Blood Lipid Control Research Articles

Association of physician's sex with risk factor control in treated hypertensive patients from Swedish primary healthcare

To study the association of physician's sex with blood pressure, lipid control, and cardiovascular risk factors in treated hypertensive men and women, stratified for the sex of their physician. In a cross-sectional survey of hypertensive patients, 264 primary care physicians (PCPs), 187 men and 77 women from across Sweden, recruited 6537 treated hypertensive patients (48% men) during 2002-2005, consecutively collected from medical records and registered on a web-based form connected to a central database. Patients were included consecutively in the same order as they visited the healthcare centre. Hypertensive women more often reached target systolic/diastolic blood pressure levels (<140/90 mmHg) when treated by female PCPs than when they were treated by male PCPs (32 vs. 24%, P < 0.001). This difference remained when comparing female and male physicians' nondiabetic female patients. Both male and female patients had better control of total cholesterol and low-density lipoprotein cholesterol levels when treated by female PCPs than when treated by male PCPs (total cholesterol <5 mmol/l: women 30 vs. 24%, P < 0.001; men 42 vs. 34%, P < 0.001; low-density lipoprotein cholesterol <3 mmol/l: women 39 vs. 33%, P < 0.01; men 41 vs. 35%, P < 0.05). Female PCPs had a higher proportion of treated hypertensive patients with diabetes than did male PCPs but male PCPs had a higher prevalence of treated hypertensive men with microalbuminuria compared with female PCPs. Female physicians appeared more often to reach the treatment goal for blood pressure in female patients and cholesterol levels in all patients than did male physicians.

Single-pill amlodipine/atorvastatin helps patients of diverse ethnicity attain recommended goals for blood pressure and lipids (the Gemini-AALA study)

The Gemini-AALA (Australia, Asia, Latin America, Africa/Middle East) study evaluated the efficacy and safety of single-pill amlodipine/atorvastatin (Caduet) for the treatment of patients of diverse ethnicity with concomitant hypertension and dyslipidaemia. This was a 14-week, open-label study including patients from 27 countries across the Middle East, Asia-Pacific, Africa and Latin America. Eight dosage strengths of single-pill amlodipine/atorvastatin (5/10, 10/10, 5/20, 10/20, 5/40, 10/40, 5/80 and 10/80 mg) were titrated to improve blood pressure and lipid control. Blood pressure and lipid goals were determined according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP ATP III) guidelines, respectively (blood pressure, <140/90 or <130/80 mm Hg; low-density lipoprotein cholesterol (LDL-C), <4.1 to <2.6 mmol l(-1) (<160 to <100 mgdl(-1))). Overall, 1649 patients received study medication. Most patients (91.4%) had >or=1 cardiovascular risk factor (as defined by NCEP ATP III guidelines) in addition to hypertension/dyslipidaemia, and 61.7% had coronary heart disease/risk equivalent. At baseline, mean blood pressure was 146.6/88.3 mm Hg and LDL-C was 3.4 mmol l(-1) (130.2 mgdl(-1)). At week 14, 55.2% of patients reached both blood pressure and lipid goals, 61.3% reached blood pressure goal and 87.1% reached lipid goal (34.0% were at lipid goal at baseline). Mean blood pressure reduction was 20.2/11.4 mm Hg. For patients who were lipid-lowering drug naive at baseline, mean reduction in LDL-C was 41.0%. Treatment-related adverse events led to the discontinuation of 3.6% of patients. Single-pill amlodipine/atorvastatin therapy was well tolerated and effective for the reduction of blood pressure and lipids to recommended goals in patients from diverse ethnic backgrounds.

