Cholesterol Goal Attainment Research Articles

Effects of Rosuvastatin and Atorvastatin on LDL and HDL Particle Concentrations in Patients With Metabolic Syndrome

OBJECTIVEThe purpose of this study was to examine the effects of statin therapy on lipoprotein particle concentrations in patients with the metabolic syndrome. Changes in lipoprotein particle concentration may predict the risk of coronary heart disease more accurately than lipoprotein cholesterol levels.RESEARCH DESIGN AND METHODSPatients with dyslipidemia and the metabolic syndrome (n = 318) were randomly assigned in a double-blind study comparing 10 mg rosuvastatin (RSV), 10 mg atorvastatin, or placebo daily for 6 weeks. From weeks 6 to 12, patients in the RSV and placebo groups received 20 mg RSV, whereas the ATV group increased their dose to 20 mg daily. Lipoprotein particle concentrations were measured by nuclear magnetic resonance spectroscopy, LDL cholesterol was measured by β-quantification, and other lipoproteins were measured by standard methods at baseline, 6 weeks, and 12 weeks. Lipoprotein levels were compared by analysis of covariance.RESULTSStatins reduced LDL particle concentration less than LDL cholesterol (−30 to −38 vs. −38 to −51%). Reductions were greater with RSV than with ATV (P < 0.05 for LDL particle concentration and P < 0.001 for LDL cholesterol). Most patients attained LDL cholesterol <2.59 mmol/l (100 mg/dl) at 12 weeks (80% with RSV and 59% with ATV; P = 0.003), but only 27% of patients receiving RSV and 19% receiving ATV attained the goal of LDL particle concentration <1,000 nmol/l (P = 0.07).CONCLUSIONSIn patients with the metabolic syndrome, statin-induced changes in LDL cholesterol do not accurately reflect changes in LDL particle concentration. Consequently, despite attainment of LDL cholesterol goals, these patients may retain considerable residual coronary heart disease risk.

A medication therapy management program's impact on low-density lipoprotein cholesterol goal attainment in Medicare Part D patients with diabetes

To determine a medication therapy management (MTM) service's impact on (1) Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and (2) use and cost expenditures. Nonequivalent group, quasiexperimental study. Florida, January 1, 2006, through September 30, 2007. 2,114 Florida Health Care Plans Medicare Part D enrollees with diabetes. Intervention group participated in the MTM program during the HEDIS measurement year. Presence of low-density lipoprotein cholesterol (LDL-C) screening, LDL-C values, and LDL-C control (<100 mg/dL). The use measure was the total number of 30-day medication equivalents. Cost measures were (1) total Medicare Part D drug cost, (2) enrollees' out-of-pocket Part D medication costs, and (3) total medication copayments. Statistical analyses included chi-square, independent and paired t tests, and analysis of variance with post hoc comparisons. Of 2, 114 enrollees eligible for comprehensive diabetes care (CDC) according to HEDIS guidelines, 255 participated in the MTM intervention group and 56 patients were MTM eligible but opted out of the program or could not be reached for medication review during 2008 (MTM nonparticipants). A higher proportion of patients in the MTM participant group had LDL-C levels less than 100 mg/dL (69.0%) compared with those in the MTM nonparticipant (50.0%) and CDC only (54.1%) groups (chi2 = 20.9(3), P < 0.001). The two control groups' average LDL-C (90.8 and 93.6 mg/dL) was significantly higher than the intervention group (83.4 mg/dL, P < 0.001). Overall, per member per month use and drug costs differed from 2007 to 2008 and enrollees in the MTM participant group had greater percentage cost reductions. Enrollees who were eligible for MTM services but did not receive them had poorer clinical, use, and cost outcomes compared with the MTM intervention group. Pharmacists collaborating with physicians through a MTM program can improve quality of metrics for chronic diseases and reduce medication costs.

