into high-risk (10-year absolute coronary risk >20%; n = 367) and lower risk groups (n = 73). Cholesterol goals were TC <4.5 mmol/L (<175 mg/dL) and LDL-C <2.5 mmol/L (<100 mg/dL) for the high-risk group and TC <5.0 mmol/L (<193 mg/dL) and LDL-C <3.0 mmol/L (<117 mg/dL) for those at lower risk.

RESULTS

Among 440 patients (n = 312 with CHD or CHD risk equivalents), 374 (85%) were initiated on HMG-CoA reductase inhibitors (statin monotherapy), 44 (10%) received fibric acid derivatives and 22 (5%) received combination regimens. Although >50% of patients needed >35% TC lowering to reach goal, <10% of patients received high or very high potency lipid-modifying regimens or combination regimens initially. A total of 116 (26.4%) patients achieved their TC goals after >/=1 year of treatment, including 27.9% of patients with CHD/risk equivalents and 22.7% of those with risk factors only. Sixty-six (15%) patients achieved goal on initial lipid-modifying regimens, while a further 50 (11.4%) achieved goal following treatment changes, including upward dosage adjustments.

CONCLUSION

Approximately 74% of Hungarian patients receiving lipid-modifying therapy in our study did not achieve cholesterol goals. The proportion of patients realising their TC goals was higher in those treated by specialists but still did not exceed one-third.

Achieving low-density lipoprotein cholesterol goals in high-risk patients in managed care: comparison of rosuvastatin, atorvastatin, and simvastatin in the SOLAR trial

OBJECTIVE

To evaluate attainment of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III low-density lipoprotein cholesterol (LDL-C) goal of less than 100 mg/dL with statin treatments in managed care patients at high risk for coronary heart disease.

PATIENTS AND METHODS

In a randomized, open-label, multicenter trial (SOLAR [Satisfying Optimal LDL-C ATP III goals with Rosuvastatin]) performed at 145 US clinical centers from June 5, 2002 to July 12, 2004, high-risk men and women in a managed care population received typical starting doses of rosuvastatin (10 mg/d), atorvastatin (10 mg/d), or simvastatin (20 mg/d) for 6 weeks. Those who did not meet the LDL-C target of less than 100 mg/dL at 6 weeks had their dose titrated (doubled), and all patients were followed up for another 6 weeks.

RESULTS

A total of 1632 patients were randomized to 1 of the 3 treatment regimens. After 6 weeks, 65% of patients taking rosuvastatin reached the LDL-C target of less than 100 mg/dL vs 41% with atorvastatin and 39% with simvastatin (P<.001 vs rosuvastatin for both). After 12 weeks, 76% of patients taking rosuvastatin reached the LDL-C target of less than 100 mg/dL vs 58% with atorvastatin and 53% with simvastatin (P<.001 vs rosuvastatin for both). Reductions in the LDL-C level, total cholesterol level, non-high-density lipoprotein cholesterol (non-HDL-C) level, and non-HDL-C/HDL-C ratio were significantly greater with rosuvastatin at both 6 and 12 weeks compared with the other statins. Adverse events were similar in type and frequency in all treatment groups, and only 3% of all patients discontinued treatment because of adverse events. No myopathy was observed, no clinically important impact on renal function was attributed to study medications, and clinically important increases in serum transaminases were rare.

CONCLUSION

In a managed care population, 10 mg of rosuvastatin treatment resulted in more patients reaching the NCEP ATP III LDL-C goal compared with 10 mg of atorvastatin and 20 mg of simvastatin, potentially reducing the need for titration visits.

Preventing cardiovascular disease among Canadians: what are the potential benefits of treating hypertension or dyslipidemia?

BACKGROUND

Treatments for hypertension and dyslipidemia to prevent the development of cardiovascular disease compete for the same finite number of health care dollars. Therefore, the potential benefits of treating Canadians without cardiovascular disease or diabetes who would currently be targeted by the national treatment guidelines were estimated and compared.

STUDY DESIGN

Canadian Heart Health Surveys data were used to estimate the number of Canadians requiring intervention. The Cardiovascular Life Expectancy Model, a previously validated Markov model, was used to calculate the increased life expectancy and decreased morbidity associated with treating risk factors to target.

RESULTS

Among 8.44 million adults 40 to 74 years of age without cardiovascular disease or diabetes, it was estimated that approximately 2.33 million would require treatment for dyslipidemia and 2.34 million for hypertension. The estimated Framingham 10-year coronary risk averaged 12.4% versus 9.6%, respectively. Treating dyslipidemia was associated with an average increased life expectancy of 1.67 years and 1.81 years of life free of cardiovascular disease. Treating hypertension was expected to increase life expectancy by 0.94 years and years of life free of cardiovascular disease by 1.29 years. The population benefits associated with treating dyslipidemia or hypertension would be 2.5 million and 1.4 million person years of life saved, respectively. Overall, the person years of treatment required to save one year of life was estimated to average 20 years for dyslipidemia therapy and 38 years for hypertension.

CONCLUSIONS

The potential benefits associated with treating hypertension or dyslipidemia to prevent cardiovascular disease are substantial. However, compared with hypertension guidelines, dyslipidemia guidelines target higher-risk patients. Accordingly, given the relative efficacy of each treatment, the forecasted benefits associated with treating dyslipidemia are substantially greater than those associated with hypertension therapy.

Dose-Dependent Effects of Docosahexaenoic Acid Supplementation on Blood Lipids in Statin-Treated Hyperlipidaemic Subjects

The objective of the study was to evaluate potential benefits of docosahexaenoic acid (DHA) rich fish oil supplementation as an adjunct to statin therapy for hyperlipidaemia. A total of 45 hyperlipidaemic patients on stable statin therapy with persistent elevation of plasma triglycerides (averaging 2.2 mmol/L) were randomised to take 4 g/day (n = 15) or 8 g/day (n = 15) of tuna oil or olive oil (placebo, n = 15) for 6 months. Plasma lipids, blood pressure and arterial compliance were assessed initially and after 3 and 6 months in 40 subjects who completed the trial. Plasma triglycerides were reduced 27% by 8 g/day DHA-rich fish oil (P < 0.05) but not by 4 g/day when compared with the placebo and this reduction was achieved by 3 months and was sustained at 6 months. Even though total cholesterol was already well controlled by the statin treatment (mean initial level 4.5 mmol/L), there was a further dose-dependent reduction with fish oil supplementation (r = -0.344, P < 0.05). The extent of total cholesterol reduction correlated (r = -0.44) with the initial total cholesterol levels (P < 0.005). In the subset with initial plasma cholesterol above 3.8 mmol/L, plasma very low density lipoprotein (VLDL), intermediate-density lipoprotein (IDL) and low-density lipoprotein (LDL) were isolated and assayed for cholesterol and apolipoprotein B (apoB) at the commencement of the trial and at 3 months of intervention. Fish oil tended to lower cholesterol and apoB in VLDL and raise both in LDL. There were no changes in IDL cholesterol, IDL apoB and high-density lipoprotein cholesterol. The results demonstrate that DHA-rich fish oil supplementation (2.16 g DHA/day) can improve plasma lipids in a dose-dependent manner in patients taking statins and these changes were achieved by 3 months. Fish oil in addition to statin therapy may be preferable to drug combinations for the treatment of combined hyperlipidaemia.