Reducing the rise in type 2 diabetes

The York and Humber Public Health Observatory1 reports that 4.7% of the population now have diabetes, of which 92% (4.3% of the population) have type 2 diabetes. The diagnosed prevalence has doubled between 1994 and 2003. The increasing number of people with type 2 diabetes reflects several factors: an ageing population; a true increase in prevalence, related to increased prevalence of overweight and obesity; decreasing physical activity; better survival of those with diabetes due to improved control of blood glucose, blood pressure, and lipids; and earlier diagnosis, partly from informal screening. (A recent study using British general practice data found that one-third of people aged over 40 years [excluding those known to have diabetes] underwent blood glucose measurement in the previous 2 years.2)

A natural history and framework for managing diabetic foot ulcers

When treating diabetic foot ulcers it is important to be aware of the natural history of the diabetic foot, which can be divided into five stages: stage 1 - normal foot; stage 2 - high risk foot; stage 3 - ulcerated foot; stage 4 - infected foot; stage 5 - necrotic foot. This covers the entire spectrum of foot disease but emphasizes the development of the foot ulcer as a pivotal event in stage 3, demanding urgent and aggressive management. Diabetic foot wound care in all stages needs multidisciplinary management to control mechanical, wound, microbiological, vascular, metabolic and educational aspects. Achieving good metabolic control of blood glucose, lipids and blood pressure is important in each stage, as is educational control to teach proper foot care appropriate for each stage. Aggressive management of diabetic foot ulceration will reduce the number of feet proceeding to infection and necrosis and thus reduce the number of major amputations in diabetic foot patients.

Sex differences in risk factor control of treated hypertensives: a national primary healthcare-based study in Sweden

To evaluate potential sex differences, this study aimed to investigate blood pressure and lipid control and other risk factors for cardiovascular disease in treated hypertensive (tHT) patients from primary healthcare. This cross-sectional survey of tHT patients was carried out between 2002 and 2005 by 264 primary care physicians from Sweden who consecutively recruited 6537 tHT patients (48% men and 52% women) from medical records. tHT men more often reached the treatment goal for systolic/diastolic blood pressure, less than 140/90 mmHg, than tHT women (30 vs. 26%, P<0.01). Men had lower systolic blood pressure than women, however, women had lower diastolic blood pressure and higher pulse pressure. More tHT women had total cholesterol>or=5.0 mmol/l than corresponding men (75 vs. 64% P<0.001). Men more often had diabetes (25 vs. 20% P<0.001), left ventricular hypertrophy (20 vs. 16% P<0.001), and microalbuminuria (24 vs. 16% P<0.001). Women were more often treated with diuretics (64 vs. 48%) and beta-receptor blockers (54 vs. 51%), and men more often treated with angiotensin-converting enzyme inhibitors (27 vs. 18%), calcium channel blockers (34 vs. 26%), and lipid-lowering drugs (34 vs. 29%). A need still exists for more intensified treatment of elevated blood pressure and hypercholesterolemia, especially in women. In hypertensives of both sexes, smoking and other risk factors also need to be addressed to reduce the risk of cardiovascular disease.

Metabolic syndrome and the menopause

The metabolic syndrome consists of a combination of risk factors that include abdominal obesity, atherogenic dyslipidaemia, hypertension and insulin resistance. It increases the risk of cardiovascular disease and type 2 diabetes. The increased risk of cardiovascular disease is higher in women than in men. The first manifestation of metabolic syndrome may occur in pregnancy presenting as gestational diabetes or preeclampsia. Both conditions are associated with increased insulin resistance. Also metabolic syndrome is more common in polycystic ovarian syndrome. It has been suggested that there is a metabolic syndrome resulting from the menopause due to estrogen deficiency, as many of the risk factors are more prevalent in postmenopausal women. Also estrogen replacement improves insulin sensitivity and reduces the risk of diabetes. The key elements in managing the metabolic syndrome are weight reduction, increasing physical activity and diet modification. If blood pressure, lipid and glycaemic control are not achieved through these interventions then pharmacological therapy will be required.

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Effectiveness of chronic care model-oriented interventions to improve quality of diabetes care: a systematic review