Assessment of Cholesterol Goal Attainment and Statin Dosing Considerations in Nursing Home Residents

Assessment of Cholesterol Goal Attainment and Statin Dosing Considerations in Nursing Home Residents

The Use of a Single‐Pill Calcium Channel Blocker/Statin Combination in the Management of Hypertension and Dyslipidemia: A Randomized, Placebo‐Controlled, Multicenter Study

Poor control of hypertension or dyslipidemia may at least in part be due to these risk factors being treated in isolation. The Caduet in Untreated Subjects Population (CUSP) trial was an 8-week, randomized, double-blind, placebo-controlled trial evaluating the efficacy/safety of the combination of a calcium channel blocker (amlodipine besylate) and a statin (atorvastatin calcium) in a single-pill form (5/20 mg) plus therapeutic lifestyle changes (TLC) compared with placebo plus TLC in patients with comorbid hypertension and dyslipidemia without evidence of cardiovascular disease. At week 4, additional antihypertensive/lipid-lowering medication was permitted. The primary end point was the proportion of patients in whom the dual goal of blood pressure (<140/90 mm Hg) and low-density lipoprotein cholesterol control (<100 mg/dL) was met at week 4. This dual goal attainment was significantly greater with amlodipine/atorvastatin plus TLC compared with placebo plus TLC at week 4 (47.6% vs 1.7%; P<.001), with further improvements at week 8. Most adverse events were mild to moderate. Therapy with single-pill amlodipine/atorvastatin plus TLC in these patients significantly increased dual blood pressure/low-density lipoprotein cholesterol goal attainment compared with placebo plus TLC.

LDL-C reductions and goal attainment among naive statin users in the Netherlands: real life results

ABSTRACTObjective: The effectiveness of statin therapy in a real life setting may differ from that in clinical trials, as physicians make non-randomised treatment decisions for patients with less uniform and possibly different characteristics. We therefore performed a study to compare the effectiveness of different statins and doses in routine clinical practice with respect to total serum cholesterol and LDL-cholesterol (LDL-C) reduction and goal attainment according to European guidelines on the prevention of cardiovascular disease (CVD).Research design and methods: Naive statin users starting treatment in 2003 and 2004 with LDL-C measurements at baseline and between 30 and 365 days after start of treatment were extracted from the PHARMO database. During treatment with their initial statin dose LDL-C reduction and attainment of cholesterol goals were compared between different statins and doses.Results: Of 2303 identified naive patients, approximately 30% were allocated to the high CVD-risk group. Average LDL-C reductions were 48%, 42%, 39%, and 32% at mean doses of 11 mg rosuvastatin, 17 mg atorvastatin, 22 mg simvastatin and 35 mg pravastatin, respectively. The proportion of patients attaining cholesterol goals was 75% for rosuvastatin, 68% for atorvastatin, 56% for simvastatin, and 42% for pravastatin. Dose comparisons showed greater LDL-C reduction and increased goal attainment for rosuvastatin 10 mg compared to other statins at most doses (adjusted p < 0.05).Conclusions: In a real life setting, both LDL-C reduction and the proportion of patients attaining cholesterol goals appear to be significantly increased among users of rosuvastatin compared to other statins. These results confirm and extend reported clinical trial results to a real world setting.

Current status of cholesterol goal attainment after statin therapy among patients with hypercholesterolemia in Asian countries and region: the Return on Expenditure Achieved for Lipid Therapy in Asia (REALITY-Asia) study

ABSTRACTBackground: Data on achieving National Cholesterol Education Program Adult Treatment Panel III (ATP III) goals in Asia are limited.Objective: To examine treatment patterns, goal attainment, and factors influencing treatment among patients in 6 Asian countries who were taking statins.Methods: A retrospective cohort study was conducted in China, Korea, Malaysia, Singapore, Taiwan, and Thailand, where 437 physicians (41% cardiologists) recruited adults with hypercholesterolemia newly initiated on statin monotherapy.Results: Of 2622 patients meeting inclusion and exclusion criteria, approximately 66% had coronary heart disease (CHD)/diabetes mellitus, 24% had no CHD but ≥2 risk factors, and 10% had no CHD and <2 risk factors. Most patients (∼90%) received statins at medium or lower equipotency doses. Across all cardiovascular risk categories, 48% of patients attained ATP III targets for low-density lipoprotein cholesterol (LDL-C), including 38% of those with CHD/diabetes (goal: <100 mg/dL), 62% of those without CHD but with ≥2 risk factors (goal: <130 mg/dL), and 81% of those without CHD and <2 risk factors (goal: <160 mg/dL). Most patients who achieved goals did so within the first 3 months. Increasing age (odds ratio (OR) = 1.015 per 1-year increment; 95% confidence interval (CI) = 1.005–1.206; p = 0.0038) and initial statin potency (OR = 2.253; 95% CI = 1.364–3.722; p = 0.0015) were directly associated with goal attainment, whereas increased cardiovascular risk (OR=0.085; 95% CI = 0.053–0.134; p < 0.0001 for CHD/diabetes mellitus at baseline compared with <2 risk factors,) and baseline LDL-C (OR = 0.990; 95% CI = 0.987–0.993); p < 0.0001 per 1-mg/dL increment) were inversely associated with LDL-C goal achievement. Limitations of this study include potential differences in treatment settings and cardiovascular risk factors between different countries and centers. In addition, the effects on cholesterol goal achievement of concomitant changes in lifestyle were not assessed.Conclusion: LDL-C goal attainment is low in Asians, particularly those with CHD/diabetes. More effective patient monitoring, treatments, including combining regimens and dose titration, and adherence to these treatments along with therapeutic lifestyle counseling may facilitate goal attainment.