Ezetimibe added to ongoing statin therapy improves LDL-C goal attainment and lipid profile in patients with diabetes or metabolic syndrome

This analysis of the Ezetimibe Add-on to Statin for Effectiveness (EASE) trial examined the effectiveness and safety of ezetimibe 10 mg added to ongoing statin therapy in patients with diabetes, metabolic syndrome without diabetes, or neither disorder who had low-density lipoprotein cholesterol (LDL-C) levels exceeding National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) goals. After six weeks of treatment, ezetimibe added to statin reduced LDL-C in patients with diabetes by 28%, metabolic syndrome by 24%, or neither by 26%, compared with a 3% reduction for placebo for each group. In each group, more patients receiving ezetimibe plus statin reached LDL-C goal (67-74%) compared with those receiving placebo plus statin (19-22%). Other parameters demonstrating greater improvement with ezetimibe included triglycerides, apolipoprotein (Apo)B/Apo A-I ratio, high-density lipoprotein cholesterol (HDL-C), and C-reactive protein. Ezetimibe plus statin was well tolerated in each group. Ezetimibe added to ongoing statin therapy offers a new treatment option that is consistently effective in improvement of lipid profiles and attainment of LDL-C goals in patients with without diabetes or metabolic syndrome.

Effects of combination treatment with policosanol and omega-3 fatty acids on platelet aggregation: A randomized, double-blind clinical study

BACKGROUND

Policosanol is a mixture of long-chain primary aliphatic alcoholspurified from sugar cane wax that has cholesterol lowering and antiplatelet effects. Omega-3 fatty acids (FA) have triglyceride lowering and antiplatelet effects. Combination treatment with policosanol and omega-3 FA (Ω23FA) has been associated with significant inhibition of platelet aggregation in rabbits compared with either drug alone.

OBJECTIVE

The aim of this study was to investigate the effects of combination treatment with Ω3FA (1 g/d) and policosanol (Ω3FA+Poli) compared with Ω3FA (1 g/d) plus placebo (Ω3FA+Pla) on platelet aggregation in human patients with hypercholesterolemia.

METHODS

This randomized, double-blind, clinical study at the Surgical Medical Research Center (Havana City, Cuba) recruited outpatients from lipid clinics, with some atherosclerotic risk factors. Outpatients of both sexes aged 20 to 75 years with serum total cholesterol (TC) levels ≥5 and <6 mmol/L were eligible to enroll. They were included in the study at the end of a 4-week diet stabilization period if their platelet aggregation to arachidonic acid (AA) was ≥50% and serum TC level remained ≥5 mmol/L. Patients were then evenly randomized to receive Ω3FA (1 g/d) + placebo or Ω3FA (1 g/d) + policosanol (10 mg/d) to be taken PO with the evening meal for 21 days. Treatment was assigned according to a randomization code using balanced blocks and a 1:1 allocation ratio. Inhibition of platelet aggregation to AA was the primary efficacy variable, while effects on platelet aggregation to collagen and epinephrine and on lipid profile were secondary variables. Drug compliance and adverse events (AEs) were monitored. Tolerability was assessed using physical examinations and laboratory test results.

RESULTS

Sixty-four subjects were initially enrolled. Fifty-four patients (30 women, 24 men; mean [SD] age, 58.4 [12] years, [range, 40-70 years]) met the inclusion criteria and were randomized to treatment; 2 groups of 27. After 21 days, platelet aggregation to AA was significantly inhibited in the 2 groups. Ω3FA+Poli inhibited platelet aggregation to all agonists by ≥20%. Platelet aggregation to AA 1.0 and 1.5 mM was inhibited with combination treatment (39.6% and 33.9%, respectively; both P < 0.001 vs baseline; P < 0.001 and P < 0.01, respectively, vs Ω3FA+Pla) and with Ω3FA+Pla (11.0% and 13.3%; both, P < 0.001). Combination treatment was more effective in inhibiting platelet aggregation to AA 1.0 and 1.5 mM in 28.6% (P < 0.001) and 20.6% (P < 0.01), respectively. Platelet aggregation to collagen 1 μg/mL was significantly inhibited with combination treatment and with Ω3FA+Pla compared with baseline (43.2% and 15.1%, respectively; both, P < 0.001), but the effects of combination treatment were significantly greater (P < 0.01). Platelet aggregation to epinephrine 0.1 mM was inhibited with Ω3FA+Poli and Ω3FA+Pla (34.8% and 20.1%; both, P < 0.001), with similar results for both groups. Bleeding time did not change significantly for either group and Ω3FA+Pla did not significantly change the lipid profile. Combination treatment did significantly reduce levels of low-density lipoprotein cholesterol (LDL-C) (17.4%; P < 0.001 vs baseline, P < 0.05 vs Ω3FA+Pla) and TC (10.1%; P < 0.001 vs baseline, P < 0.05 vs Ω3FA+Pla), increase high-density lipoprotein cholesterol (HDL-C) levels (18.0%; P < 0.001 vs baseline), but did not significantly change triglyceride levels. Three patients (2 from the Ω3FA+Poli group and 1 from the Ω3FA+Pla group) withdrew from the trial, though none were due to AEs. Two patients receiving combination treatment reported mild AEs (headache). All treatments were well tolerated.

CONCLUSIONS

In these patients, policosanol (10 mg/d) administered concomitantly with Ω3FA (1 g/d) enhanced the inhibition of platelet aggregation to AA and collagen, but not to epinephrine, compared with Ω3FA+Pla, without significantly affecting bleeding time. Concomitant treatment was also associated with reduced levels of LDL-C and TC and raised HDL-C levels. All treatments were well tolerated.