BackgroundThe chronic care model (CCM) has been widely used in a variety of health care settings to guide system improvement for chronic illness care, including diabetes care. However, the evidence base for the specific components of the model has not been systematically reviewed. This review aimed at examining the extent to which interventions featuring the CCM components improve diabetes care and determining the relative effectiveness of different CCM components.MethodsWe systematically searched MEDLINE (1966 to December 2004), the Cochrane Effective Practice and Organisation of Care and the Cochrane Controlled Trials Register to identify interventions featuring one or more system components of the CCM for diabetes care. Outcome measures included HbA1c, blood pressure and blood lipid control. We used random-effects meta-analysis and meta-regression for quantitative synthesis of data.ResultsIn all, 69 studies (43 randomized controlled trials and 26 controlled before–after studies) met inclusion criteria and were included in this review. Overall, included studies reported a mean reduction of 0.46% (95% CI 0.38, 0.54) in HbA1c, mean reduction of 2.2 (95% CI 0.9, 3.5) mmHg in systolic blood pressure, mean reduction of 1.3 (95% CI 0.6, 2.1) mmHg in diastolic blood pressure and mean reduction of 0.24 (95% CI 0.06, 0.41) mmol/L in total cholesterol. For specific CCM components, interventions that addressed delivery system design reported the largest improvements in patient outcomes, followed by those employing a self-management support component. Interventions involving decision support or clinical information systems reported relatively smaller effect sizes.ConclusionsInterventions featuring CCM components for diabetes care produced small-to-moderate improvements in a range of patient intermediate outcomes. The findings support the concept of the CCM in which the state of development of various aspects of primary care service systems defined in this model appear to be important factors in the quality of care provided to people with diabetes.

Metabolic syndrome and chronic kidney disease

Obesity is fast becoming a bane for the present civilization, as a result of sedentary lifestyle, atherogenic diet, and a susceptible thrifty genotype. The concept of metabolic syndrome, which is a constellation of metabolic disturbances, has crystallized over the last 80 years with the aim of identifying those at greater risk of developing type 2 diabetes and cardiovascular disease. These patients have visceral obesity and insulin resistance characterized by hypertyriglyceridemia. Recently, it has been realized that they are also at an increased risk of chronic renal disease. Release of adipocytokines leads to endothelial dysfunction. There is also activation of systemic and local renin-angiotensin-aldosterone system, oxidative stress, and impaired fibrinolysis. This leads to glomerular hyperfiltration, proteinuria, focal segmental glomerulosclerosis (FSGS), and ultimately end-stage renal disease (ESRD). Treatment consists of lifestyle modifications along with optimal control of blood pressure, blood sugar and lipids. Metformin and thiazolidenidiones reduce insulin resistance; while angiotensin converting enzyme inhibitors and angiotensin receptor blockers reduce proteinuria and have a renoprotective effect. Exciting new medical therapies on the horizon include rimonabant a cannabinoid receptor type 1 antagonist, soy proteins, and peroxisome proliferator-activated receptor (PPAR) agonist. Bariatric surgery for morbid obesity has also been shown to be effective in treating metabolic syndrome.

A cardiologist view of vascular disease in diabetes

Diabetes mellitus is a potent risk factor for the development of a wide spectrum of cardiovascular (CV) complications. The complex metabolic milieu accompanying diabetes alters blood rheology, the structure of arteries and disrupts the homeostatic functions of the endothelium. These changes act as the substrate for end-organ damage and the occurrence of CV events. In those who develop acute coronary syndromes, patients with diabetes are more likely to die, both in the acute phase and during follow-up. Patients with diabetes are also more likely to suffer from chronic cardiac failure, independently of the presence of large vessel disease, and also more likely to develop stroke, renal failure and peripheral vascular disease. Preventing vascular events is the primary goal of therapy. Optimal cardiac care for the patient with diabetes should focus on aggressive management of traditional CV risk factors to optimize blood glucose, lipid and blood pressure control. Targeting medical therapy to improve plaque stability and diminish platelet hyper-responsiveness reduces the frequency of events associated with atherosclerotic plaque burden. In patients with critical lesions, revascularization strategies, either percutaneous or surgical, will often be necessary to improve symptoms and prevent vascular events. Improved understanding of the vascular biology will be crucial for the development of new therapeutic agents to prevent CV events and improve outcomes in patients with diabetes.

Coronary Heart Disease Events Preventable by Control of Blood Pressure and Lipids in US Adults With Hypertension

Hypertension (HTN) and dyslipidemia are major risk factors for coronary heart disease (CHD). In 676 (projected to 26.1 million) US persons from the National Health and Nutrition Examination Survey (NHANES) 2001-2002 with HTN, the authors estimated the preventable CHD events from statistical control of blood pressure (BP) and lipid levels. Using Framingham algorithms, the authors projected the CHD events that could be prevented from statistical control of BP, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol. If BP was controlled to nominal levels, the authors projected 19% of CHD events (37% if controlled to optimal) would be prevented. Improving lipid levels to nominal levels was estimated to prevent 27% of CHD events (62% if controlled to optimal). Combined control of BP and lipid levels to nominal levels was projected to prevent 38% of CHD events (76% if controlled to optimal). The authors' results demonstrate that combined control of BP and lipid levels may prevent the majority of CHD events in Americans with HTN.