Dyslipidemia Control in Indigent Patients Receiving Medication Assistance Compared with Insured Patients

To compare dyslipidemia management with statin-based therapy in insured patients versus indigent patients receiving medication assistance, and to determine drug therapy adherence rates in the two groups. Retrospective medical record review. Setting. University-based health care system. Two hundred forty patients with dyslipidemia who received statin-based therapy from the outpatient pharmacies and clinical care at an affiliated clinic. Prescription records identified 665 patients between October 1, 2004, and September 30, 2005. Forty of these patients had insurance (with a single carrier), and the remaining 625 patients received health care subsidies from the Colorado Indigent Care Program (CICP). Using a block scheme, 200 patients from the CICP were randomly extracted. The primary objective was measured by assessment of low-density lipoprotein cholesterol (LDL) goal attainment and use of a moderate-potency, lipid-lowering regimen capable of achieving an LDL level reduction of least 30%. Of a total of 240 patients who met study criteria, 26 were excluded whose records lacked LDL measurements while receiving therapy. The LDL goal was achieved in 122 (68.9%) of the 177 patients in the CICP group versus 29 (78.4%) of the 37 patients in the insured group (p=0.34). A moderate-potency, LDL-lowering regimen was used by 90.5% of 200 patients in the CICP group and 85% of 40 patients in the insured group (p=0.45). In patients classified as having moderately high, high, or very high cardiovascular risk, LDL goals were attained in 103 (67.3%) of 153 patients in the CICP group versus 16 (69.6%) of 23 patients in the insured group (p=0.83). In this higher-risk subgroup, a moderate-potency regimen was used in 162 (92.6%) of 175 patients in the CICP group versus 23 (92%) of 25 patients in the insured group (p=0.92). Among the very high-risk patients from the two groups combined, 30 (52.6%) of 57 patients achieved LDL concentrations below 70 mg/dl, and 58 (95.1%) of 61 patients were administered a moderate-potency, LDL-lowering regimen. The secondary objective, overall adherence, as assessed by the medication possession ratio, was better in the CICP group than in the insured group. Our data suggest that quality of dyslipidemia management is similar for indigent and insured populations. Overall LDL goal attainment rates were higher than those reported in the literature. Most patients with significant cardiovascular risk, including those at very high risk, were treated according to established guidelines. Adherence rates were greater for indigent patients.

Lipid levels and low-density lipoprotein cholesterol goal attainment in diabetic patients: rosuvastatin compared with other statins in usual care