A comparison of Canadian and American guidelines for lipid management using data from the National Cholesterol Education Program Evaluation ProjecT Utilizing Novel E-technology (NEPTUNE) II survey

BACKGROUND

The United States' National Cholesterol Education Program (NCEP) Adult Treatment Panel III and the Canadian Working Group on Hypercholesterolemia and Other Dyslipidemias (CWG) have each issued guidelines for the treatment of dyslipidemia.

OBJECTIVE

The present analysis compared the percentage of patients reaching target lipid levels according to NCEP and CWG guidelines among participants of the NCEP Evaluation ProjecT Utilizing Novel E-technology (NEPTUNE) II, a survey performed in the United States.

METHODS

American physicians who were high prescribers of lipid-modifying medications (n=376) each enrolled 10 to 20 consecutive patients from February to September 2003. Medical information, laboratory measurements and treatment plans associated with a single office visit were entered into a personal digital assistant and uploaded to a central database via the Internet.

RESULTS

Under both sets of guidelines, treatment success was strongly related to risk category (P<0.001). Treatment goal achievement in the low-risk (zero or one risk factor) and moderate-risk (two or more risk factors) categories was not substantially different between NCEP and CWG guidelines; however, in the high-risk category (coronary artery disease [CAD] and risk equivalents [RE]), CWG treatment goals were met less frequently than NCEP goals. NCEP combined low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol treatment goals were met by 39% of hypertriglyceridemic patients (27% in the CAD + CAD RE category). CWG combined low-density lipoprotein cholesterol and total cholesterol/high-density lipoprotein cholesterol ratio treatment goals were met by 38% of hypertriglyceridemic patients (19% in the CAD + CAD RE category).

CONCLUSIONS

These data indicate substantial underachievement of treatment goals by patients at high risk under both the CWG and NCEP guidelines. The lower frequency of treatment success in high-risk patients according to the CWG definition indicates that more aggressive treatment is needed to reach CWG goals.

Assessment of the longer-term effects of a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia

BACKGROUND

Cholesterol-lowering foods may be more effective when consumed as combinations rather than as single foods.

OBJECTIVES

Our aims were to determine the effectiveness of consuming a combination of cholesterol-lowering foods (dietary portfolio) under real-world conditions and to compare these results with published data from the same participants who had undergone 4-wk metabolic studies to compare the same dietary portfolio with the effects of a statin.

DESIGN

For 12 mo, 66 hyperlipidemic participants were prescribed diets high in plant sterols (1.0 g/1000 kcal), soy protein (22.5 g/1000 kcal), viscous fibers (10 g/1000 kcal), and almonds (23 g/1000 kcal). Fifty-five participants completed the 1-y study. The 1-y data were also compared with published results on 29 of the participants who had also undergone separate 1-mo metabolic trials of a diet and a statin.

RESULTS

At 3 mo and 1 y, mean (+/-SE) LDL-cholesterol reductions appeared stable at 14.0 +/- 1.6% (P < 0.001) and 12.8 +/- 2.0% (P < 0.001), respectively (n = 66). These reductions were less than those observed after the 1-mo metabolic diet and statin trials. Nevertheless, 31.8% of the participants (n = 21 of 66) had LDL-cholesterol reductions of >20% at 1 y (x +/- SE: -29.7 +/- 1.6%). The LDL-cholesterol reductions in this group were not significantly different from those seen after their respective metabolically controlled portfolio or statin treatments. A correlation was found between total dietary adherence and LDL-cholesterol change (r = -0.42, P < 0.001). Only 2 of the 26 participants with <55% compliance achieved LDL-cholesterol reductions >20% at 1 y.

CONCLUSIONS

More than 30% of motivated participants who ate the dietary portfolio of cholesterol-lowering foods under real-world conditions were able to lower LDL-cholesterol concentrations >20%, which was not significantly different from their response to a first-generation statin taken under metabolically controlled conditions.

Lipids and stroke: the opportunity of lipid-lowering treatment

Dyslipemia is a clear risk factor (RF) for ischemic heart disease and peripheral artery disease, but its relation with ischemic stroke (IS) is not so clear. HMG-CoA reductase inhibitor drugs or statins (simvastatin, atorvastatin, pravastatin) reduce the relative risk of IS by between 18 and 51% in patients with IHD, in patients with high vascular disease risk and in hypertensive patients with other RFs, acute coronary syndrome, and type 2 diabetes mellitus. According to the guidelines for use, statins are indicated in the majority of patients with IS since the risk is equivalent to that of IHD or high vascular disease risk. In view of the existing clinical evidence of benefit, it would not seem unreasonable to proceed with treatment of patients using statins while awaiting specific studies justifying their use. The non-lipid-lowering mechanisms of the statins and results of studies, such as the Heart Protection Study, provide evidence for widening the indications of statins beyond the prevention of dyslipemia, as a new therapeutic approach in the prevention of IS in patients with plasma levels of total cholesterol or low density lipoproteins currently considered within the normal distribution. The neuroprotective role, which these drugs may play in the acute phase of cerebral ischemia, remains to be clarified, but very recent evidence suggests that such patients may also benefit.

Treating to low-density lipoprotein goal: a tool for initiating and optimizing lipid-lowering therapy in patients with atherosclerosis or similar risk

Compelling, consistent clinical trial evidence indicates that lipid-lowering therapy reduces the risk of recurrent cardiovascular events and improves survival in patients with coronary heart disease, cerebral vascular disease, peripheral vascular disease, and diabetes. Despite this evidence and the national clinical guidelines recommending lipid-lowering treatment and low-density lipoprotein (LDL) goal attainment in patients with clinically evident atherosclerotic vascular disease or similar risk, study after study has documented low treatment rates. Furthermore, a large proportion of high-risk patients have not achieved LDL goals, thereby creating a clinical practice and public health dilemma. This article features a tool to guide the initiation and optimization of LDL-lowering therapy and a program to improve long-term treatment rates, LDL goal attainment, and clinical outcomes.

An Assessment of Patient Knowledge and Awareness of Issues Surrounding Cholesterol Risk Management

Background:

A lack of patient understanding and awareness of issues surrounding cholesterol risk management may be one reason that a significant number of patients receiving cholesterol-lowering therapy do not achieve optimal cholesterol levels. This study was conducted to assess patients' knowledge and awareness of issues surrounding cholesterol risk management.