Control of hepatic and systemic lipid metabolism through the nuclear receptor co-factor RIP140

Hypertriglyceridemia forms a hallmark of the metabolic syndrome and represents an independent risk factor for the development of coronary heart disease. Plasma lipid levels are controlled through a complex interplay between different tissues, the molecular basis of which remains largely unknown. Given the importance of transcriptional regulation in metabolic control, we investigated the role of nuclear receptor co-factor receptor interacting protein 140 (RIP140) in the liver, a key organ in energy homeostasis. Here we show that an acute, liver-specific depletion of RIP140 caused dramatically increased blood triglyceride levels. In contrast, hepatic triglyceride content in these animals was decreased in the absence of RIP140, suggesting that the observed hypertriglyceridemia was not the consequence of increased hepatic VLDL production. Interestingly, RIP140 knockdown in the liver reduced expression of apolipoprotein A5 (ApoA5), the serum levels of which have been shown to be inversely correlated with circulating blood triglycerides. Indeed, RIP140 knockdown in a murine hepatocyte cell line decreased ApoA5 promoter activity in transient transfection studies. Conversely, RIP140 over-expression induced ApoA5 expression in these cells, strengthening the notion that RIP140 acts as a direct transcriptional co-activator on the ApoA5 promoter. ApoA5 has been shown to control blood lipid levels, at least in part, by accelerating the hydrolysis of triglycerides by lipoprotein lipase (LPL) in adipose and muscle tissue. By influencing hepatic ApoA5 release, transcriptional control via RIP140 in the liver might, therefore, provide a novel mechanism of metabolic tissue crosstalk and the development of dyslipidemia associated with the metabolic syndrome.

Effects of Sodium Bicarbonate and Albumin on theIn VitroWater-Holding Capacity and Some Physiological Properties ofTrigonella foenum graecumL. Galactomannan in Rats

This study seeks to improve the beneficial effects of fenugreek (Trigonella foenum graecum L.) galactomannan (GM) in lowering the plasma lipid profile and weight. Three different combinations of diets were prepared with fenugreek GM--(a) fenugreek GM + water (GM); (b) fenugreek GM + sodium bicarbonate (GMB); and (c) fenugreek GM + bicarbonate + albumin (GMBA)--and their in vitro water retention capacity and in vivo lipid-lowering effect were studied. Distilled water and sodium bicarbonate were used as controls. The sodium bicarbonate significantly increased the in vitro water-holding capacity of fenugreek GM (49.1 +/- 8.7 vs. 21.6 +/- 0.9 g of water/g of dry weight, P < .01). Administration by oral intubation of the combination GMBA to male albino Wistar rats (250 mg/kg of body weight) over a 4-week period was the most effective in reducing body weight (-27.0 +/- 0.4%, P < .001). Within this period, the combinations GMBA and GMB brought about the most significant reduction in the levels of plasma total cholesterol (P < .005). The GMBA combination was also the most effective in reducing levels of plasma low-density lipoprotein cholesterol (P < .001) and the atherogenicity indices. GM, GMB, and GMBA brought about significant (P < .01, .001, and .001, respectively) increases in the plasma high-density lipoprotein cholesterol levels, with the highest increase coming with GMBA. A significant increase in plasma triglycerides (P < .05) was brought about by the GMBA combination, probably resulting from the rapid reduction of body weight observed. Food intake was reduced by GM, GMB, and GMBA, while water intake increased in that order. The GMB combination significantly reduced transit time (P < .01) compared to GM. On the other hand, GMB and GMBA improved glycemic control, compared to GM. We conclude that albumin and sodium bicarbonate have the ability to improve some beneficial physiological effects of fenugreek GM. This finding could have applications in the areas of human obesity, weight loss, and the control of blood lipids.