Objective: To compare change in low-density lipoprotein cholesterol (LDL-C) levels and National Cholesterol Education Program (NCEP) Adult Treatment Panel III LDL-C goal attainment in diabetic patients treated with rosuvastatin versus other statins in a large, managed care health plan. Research Design and Methods: This retrospective cohort analysis used medical and pharmacy claims linked to laboratory results from a commercial/MedicareAdvantage health plan. Study participants were ≥ 18 years of age, had a diagnosis of diabetes, were newly treated with statins from 8/1/03 to 2/28/05, and were considered at high risk for cardiovascular events as defined by NCEP guidelines. Subjects were continuously enrolled for 12 months pre-index and ≥ 30 days post-index, with variable follow-up until therapy discontinuation or end of health plan eligibility. Main Outcome Measures: Change in LDL-C from baseline, and attainment of NCEP LDL-C goal among patients not at goal before starting therapy. Results: A total of 3337 adult patients with diabetes were identified with new use of statin therapy during the identification period. A total of 9% (n = 301) started on rosuvastatin, 49.4% (n = 1,649) on atorvastatin, 20.7% (n = 690) on simvastatin, 7.0% (n = 234) on pravastatin, 11.7% (n = 391) on lovastatin and 2.2% (n = 72) on fluvastatin. After controlling for covariates, rosuvastatin patients experienced a significantly greater decrease in LDL-C from baseline (38.7%) than patients taking atorvastatin (34.2%) (p = 0.05), simvastatin (31.5%), pravastatin (24.2%), fluvastatin (26.3%) or lovastatin (24.9%) (p < 0.0001). Rosuvastatin users were significantly more likely to attain LDL-C goal than those taking the other statins (odds ratio: 0.44, 0.28, 0.14, 0.14, 0.19, respectively; p < 0.001). Predicted percent attaining goal was significantly greater for those taking rosuvastatin (87.3%) than for those taking atorvastatin (76.9%), simvastatin (68.7%), pravastatin (55.0%), lovastatin (55.3%) or fluvastatin (61.3%) (p < 0.001). Conclusion: For diabetic patients, rosuvastatin is more effective at reducing LDL-C levels and attaining NCEP ATP III LDL-C goal than other statins in real-world clinical practice.

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.

Improved Attainment of Blood Pressure and Cholesterol Goals Using Single-Pill Amlodipine/Atorvastatin in African Americans: The CAPABLE Trial

To investigate the efficacy and safety of single-pill amlodipine/atorvastatin therapy for the simultaneous treatment of hypertension (HTN) and dyslipidemia in African Americans. Conducted between July 19, 2004, and August 9, 2005, the Clinical Utility of Caduet in Simultaneously Achieving Blood Pressure and Lipid End Points trial was a 20-week, open-label, noncomparative, multicenter trial of the efficacy and safety of single-pill amlodipine/atorvastatin in controlling elevated blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in African Americans with concomitant HTN and dyslipidemia and either no additional risk factors, 1 or more cardiovascular risk factors, or coronary heart disease or a risk equivalent. Eight dosage strengths of single-pill amlodipine/atorvastatin were flexibly titrated. The primary efficacy assessment of the main trial was the percentage of patients who attained the LDL-C treatment goals of both the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National Cholesterol Education Program Adult Treatment Panel III. Of the 1170 African American patients screened, 501 were enrolled in the study and 499 received drug therapy. At end point, 236 (48.3%) of 489 patients reached both their BP and LDLC goals (vs 4 [0.8%] of 484 at baseline); 280 (56.8%) of 493 reached BP goals (vs 7 [1.4%] of 494 at baseline); and 361 (73.7%) of 490 reached LDL-C goals (vs 138 [28.5%] of 484 at baseline). Among the 499 patients receiving drug therapy, common treatment-related adverse events were peripheral edema (17 patients [3.4%]), headache (11 [2.2%]), myalgia (11 [2.2%]), and constipation (10 [2.0%]). Single-pill amlodipine/atorvastatin therapy was well tolerated and effectively targeted HTN and dyslipidemia in this population of African Americans who were at risk of cardiovascular disease.

Intensity of lipid-lowering therapy and low-density lipoprotein cholesterol goal attainment among the elderly before and after the 2004 National Cholesterol Education Program Adult Treatment Panel III update

In 2004, the Coordinating Committee of the National Cholesterol Education Program issued an update to the Adult Treatment Panel III guidelines on cholesterol management (the Update). Our objectives were to compare the proportion of elderly patients receiving intensive or minimal-guideline lipid-lowering therapy and the proportions meeting low-density lipoprotein cholesterol (LDL-C) goals before and after the update. We used dispense records from Kaiser Permanente Northwest (Portland, OR) to identify elderly patients who received statin therapy in 2003 (n = 14425) and 2005 (n = 19422) and laboratory records to assess LDL-C goal attainment. Among new statin initiators, 85.4% of very-high-risk patients received minimal-guideline therapy in 2005, compared with 65.3% (P < .0001) in 2003. Of all new initiators, <1% received very aggressive therapy in either year (0.4% vs 0.3%, P = .315). Overall, 77.7% and 59.0% of ongoing users in 2005 and 2003, respectively, received minimal-guideline therapy (P < .0001). Low-density lipoprotein cholesterol goal attainment did not differ between 2003 and 2005 continuing statin users. Among very-high-risk patients who initiated statin treatment, a significantly greater proportion of patients in 2005 versus 2003 attained the optional goal of <70 mg/dL (45.5% vs 34.4% P = .014). However, there was no significant difference in the proportion attaining <100 mg/dL (77.8% vs 81.8%, P = .281). After the Update, more elderly patients were receiving intensive or minimal-guideline statin therapy. Low-density lipoprotein cholesterol goal attainment was isolated and appeared to occur by shifting already well-controlled patients to lower LDL-C levels. Although these findings may translate into less overall coronary heart disease risk, more aggressive lipid-lowering therapy would likely further reduce risk.