Methods:

Community pharmacists within the Edmonton, Alberta, area were identified and asked to recruit patients within their practice who had been receiving cholesterol-lowering therapy for a minimum of six weeks. A 32-question telephone survey was developed and used as the instrument to assess patient knowledge and awareness. All surveys were conducted by the same individual, and data analysis was primarily descriptive.

Results:

Seventeen community pharmacies recruited 136 potential subjects over an eight-week period. Surveys were conducted with 105 (77%) of the eligible subjects. Of those surveyed, 37% identified elevated cholesterol as a risk factor for heart disease. While the majority of respondents felt it important to know their cholesterol targets (82%) and their specific levels (91%), only 23% and 29% of respondents indicated that they knew their high-density lipoprotein cholesterol and low-density lipoprotein cholesterol levels, respectively. Gaps in knowledge with respect to cholesterol-lowering therapy also existed.

Conclusions:

The results of this survey indicate gaps in patient knowledge of various issues surrounding cholesterol risk management. Pharmacists are in an excellent position to provide better education to patients about cholesterol levels and cardiovascular disease risk management. Further research is required to determine whether improved patient knowledge leads to improved clinical outcomes.

Impact of computer-generated personalized goals on cholesterol lowering

OBJECTIVES

The National Cholesterol Education Program (NCEP) has enhanced public awareness of the importance of cholesterol in the development of heart disease, yet most patients with cardiovascular disease (CVD) do not know or achieve their low-density lipoprotein cholesterol (LDL-C) goals. This randomized, controlled trial was designed to evaluate the impact of a system that provides uniquely formatted laboratory results to patients with CVD on their changes in LDL-C levels.

METHODS

Eighty patients with CVD were randomized to receive standard care or the intervention inclusive of a computer-generated, 11''x17'' color poster depicting an individual's LDL-C status and goals along with personalized steps to aid in goal achievement. Cholesterol profiles were obtained at baseline and 6 months after enrollment. Physicians received standard laboratory reports and were blinded to the randomization.

RESULTS

There were no significant differences between patient groups in age, education level, race, baseline cholesterol levels, comorbidities, or percentage of patients in each group who met their NCEP goal at baseline. Patients receiving intervention tools had significant reductions in LDL-C from baseline compared with patients in the control group. Intervention patients who did not meet NCEP goals at baseline had the greatest reduction in LDL-C, with a mean change from baseline of -21.5 mg/dL (P<0.001) whereas standard care patients had no significant change in the LDL-C levels (-4.6 mg/dL, P=0.28). At study close, 73% of intervention patients reported that their posters remained displayed on their refrigerator.

CONCLUSION

This unique and personalized intervention resulted in the LDL-C lowering benefit among patients with CVD comparable to that of lipid lowering agents.

Management of hereditary dyslipidaemia; the paradigm of autosomal dominant hypercholesterolaemia

Inherited, or autosomal dominant, hypercholesterolaemia, with an average global prevalence of one in 500 individuals, is one of the most frequent inherited metabolic disorders. The disorder is associated with a high risk for premature cardiovascular disease (CVD) and death as a consequence of accelerated atherosclerosis. Although the molecular genetic basis is largely elucidated and effective medical treatment, in the form of inhibitors of intracellular cholesterol synthesis, is available, the disorder is severely underdiagnosed and undertreated. On the other hand, with the well-understood aetiology, the accurate diagnosis, the availability of sensitive predictive makers and efficacious therapy, this disorder can serve as a model for disease management: from early presymptomatic diagnosis, accurate prognosis, optimal treatment and large-scale screening to population-based prevention of CVD.

Failure to achieve recommended LDL cholesterol levels by suboptimal statin therapy relates to elevated cardiac event rates

OBJECTIVES

The majority of patients with myocardial infarction (MI) and hypercholesterolaemia does not achieve guideline recommended low-density lipoprotein cholesterol (LDL) levels. Suboptimal dosages of statins explain this dilemma in most patients.

DESIGN AND SETTING

We evaluated the relationship between statin treatment quality (optimal: LDL<115 mg/dl, suboptimal: LDL>/=115 mg/dl, no statin therapy despite hypercholesterolaemia) and the subsequent incidence of coronary events (coronary death, nonfatal MI, bypass surgery) over a 30 months follow-up in a large cohort of post MI patients with hypercholesterolaemia (n=2045). Analysis was performed in a nested case-control manner comparing 173 cases with a coronary event and 346 matched controls.

RESULTS

Patients who developed a coronary event were treated optimally in 11.0%, suboptimally in 43.4% (p<0.05 vs. optimal treatment) and were untreated in 45.7% (p<0.001 vs. optimal treatment). Respective numbers in event-free patients were 21.4%, 47.7%, and 30.9%. After adjustment for most potential confounders, including all cardiovascular risk factors and medication, the relative risk of future non-fatal MI and coronary death associated with a suboptimal statin treatment was 2.02 (95% CI 1.04 to 4.18) compared to optimal statin treatment. Moreover, the statin equivalent dose in optimally treated individuals was significantly higher than in suboptimally treated individuals (0.85+/-0.03 vs. 0.78+/-0.02, p<0.05).

CONCLUSION

In this community-based study, a lipid lowering therapy with statins into the recommended target range of LDL levels may be associated with decreased cardiovascular risk compared to a statin therapy without titrating the LDL level below 115 mg/dl. Thus, the quality of statin treatment was identified as an independent predictor of coronary events in post MI patients.

Meta-Analysis of Natural Therapies for Hyperlipidemia: Plant Sterols and Stanols versus Policosanol

STUDY OBJECTIVE

To compare the efficacy and safety of plant sterols and stanols as well as policosanol in the treatment of coronary heart disease, as measured by a reduction in low-density lipoprotein cholesterol (LDL) levels.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

PATIENTS

A total of 4596 patients from 52 eligible studies.