Prevention of Cardiovascular Risk in Diabetic Patients – An Update

Patients with type 2 diabetes have a well-documented increased risk for cardiovascular disease (CVD) that is more than two to three times higher than the risk seen in non-diabetic subjects.1 In spite of modern methods to treat diabetes and its complications, the increased risk is still substantial even if data on risk factor controls in national surveys have shown improving trends for blood pressure and lipid control, for example from Sweden.2 The most important CVD risk factors to detect, treat, and make follow-up visits for are elevated blood-pre

Prevention of Cardiovascular Risk in Diabetic Patients – An Update

Patients with type 2 diabetes have a well-documented increased risk of cardiovascular disease (CVD) that is more than two to three times higher than the risk seen in non-diabetic subjects.1 In spite of modern methods to treat diabetes and its complications, the increased risk is still substantial even if data on risk factor controls in national surveys have shown improving trends for blood pressure and lipid control, for example from Sweden.2 The most important CVD risk factors to detect, treat and make follow-up visits for are elevated blood-pressure levels, dyslipidaemia and elevated low-density lipoprotein (LDL) cholesterol, as well as hyperglycaemia and smoking. In addition, chronic inflammation, defects in fibrinolytic function and adverse psychosocial conditions could all contribute to this risk, besides the impact of background factors that it is not possible to change such as age, gender and diabetes duration. For a number of years data have been accumulating on treatment benefits of risk-factor control based on reports from large-scale clinical trials involving patients with type 1 diabetes ‐ i.e. Diabetes Control and Complications Trial (DCCT) ‐ or type 2 diabetes ‐ i.e. UK Prospective Diabetes Study (UKPDS), Heart Protection Study (HPS), Reduction of Endpoints in NIDDM [non-insulin-dependent diabetes mellitus] with the Angiotensin II Antagonist Losartan (RENAAL), Irbesartan Diabetic Nephropathy Trial (IDNT), Collaborative Atorvastatin Diabetes Study (CARDS), Losartan Intervention For Endpoint Reduction in Hypertension (LIFE) and Anglo‐Scandinavian Cardiac Outcomes Trial (ASCOT). Therefore, we have so far had strong support for some, but not all, of the goals for risk factor control stated in contemporary guidelines for treatment of patients with diabetes, from both the joint American Diabetes Association (ADA) and American Heart Association (AHA) guidelines3 and the corresponding joint European Society of Cardiology (ESC) and European Association for the Study of Diabetes (EASD) guidelines.4 For example, the recommended goal of blood-pressure control in patients with diabetes and hypertension (<130/80mmHg)3,4 was not based on solid evidence from intervention studies, but from observational studies, most notably from the observational arm of UKPDS where a linear association between systolic blood pressure and risk of coronary artery disease (CAD) was noticed.5

A High-Carbohydrate, High-Fiber Meal Improves Endothelial Function in Adults With the Metabolic Syndrome

Brachial artery flow-mediated dilation (FMD) using high-resolution ultrasound is a well-accepted, noninvasive bioassay for in vivo endothelium-generated nitric oxide (NO) in humans (1). Impaired NO generation characterizes the endothelial phenotype prone to the development of atherosclerosis and is linked to acute cardiovascular events. In several studies (2,3), endothelial dysfunction is an independent predictor of future cardiovascular morbidity and mortality. The postprandial state may be critical in the development of atherosclerosis (4). A single high-fat meal can induce endothelial dysfunction, whereas low-fat meals generally neither improve nor worsen FMD (5–8). The lack of a reported effect of low-fat meals on FMD may be attributable in part to insufficient dietary fiber in the meal. In particular, increased cereal fiber consumption is associated with reduced cardiovascular disease incidence and mortality (9–11) and lower prevalence of the metabolic syndrome (12) and may reduce systemic inflammation (13). We examined whether a high-carbohydrate meal, rich in cereal fiber, would improve brachial artery FMD in adults with the metabolic syndrome. For comparison, we also examined the impact of a low-carbohydrate, low-fiber meal. Twelve (9 women and 3 men: 44.7 ± 7.9 years of age, 98.9 ± 16.6 kg, 1.70 ± 0.07 m) nonsmoking, nondiabetic adults who met the International Diabetes Federation criteria for the metabolic syndrome participated in the study (14). Subjects were not taking medications to control blood lipids, blood …