Determinants of cholesterol goal attainment at 12 months in patients with hypercholesterolaemia not at consensus goal after 3 months of treatment with lipid-lowering drugs

Less than half of patients in Scandinavian societies achieve target cholesterol values established by consensus coronary prevention panels. Using logistic regression analysis, we determined that patients not at consensus cholesterol goals after 3 months of treatment using lipid-lowering medications were significantly more likely to achieve these goals at 12 months if they were treated with an active management strategy (changes in lipid-lowering therapy within 3 months), had a diagnosis of diabetes mellitus, or initiated lipid-lowering more recently, compared with their counterparts without these factors. An active management strategy is associated with a higher probability of achieving treatment goals in patients not at goal after 3 months following treatment initiation.

404: Assessment of Statin Non-Adherence to Improve LDL Cholesterol Goal Attainment: A Medical Office Practice Evaluation

404: Assessment of Statin Non-Adherence to Improve LDL Cholesterol Goal Attainment: A Medical Office Practice Evaluation

Use of maximum-dose simvastatin or atorvastatin in an ethnically diverse population

The use of maximum-dose simvastatin or atorvastatin in an ethnically diverse population was studied. This retrospective analysis was conducted at a publicly funded teaching institution whose predominant patient population consists of Hispanics and Asians. A computer-generated report was used to identify outpatients who received a prescription for maximum-dose simvastatin or atorvastatin between January 1, 2002, and January 1, 2004. Data evaluated included demographic information; metabolic syndrome elements; coronary heart disease (CHD) risk equivalents; clinical characteristics placing patients at very high risk of having a CHD event; 10-year Framingham risk score; documentation of hepatotoxicity, myalgia, myositis, or rhabdomyolysis during maximum-dose therapy; concomitant medication during maximumdose therapy; relevant laboratory test values; and physician response to biochemical abnormalities or adverse events associated with maximum-dose therapy. Of the 232 outpatients identified, 173 were eligible for study inclusion. A total of 135 patients were classified as having a high or very-high risk of developing CHD (68 and 67, respectively). The success rates for low-density-lipoprotein (LDL) cholesterol goal attainment by very-high-risk patients and high-risk patients were 19.4% and 44.1%, respectively. Thirteen patients developed myalgia. Alanine transaminase levels were monitored for 38.8% of the study patients. Approximately 9% of patients were prescribed one interacting medication while on maximum-dose simvastatin or atorvastatin. The most commonly prescribed interacting drug was gemfibrozil. Despite the use of maximum-dose simvastatin or atorvastatin, target LDL cholesterol goals were not achieved and statin use was not adequately monitored in an ethnically diverse population with a high or very high risk of developing CHD.

Lipid-Modifying Therapy and Attainment of Cholesterol Goals in Hungary

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. 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. 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. 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.

Treatment and Control of BP and Lipids in Patients with Hypertension and Additional Risk Factors