MEASUREMENTS AND MAIN RESULTS

We searched MEDLINE, EMBASE, the Web of Science, and the Cochrane Library from January 1967-June 2003 to identify pertinent studies. Reduction of LDL levels was the primary end point; effects on other lipid parameters and withdrawal of study patients due to adverse effects were the secondary end points. Weighted estimates of percent change in LDL were -11.0% for plant sterol and stanol esters 3.4 g/day (range 2-9 g/day [893 patients]) versus -2.3% for placebo (769 patients) in 23 eligible studies, compared with -23.7% for policosanol 12 mg/day (range 5-40 mg/day [1528 patients]) versus -0.11% for placebo (1406 patients) in 29 eligible studies. Cumulative p values were significantly different from placebo for both (p<0.0001). The net LDL reduction in the treatment groups minus that in the placebo groups was greater with policosanol than plant sterols and stanols (-24% versus -10%, p<0.0001). Policosanol also affected total cholesterol, high-density lipoprotein cholesterol (HDL), and triglyceride levels more favorably than plant sterols and stanols. Policosanol caused a clinically significant decrease in the LDL:HDL ratio. Pooled withdrawal rate due to adverse effects and combined relative risk for patients who withdrew were 0% and 0.84, respectively (95% confidence interval [CI] 0.36-1.95, p=0.69), for plant sterols and stanols across 20 studies versus 0.86% and 0.31, respectively (95% CI 0.20-0.48, p<0.0001), for policosanol across 28 studies.

CONCLUSION

Plant sterols and stanols and policosanol are well tolerated and safe; however, policosanol is more effective than plant sterols and stanols for LDL level reduction and more favorably alters the lipid profile, approaching antilipemic drug efficacy.

Effects of Addition of Policosanol to??Omega-3 Fatty Acid Therapy on the??Lipid Profile of Patients with Type??II Hypercholesterolaemia

BACKGROUND

Policosanol is a mixture of higher aliphatic primary alcohols purified from sugar-cane wax. The mixture has cholesterol-lowering efficacy, its specific effects being to reduce serum total (TC) and low-density lipoprotein cholesterol (LDL-C), and to increase high-density lipoprotein cholesterol (HDL-C). The effects of policosanol on triglycerides (TG) are modest and inconsistent. Omega-3 fatty acids (FA) from fish oil protect against coronary disease, mainly through antiarrhythmic and antiplatelet effects. Omega-3 FA also have lipid-modifying effects, mostly relating to TG reduction. Thus, potential benefits could be expected from combined therapy with omega-3 FA and policosanol.

OBJECTIVE

To investigate whether combined therapy with omega-3 FA + policosanol offers benefits compared with omega-3 FA + placebo with respect to the lipid profile of patients with type II hypercholesterolaemia.

METHODS

This randomised, double-blind study was conducted in 90 patients with type II hypercholesterolaemia. After 5 weeks on a cholesterol-lowering diet, patients were randomised to omega-3 FA + placebo, omega-3 FA + policosanol 5 mg/day or omega-3 FA + policosanol 10 mg/day for 8 weeks. Omega-3 FA was supplied as 1g capsules (two per day); placebo and policosanol were provided in tablet form. Physical signs and laboratory markers were assessed at baseline and after 4 and 8 weeks on therapy. Drug compliance and adverse experiences (AEs) were assessed at weeks 4 and 8. The primary efficacy variable was LDL-C reduction; other lipid profile markers were secondary variables.

RESULTS

After 8 weeks, omega-3 FA + policosanol 5 and 10 mg/day, but not omega-3 FA + placebo, significantly reduced LDL-C by 21.1% and 24.4%, respectively (both p < 0.0001). Omega-3 FA + policosanol 5 mg/day also significantly lowered TC (12.7%; p < 0.01) and TG (13.6%; p < 0.05), and significantly increased HDL-C (+14.4%; p < 0.001). Omega-3 FA + policosanol 10 mg/day significantly decreased TC (15.3%; p < 0.001) and TG (14.7%; p < 0.01), and significantly increased HDL-C (+15.5%; p < 0.0001). Omega-3 FA + placebo significantly reduced TG (14.2%; p < 0.05) but had no significant effect on other lipid profile variables. The proportion of randomised patients in the omega-3 FA + policosanol 5 or 10 mg/day groups that achieved LDL-C targets or reductions 15% was significantly greater than in the omega-3 FA + placebo group (p < 0.001). Combined therapy with omega-3 FA + policosanol 5 or 10 mg/day resulted in significantly greater changes in LDL-C, TC and HDL-C than treatment with omega-3 FA + placebo, but did not modify the TG response compared with the omega-3 FA + placebo group. Four patients (two in the omega-3 FA + placebo group and two in the omega-3 FA + policosanol 10 mg/day group) withdrew from the study; none of these withdrawals was due to AEs. Two patients reported mild AEs, namely nausea/headache (one in the omega-3 FA + placebo group) and heartburn (one in the omega-3 FA + policosanol 5 mg/day group).

CONCLUSIONS

Policosanol 5 or 10 mg/day administered concomitantly with omega-3 FA 1 g/day improved LDL-C, TC and HDL-C, maintained the reduction in TG attributable to omega-3 FA monotherapy, and was well tolerated. Treatment with omega-3 FA + policosanol could be useful for regulating lipid profile in patients with type II hypercholesterolaemia, but further studies involving larger sample sizes are needed before definitive conclusions can be drawn.

Economic evaluation of a compliance-enhancing intervention in patients with hypercholesterolemia: design and baseline results of the Open Label Primary Care Study: Rosuvastatin Based Compliance Initiatives To Achievements of LDL Goals (ORBITAL) study

BACKGROUND

Previous studies investigating the effectiveness of compliance programs in patients with cardiovascular risk factors have been inconclusive and have not included economic analyses. The primary aim of this Open Label Primary Care Study: Rosuvastatin Based Compliance Initiatives To Achievements of LDL Goals (ORBITAL) study is to determine the long-term cost-effectiveness of a compliance-enhancing intervention in patients with hypercholesterolemia (HC). Secondary objectives include the assessment of compliance, cardiovascular events, and health-related quality of life.

STUDY DESIGN

A total of 7598 patients (56% men, age 60 +/- 10 years, and 44% women, 64 +/- 10 years) with HC requiring statin therapy according to the Second Joint European Guidelines were recruited at presentation to 1961 primary care physicians in Germany. Patients were randomized to rosuvastatin therapy with or without a compliance-enhancing program (including standardized contacts between the study center and patients, 9 mailings, 6 telephone calls, and access to a Web page and hotline) for 12 months. Following the intervention phase, there will be a 24-month observational period with patients receiving usual care. Baseline and 6-monthly follow-up assessments are to be obtained from patients and their physicians using standardized questionnaires to evaluate medical and economic parameters. Cumulative direct and indirect disease-related costs (including resource utilization for ambulatory, hospital, rehabilitative, and nursing care, medication, physiotherapy, and transportation, and loss of productivity) will be compared applying a societal perspective.