Treatment of Cardiac Risk Factors Among Patients With Schizophrenia and Diabetes

The appropriateness and effectiveness of the outpatient medical management of cardiac risk factors for patients with diabetes who had a diagnosis of schizophrenia or a related psychotic syndrome were examined. In a cross-sectional analysis of 4,236 patients with diabetes, ICD-9 billing codes were used to identify 214 patients with schizophrenia or a schizophrenia-related syndrome. Measures of treatment appropriateness and effectiveness for the management of cardiac risk factors (control of blood sugar, blood pressure, and lipids) were assessed for this group and compared with measures from patients with diabetes but no severe mental illness (N = 3,594). Odds ratios were adjusted for between-group differences in gender, race, age, and clinic setting. There were no statistically significant between-group differences on any of the five measures of treatment appropriateness, indicating that patients with schizophrenia received a similar regimen of medical treatment for cardiac factors. However, two of the seven measures of treatment effectiveness indicated significant deficiencies, with fewer patients with schizophrenia meeting the clinical quality benchmarks for cholesterol and low-density lipoprotein control. This disparity may have been caused by factors other than the measured treatment appropriateness variables, including the prescription of older lipid-lowering agents and a higher rate of missed appointments in the group with schizophrenia. Effective lipid control may be more difficult to attain for at least some patients with schizophrenia. Given that population's high rates of cardiovascular mortality, additional research to clarify the barriers to effective lipid management is essential.

Pioglitazone: an antidiabetic drug with cardiovascular therapeutic effects

The antidiabetic compound pioglitazone, an activator of the intracellular peroxisome proliferator-activated receptor-γ, and decreases metabolic and vascular insulin resistance. The drug is well tolerated, and its metabolic effects include improvements in blood glucose and lipid control. Vascular effects consist of improvements in endothelial function and hypertension, and a reduction in surrogate markers of artherosclerosis. In a large, placebo-controlled, outcome study in secondary prevention, PROactive study, the use of pioglitazone in addition to an existing optimized macrovascular risk management resulted in a significant reduction of macrovascular endpoints within a short observation period that was comparable to the effect of statins and angiotensin converting enzyme inhibitors in other trials. These results underline the value of pioglitazone for managing the increased cardiovascular risk of patients with a metabolic syndrome or Type 2 diabetes mellitus.

Coronary heart disease events preventable by control of blood pressure and lipids in us adults with hypertension and dyslipidemia

Coronary heart disease events preventable by control of blood pressure and lipids in us adults with hypertension and dyslipidemia

Impaired fibrinolytic activity in type II diabetes: Correlation with urinary albumin excretion and progression of renal disease

Progression of renal disease and cardiovascular complications in type II diabetes mellitus have been shown to correlate with control of blood glucose, lipids, blood pressure, and smoking. These factors, however, do not appear to totally explain these diabetic complications. Renal disease and cardiovascular complications in type II diabetes are associated with vascular abnormalities and fibrosis, both of which may occur with impaired fibrinolysis. A cross-sectional study was therefore performed in 107 type II diabetic patients recruited from the Denver Metropolitan Area to examine the effect of impaired fibrinolysis, as assessed by the ratio of plasminogen activator inhibitor (PAI-1) to tissue-type plasminogen activator (t-PA). With urinary albumin excretion (UAE) as a risk factor for both renal disease progression and cardiovascular complications, the patients were analyzed with respect to UAE less than and greater than 1 gm/day. The age, blood glucose, hemoglobin A1C, duration of diabetes, lipids, body mass index, and smoking were no different between the groups. As expected, the group with greater UAE had worse renal function, the serum creatinine (1.98 +/- 0.24 vs 1.21 +/- 0.05 mg/dl, P < 0.001) and creatinine clearance (55.5 +/- 6.0 vs 76.8 +/- 2.7 ml/min, P < 0.001) were significantly different. The type II diabetic patients with greater UAE exhibited significantly higher PAI-1/t-PA (2.43 +/- 0.26 vs 1.85 +/- 0.07, P < 0.03). The past history of cardiac complications was also higher (87.5 vs 72.3%, P < 0.07) in the diabetic patients with more impaired fibrinolysis and greater UAE. Thus a prospective, randomized clinical trial in type II diabetes with PAI-1 inhibitors is needed.