NCEP ATP III (National Cholesterol Education Program Adult Treatment Panel III) guidelines recommend that for patients at high risk for cardiovascular disease (CVD), lipid-lowering therapy should be considered even at relatively low cholesterol levels (low-density lipoprotein-cholesterol>or=100 mg/dL). Furthermore, the ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm) has demonstrated the importance of statin therapy in the primary prevention of major cardiovascular events in people with hypertension and>or=3 cardiovascular risk factors with total cholesterol levels of<or=250 mg/dL (<or=6.5 mmol/L). To analyze the utilization of antihypertensive and lipid-lowering medications, and associated rates of BP and cholesterol goal attainment, in the primary prevention of CVD among patients with hypertension. Retrospective cross-sectional analysis of data from outpatient medical records (including BP, co-morbidities, and medications) abstracted for visits between 1 October 2001 and 30 September 2003 to the Atlanta Veterans Affairs Medical Center (VAMC). Patients were tracked for at least 1 year. Veterans newly diagnosed with hypertension, with lipid levels<or=240 mg/dL (<or=6.2 mmol/L) and no prior coronary heart disease, and who were seeking care at the VAMC were included in the analysis. Patients were grouped by the presence of<3 or>or=3 cardiovascular risk factors in addition to hypertension. The frequency of utilizing antihypertensive and lipid-lowering medications, and attainment of BP targets were assessed based on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines (<140/90 mm Hg, or<130/80 mm Hg for patients with diabetes mellitus or chronic kidney disease) and a ratio of total cholesterol/high-density lipoprotein-cholesterol (HDL-C)<6. A total of 7839 veterans were included. Mean age was 58.7+/-13.2 years, and 93.8% were men. Among patients with>or=3 cardiovascular risk factors, 81.9% received any antihypertensive medication and 60.4% were prescribed multiple antihypertensive agents compared with 69.7% and 44.3% of patients, respectively, in the group with<3 cardiovascular risk factors. Lipid-lowering medications were prescribed to 55.3% of patients with>or=3 cardiovascular risk factors, and to 33.8% of those with<3 cardiovascular risk factors. Overall, 14.3% of patients met both BP and lipid targets (8.1% and 17.4% of patients with>or=3 and<3 cardiovascular risk factors, respectively [p<0.0001]). JNC 7 goals were attained in 27.9% of patients with>or=3 cardiovascular risk factors and 41.7% of those with<3 cardiovascular risk factors (p<0.001). Total cholesterol/HDL-C ratio<6 was achieved by 32.3% of patients with>or=3 cardiovascular risk factors and 52.1% of those with<3 cardiovascular risk factors (p<0.001). Veterans with>or=3 risk factors for CVD were treated more intensively, but levels of goal attainment were lower compared with patients with<3 cardiovascular risk factors. Our results suggest that the therapeutic strategies used by physicians in the Atlanta VAMC need to be adapted in order to improve lipid goal attainment among patients with hypertension, and thereby further reduce the risk of cardiovascular events.

Effectiveness of Ezetimibe Added to Ongoing Statin Therapy in Modifying Lipid Profiles and Low-Density Lipoprotein Cholesterol Goal Attainment in Patients of Different Races and Ethnicities: A Substudy of the Ezetimibe Add-On to Statin for Effectiveness Trial

To examine whether the improvements in lipid profiles and low-density lipoprotein cholesterol (LDL-C) goal attainment found in the Ezetimibe Add-On to Statin for Effectiveness trial occurred equally in the black, Hispanic, and white patient populations enrolled in the study. In this double-blind, placebo-controlled study, patients were recruited from 299 community-based practices across the United States (January to August 2003). Patients with, hypercholesterolemia and LDL-C levels exceeding National Cholesterol Education Program Adult Treatment Panel III goals were randomized (2:1) to receive either ezetimibe (10 mg/d) or placebo in addition to their ongoing statin therapy for 6 weeks. A total of 5802 patients were screened at baseline for the Ezetimibe Add-On to Statin for Effectiveness study. Of these, 2772 were excluded, and the remaining 3030 eligible patients were randomized. Ezetimibe, compared with placebo, added to statin therapy significantly reduced LDL-C levels from statin-treated baseline by 23.0% (white patients), 23.0% (black patients), and 21.0% (Hispanic patients). This effect was consistent across race and ethnicity groups (P > .50 for treatment-by-race interactions). Ezetimibe added to statin therapy also statistically significantly (P < .001) increased the percentage of patients attaining their LDL-C goal for their National Cholesterol Education Program Adult Treatment Panel III risk category in black (63.0%), Hispanic (64.8%), and white (72.3%) patients compared with placebo plus statin (32.9% black patients, 19.0% Hispanic patients, and 19.7% white patients). Ezetimibe treatment improved other lipid parameters across groups, including triglyceride, high-density lipoprotein cholesterol, non-high-density ilpoprotein cholesterol, and total cholesterol levels. Finally, the addition of ezetimibe reduced high-sensitivity C-reactive protein levels overall, and no significant interaction of treatment by race occurred (P = .83), Indicating a consistent effect across races. Ezetimibe was generally well tolerated, and no detectable differences occurred in the adverse event profile by race or ethnicity. Ezetimibe added to statin therapy is effective and well tolerated for improving the lipid profile and LDL-C goal attainment of patients regardless of race or ethnicity.