CONCLUSIONS

The results of this ORBITAL study will provide a basis to develop cost-effective compliance strategies and eventually improve medical care for patients with HC.

Cost of a pharmacist-directed intervention to increase treatment of hypercholesterolemia

STUDY OBJECTIVE

To evaluate the cost of a pharmacist-directed intervention that prompts physicians to treat hypercholesterolemia more aggressively in patients with coronary heart disease (CHD).

METHODS

Health care resource use and CHD outcomes were evaluated for 612 patients with CHD followed for 2 years after an index hospitalization for an ischemic event. After discharge, the physicians of 309 patients who had been admitted from January 1--March 31, 1999, were contacted by telephone and mail concerning lipid profiles and statin therapy. These patients were the intervention group. Controls were 303 patients admitted from October 1--December 31, 1998; their physicians were not contacted. Costs of the physician-prompting intervention, clinic visits, laboratory tests, statin drugs, and CHD outcomes were compared between these two patient groups.

RESULTS

The number of clinic visits, laboratory tests, and statins prescribed was significantly greater for the intervention group versus the controls. A significantly higher percentage of patients in the intervention group (55%) than in the control group (18%) achieved their National Cholesterol Education Program target low-density lipoprotein cholesterol level and had significantly better CHD outcomes. The cost of the physician-prompting intervention (pharmacist salaries, postage, telephone calls) was $102,941. For patients in the intervention and control groups, respectively, the cost of statin therapy was $352,365 and $200,087, the cost of clinic visits and laboratory tests $48,097 and $27,367, and the cost of coronary heart disease outcomes, such as myocardial infarction, coronary artery bypass graft, percutaneous transluminal and coronary angioplasty, $1,073,495 and $1,741,220. The total cost was $1,576,898 and $1,968,674, respectively, for patients in the intervention and control groups. Net savings was $1394/patient over the 2-year period.

CONCLUSION

A relatively simple physician-prompting intervention involving patients with CHD significantly improved the use of lipid testing and statin therapy. Improved use of statins was associated with better CHD outcomes. As a result, the physician-prompting intervention was associated with cost savings. This intervention should be implemented for patients with CHD discharged after hospitalization for an ischemic event.

More Western hypercholesterolemic patients achieve Japan Atherosclerosis Society LDL-C goals with rosuvastatin therapy than with atorvastatin, pravastatin, or simvastatin therapy

BACKGROUND

Data from Western comparative trials suggest that rosuvastatin is more effective than atorvastatin, simvastatin, and pravastatin in helping hypercholesterolemic patients achieve US and European lipid-lowering guidelines. The purpose of this analysis was to assess the comparative efficacy of rosuvastatin in reducing low-density lipoprotein cholesterol (LDL-C) to levels recommended by the Japan Atherosclerosis Society (JAS).

METHODS AND RESULTS

A post hoc analysis of data from 6 randomized, double-blind, active-controlled trials was conducted to evaluate the relative efficacy of rosuvastatin and comparator statins in helping patients achieve the LDL-C goals established by the JAS. The first 5 trials, prospectively designed for pooling, were originally conducted to compare the effects of rosuvastatin with either atorvastatin, simvastatin, or pravastatin in reducing lipid levels and helping patients achieve the LDL-C goals established by the National Cholesterol Education Program. The 6th trial was conducted with similar objectives, but in patients with heterozygous familial hypercholesterolemia (HeFH). Data from 2,139 hypercholesterolemic patients in the first 5 trials were pooled for analysis: rosuvastatin 5 mg (n=390) or 10 mg (n=389) vs atorvastatin 10 mg (n=393); rosuvastatin 5 mg (n=240) or 10 mg (n=226) vs simvastatin 20 mg (n=249) or pravastatin 20 mg (n=252). In the studies with atorvastatin as the comparator, JAS-defined LDL-C goals were reached by 67.2% of the rosuvastatin 5-mg group, 82.3% of the rosuvastatin 10-mg group, and 58.0% of the atorvastatin 10-mg group (p<0.001 for both rosuvastatin groups vs atorvastatin) at 12 weeks. Similarly, in the trials with pravastatin and simvastatin as comparators, the JAS LDL-C goals were reached by 77.5% of the rosuvastatin 5-mg group, 86.7% of the rosuvastatin 10-mg group, 45.2% of the pravastatin 20-mg group and 65.5% of the simvastatin 20-mg group (p<0.001 for both rosuvastatin groups vs pravastatin and simvastatin). In the trial of HeFH patients (n=433 for rosuvastatin, n=187 for atorvastatin), 31.9% of patients treated with rosuvastatin 20 mg achieved JAS LDL-C goals, compared with 17.6% of patients treated with atorvastatin 20 mg (p<0.001).

CONCLUSIONS

Rosuvastatin has demonstrated clinical superiority over atorvastatin, pravastatin, and simvastatin in reducing LDL-C levels and in enabling patients to reach goals established by the JAS.

Pharmacodynamic interaction between ezetimibe and rosuvastatin

BACKGROUND

Ezetimibe is a lipid-lowering drug indicated for the treatment of hypercholesterolemia as co-administration with HMG-CoA reductase inhibitors (statins) or as monotherapy. The primary objectives of this study were to evaluate the pharmacodynamic effects and safety of the co-administration of ezetimibe and the new statin rosuvastatin. A secondary objective was to examine the potential for a pharmacokinetic interaction between ezetimibe and rosuvastatin.

METHODS

This was a randomized, evaluator (single)-blind, placebo-controlled, parallel-group study in healthy hypercholesterolemic subjects (untreated low-density lipoprotein cholesterol [LDL-C] > or = 130 mg/dL [3.37 mmol/L]). After the outpatient screening and NCEP Step I diet stabilization periods, 40 subjects were randomized to one of the 4 following treatments: rosuvastatin 10 mg plus ezetimibe 10 mg (n = 12); rosuvastatin 10 mg plus placebo (matching ezetimibe 10 mg) (n = 12); ezetimibe 10 mg plus placebo (matching ezetimibe 10 mg) (n = 8); or placebo (2 tablets, matching ezetimibe 10 mg) (n = 8). All study treatments were administered once daily in the morning for 14 days as part of a 16-day inpatient confinement period. Fasting serum lipids were assessed pre-dose on days 1 (baseline), 7, and 14 by direct quantitative assay methods. Safety was evaluated by monitoring laboratory tests and recording adverse events. Blood samples were collected for ezetimibe and rosuvastatin pharmacokinetic evaluation prior to the first and last dose and at frequent intervals after the last dose (day 14) of study treatment. Plasma ezetimibe, total ezetimibe (ezetimibe plus ezetimibe-glucuronide) and rosuvastatin concentrations were determined by validated liquid chromatography with tandem mass spectrometric detection (LC-MS/MS) assay methods.

RESULTS

All active treatments caused statistically significant (p < or = 0.02) decreases in LDL-C concentration versus placebo from baseline to day 14. The co-administration of ezetimibe and rosuvastatin caused a significantly (p < 0.01) greater reduction in LDL-C and total cholesterol than either drug alone. In this 2-week inpatient study with restricted physical activity there was no apparent effect of any treatment on high-density lipoprotein cholesterol (HDL-C) or triglycerides. The co-administration of ezetimibe and rosuvastatin caused a significantly (p < 0.01) greater percentage reduction in mean LDL-C (-61.4%) than rosuvastatin alone (-44.9%), with a mean incremental reduction of -16.4% (95%CI -26.3 to -6.53). Reported side effects were generally mild, nonspecific, and similar among treatment groups. There were no significant increases or changes in clinical laboratory tests, particularly those assessing muscle and liver function. There was no significant pharmacokinetic drug interaction between ezetimibe and rosuvastatin.

CONCLUSIONS

Co-administration of ezetimibe 10 mg with rosuvastatin 10 mg daily caused a significant incremental reduction in LDL-C compared with rosuvastatin alone. Moreover, co-administering ezetimibe and rosuvastatin was well tolerated in patients with hypercholesterolemia.

Improving lipid management--to titrate, combine or switch

Despite the benefits of statin therapy, cholesterol management remains suboptimal and many patients do not achieve their recommended low-density lipoprotein cholesterol (LDL-C) goals. The use of insufficient doses, limited drug effectiveness and poor patient compliance may contribute to the treatment gap. Options for improving lipid management include dose titration, combination therapy or prescribing a more efficacious statin. LDL-C reductions are generally modest when patients' current statin dose is titrated, and there may be an increased potential for adverse effects. Combining statin therapy with another lipid-modifying agent can provide additional LDL-C reductions, but cost, tolerability and compliance should be considered. In general, switching to a more efficacious statin is a cost-effective way of enabling more patients to achieve recommended targets without increasing dosages. When considering the options available, physicians should balance efficacy, cost and safety to enable more patients to attain LDL-C goals and achieve greater therapeutic gain from statin treatment.

Ezetimibe: a novel option for lowering cholesterol

Elevated low-density lipoprotein (LDL)-cholesterol is associated with a significantly increased risk of coronary heart disease but lowering LDL-cholesterol to levels established in current National Cholesterol Education Program (NCEP) guidelines provides significant risk reduction. Nevertheless, many patients receiving lipid-lowering therapy, particularly those at highest coronary heart disease risk, do not reach LDL-cholesterol goals with their current medications. Ezetimibe (Zetia, Merck Schering-Plough) is the first of a new class of lipid-lowering drugs known as cholesterol absorption inhibitors. Ezetimibe has a favorable pharmacokinetic profile, which allows it to be administered once daily and to be given in conjunction with statins. In a series of randomized, controlled, multicenter studies, ezetimibe produced significant improvements in levels of LDL-cholesterol and other lipid parameters when used as monotherapy, with a safety profile comparable with that of placebo. Furthermore, coadministration of ezetimibe with a statin (simvastatin, atorvastatin, lovastatin, or pravastatin) was more effective than statin monotherapy in lowering LDL-cholesterol and improving other lipid parameters. Moreover, coadministration of ezetimibe with a statin allowed a greater percentage of patients to achieve treatment goals established in NCEP guidelines. The safety and side-effect profile of ezetimibe plus statin coadministration therapy was generally comparable with that of statin monotherapy. These studies establish ezetimibe as an effective lipid-lowering agent, which will likely be useful in the management of a broad range of patients with hypercholesterolemia. Ezetimibe can be used in conjunction with a statin at the beginning of therapy, or it can be added if patients do not achieve their LDL-cholesterol goal with statins alone.

Obesity as the core of the metabolic syndrome and the management of coronary heart disease

The global burden of coronary heart disease (CHD) has led to the introduction of international guidelines to minimize the morbidity and mortality that result from this condition. These guidelines recognize the contribution of multiple risk factors to the development of CHD and advocate a multifaceted approach to treatment. Obesity, particularly visceral adiposity, contributes to the clustering of many other risk factors, such as hypertension, insulin resistance/type 2 diabetes and dyslipidemia, within individual patients. The molecular mechanisms underlying the metabolic abnormalities induced by visceral adiposity have yet to be fully elucidated; however, adipocytokines such as adiponectin, tumor necrosis factor-alpha and resistin seem to play an important role in this process. Obesity is a major modifiable CHD risk factor, and the benefits of weight loss are numerous, leading to improvements in several co-morbidities. Guidelines advocate lifestyle changes to correct excess bodyweight and improve the CHD risk factor profile. In addition, pharmacologic therapy is recommended for the management of other risk factors, such as hypertension and dyslipidemia, which may not be adequately controlled by lifestyle changes alone. Lowering low-density lipoprotein cholesterol (LDL-C) levels is the primary target for drug therapy for CHD prevention, and statins are first-line lipid-modifying therapy. The introduction of more efficacious statins with favorable effects on the lipid profile will optimize the control of dyslipidemia. Combining these new treatments with lifestyle changes and drug therapies for managing other CHD risk factors, as part of a multifaceted approach to treatment, will have benefits for CHD prevention.

Apolipoprotein B and apolipoprotein A-I: risk indicators of coronary heart disease and targets for lipid-modifying therapy

Although LDL cholesterol (LDL-C) is associated with an increased risk of coronary heart disease, other lipoproteins and their constituents, apolipoproteins, may play an important role in atherosclerosis. Elevated levels of apolipoprotein (apo) B, a constituent of atherogenic lipoproteins, and reduced levels of apo A-I, a component of anti-atherogenic HDL, are associated with increased cardiac events. Apo B, apo A-I and the apo B/apo A-I ratio have been reported as better predictors of cardiovascular events than LDL-C and they even retain their predictive power in patients receiving lipid-modifying therapy. Measurement of these apolipoproteins could improve cardiovascular risk prediction.