Trends in Lipid Management Among Patients with Diabetes

To examine trends in lipid management (cholesterol testing, treatment, and goal attainment) among patients with diabetes and to analyze the factors associated with initiation of lipid-lowering therapy. We conducted a longitudinal, retrospective study of patients with diabetes identified during a 24-month baseline period (January 1, 1995, to December 31, 1996) and for whom follow-up was continued for 5 years (1997 to 2001). Generalized estimating equations were used to test for time trend effects in lipid management. We modeled the days from baseline to the first lipid-lowering prescription fill date with a multivariate Cox proportional hazards regression model. Rates of lipid testing, treatment, and goal attainment significantly improved (P<0.001) during the 5-year study period: from 37% to 67% for lipid testing; from 19% to 41% for treatment with a lipid-lowering agent; from 22% to 37% for achievement of low-density lipoprotein cholesterol (LDL-C) levels < 100 mg/dL; and from 54% to 75% for achievement of LDL-C levels < 130 mg/dL. The relative likelihood (hazard rate) of treatment with lipid-lowering agents was greater for patients with LDL-C levels > or = 100 mg/dL relative to patients with LDL-C concentrations < 100 mg/dL. Treatment with lipid-lowering agents of patients with a cardiovascular event during follow-up was approximately 3 times more likely relative to those without such an event. We found that rates of lipid testing, treatment, and goal attainment improved significantly between 1997 and 2001. Nevertheless, ample room for improvement of these rates continues to exist. Particular attention may be warranted to ensure that patients with diabetes receive lipid-lowering agents not only after a cardiovascular event but also before such an event occurs.

Effects of a global risk educational tool on primary coronary prevention: the Atherosclerosis Assessment Via Total Risk (AVIATOR) study

ABSTRACTObjective: The use of Framingham equations to determine 10-year absolute coronary risk (“global risk”) represents an accepted strategy to target coronary prevention measures and enhance clinical outcomes. The aim of this study was to determine the effects of providing global risk scores to physicians on the prescription of lipid-lowering therapy for patients at increased coronary risk.Research design and methods: This prospective, randomized controlled trial enrolled 368 primary-care patients without a history of coronary heart disease and not on therapy with a hydroxymethylglutaryl coenzyme A reductase inhibitor (i.e. statin). The study was conducted in the general medical clinics of an academic US teaching hospital. In the intervention group ( n = 186) patients’ charts were reviewed, 10‐year absolute coronary risk computed, and this information conveyed via a simple educational tool appended to charts. In the control group ( n = 182), charts were accompanied by a form with general information on coronary prevention goals and strategies.Main outcome measure: The primary endpoint was the proportion of high-risk patients receiving a new statin prescription. Secondary and tertiary endpoints included (1) the proportion of moderate-risk patients receiving a statin prescription; and (2) the proportion of patients in the whole cohort who had other coronary prevention measures recommended.Results: There was no significant difference in statin prescription to high-risk individuals in the intervention group (40.0%) compared with the control group (37.9%; p = 0.86). Moderate-risk individuals who were not eligible for treatment according to the National Cholesterol Education Program Adult Treatment Panel II guidelines were more likely to receive a statin prescription in the intervention group versus the control group (28.8% vs. 12.5%. p = 0.036)Conclusions: Although a simple global risk educational tool did not improve the targeting of statin therapy to patients at high absolute coronary risk, it may be of benefit in targeting moderate-risk individuals who do not have markedly elevated low-density lipoprotein cholesterol (LDL‐C) levels. Future research should evaluate the effects of physicians performing their own Framingham risk calculations on statin prescribing and on cholesterol goal attainment.

Therapeutic modalities following low-density lipoprotein cholesterol goal attainment

Michael Miller University of Maryland Medical Center, Associate Professor of Medicine, Epidemiology and Preventive Medicine and, Director, Center for Preventive Cardiology, Baltimore, MD 21201, USA Tel.: +1 410 328 6299; Fax: +1 410 328 4382; mmiller@heart.umaryland. edu ‘...we aim to reduce TG to below 100 mg/dl, based on observational studies and raise HDL-C to a target above 40 mg/dl (men) or 50mg/dl (women).’