Optimizing LDL-C Lowering With Statins

Clinical studies have demonstrated the efficacy of statins in reducing low-density lipoprotein cholesterol (LDL-C) and lowering coronary heart disease risk. However, many patients receiving statin therapy in clinical practice are not achieving their LDL-C goals. Generally, statins are initiated at starting doses, and doses should be titrated as needed until the goal of therapy is achieved or a second lipid-lowering drug is required; titration is required in the majority of patients who receive less efficacious agents. Most patients receiving statin therapy in clinical practice are maintained on their starting dose, and this frequently results in inadequate control of elevated cholesterol levels. A number of factors may limit dose titration in clinical practice, including the cost of therapy, safety of prescribing statins at high doses and the additional office visits required for evaluations and monitoring. There may be several solutions to this problem. The choice of statin appears to be one of the important factors influencing the success of therapy. Selecting a statin that provides greater LDL-C lowering enables more patients to achieve LDL-C goals, and the majority of patients can be effectively treated with starting doses of the more efficacious statins. Another factor influencing the success of therapy is the willingness to add other drugs to a statin to enhance LDL-C lowering. Choices here include niacin, a bile acid sequestrant, and ezetimibe, a new cholesterol absorption inhibitor. Of these approaches, use of a more efficacious statin is preferred to combination therapy because of cost, safety, effectiveness, and simplicity issues.

Patients' achievement of cholesterol targets: a cross-sectional evaluation

BACKGROUND

Despite incontrovertible evidence for the efficacy of cholesterol lowering, numerous studies suggest that patients are suboptimally treated. This study was conducted to determine the proportion of patients achieving recommended target lipid levels in a relatively unselected group of community-dwelling patients who were prescribed HMG-CoA reductase inhibitors (statins).

METHODS

Community pharmacists identified participants who were receiving an HMG-CoA reductase inhibitor at the same dosage for a minimum of 6 weeks and enrolled them into the study. Participants had an interview to determine cardiovascular risk factors and level of cardiovascular risk as defined by Canadian dyslipidemia guidelines, and a fasting lipid profile was performed using a point-of-care cholesterol assessment device.

RESULTS

During 2000, a total of 404 participants were enrolled from 16 pharmacies. The highest proportion (96%) of participants achieving low-density lipoprotein targets was in the low-risk group, and the proportion progressively decreased as cardiac risk level increased: 80% in the moderate-risk group and 82% in the high-risk group. The very-high-risk group had the lowest proportion (37%) of participants who achieved their target.

CONCLUSIONS

Consistent with other studies, this study found that as cardiac risk increased, the proportion of patients achieving their target cholesterol values decreased, such that those at the greatest risk for cardiovascular disease (who had the most to gain from aggressive lipid-lowering interventions) were least likely to achieve their cholesterol targets. This suggests a need for more-aggressive approaches to the management of cholesterol, particularly in high-risk patients.

Managing the spectrum of dyslipidemia in primary care

Dyslipidemia, especially elevated low-density lipoprotein cholesterol (LDL-C), increases the risk of coronary heart disease and subsequent morbidity or mortality. For more than a decade, the National Cholesterol Education Program (NCEP) has endeavored to raise awareness of the dangers of dyslipidemia and to encourage the implementation of recommended treatment strategies. However, despite this initiative, previously published NCEP targets were not met. The recently released NCEP-Adult Treatment Panel III guidelines recommend more aggressive LDL-C reduction, elevation of categorical low high-density lipoprotein binding protein, and increased monitoring of moderate triglyceride elevations. Although the 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors (statins) are the most powerful medications available to reduce LDL-C, studies have shown that more than half of patients treated with these drugs do not achieve therapeutic targets and the resultant decrease in coronary heart disease events. There are a number of possible reasons for this, including potency of the statins and a lack of compliance on the part of patients and providers. Another concern with the available statins is the issue of drug-drug interactions. Some of these concerns may be addressed by newer agents in this drug class that are in development. They appear to have the potential to induce even greater reductions in LDL-C and to positively affect other lipoproteins. They also have the potential for less risk of drug-drug interactions. Nurse practitioners can play a pivotal role in improving the management of dyslipidemia by ensuring the proper implementation of current guidelines, helping patients adhere to treatment protocols, and remaining abreast of developments that may pave the way toward even more effective intervention in the future.

Achievement of low-density lipoprotein cholesterol goals: new strategies to address new guidelines

Evidence that CHD morbidity and mortality can be reduced with reduction of LDL-C to less than 100 mg/dL (2.6 mmol/L) is rapidly accumulating. NCEP-ATP III guidelines should be considered minimal goals of therapy. Regarding the prevention and treatment of CHD, health care providers need to recognize the wide therapeutic gap between evidence-based medicine and customary clinical practice. Aggressive pharmacologic therapy is probably required to achieve optimal LDL-C levels in many hyperlipidemic patients. Novel agents, including selective cholesterol absorption inhibitors, will provide clinicians with a tool to safely and effectively target the exogenous pathway of cholesterol metabolism. Combination therapy with cholesterol-lowering agents that have complementary mechanisms of action and can be safely co-administered may be a new option to achieve broader lipid control.

Aggressive lipid management for cardiovascular prevention: evidence from clinical trials

Epidemiologic evidence shows that elevated serum cholesterol, specifically low-density lipoprotein cholesterol (LDL-C), increases the risk of coronary heart disease (CHD). Moreover, large-scale intervention trials demonstrate that treatment with HMG-CoA reductase inhibitors (statins), the most effective drug class for lowering LDL-C, significantly reduces the risk of CHD events. Unfortunately, only a moderate percentage of hypercholesterolemic patients are achieving LDL-C targets specified by the National Cholesterol Education Program (NCEP), in part because clinicians are not effectively titrating medications as needed to achieve LDL-C goals. Recent evidence suggests that more aggressive LDL-C lowering may provide greater clinical benefit, even in individuals with moderately elevated serum cholesterol levels. Furthermore, recent studies suggest that statins have cardioprotective effects in many high-risk individuals, including those with baseline LDL-C <100 mg/dl. High-density lipoprotein cholesterol (HDL-C) was recognized by the NCEP-Adult Treatment Panel II (ATP II) as a negative risk factor for CHD. The NCEP-ATP III guidelines have also reaffirmed the importance of HDL-C by increasing the low HDL-C designation from <35 to <40 mg/dl as a major risk factor for CHD. Similarly, triglyceride control will play a larger role in dyslipidemia management. As more clinicians effectively treat adverse lipid and lipoprotein cardiovascular risk factors, patients will likely benefit from reductions in cardiovascular events.