Coronary Artery Disease Risk Equivalent Research Articles

COVID-19 Is a Coronary Artery Disease Risk Equivalent and Exhibits a Genetic Interaction With ABO Blood Type.

COVID-19 is associated with acute risk of major adverse cardiac events (MACE), including myocardial infarction, stroke, and mortality (all-cause). However, the duration and underlying determinants of heightened risk of cardiovascular disease and MACE post-COVID-19 are not known. Data from the UK Biobank was used to identify COVID-19 cases (n=10 005) who were positive for polymerase chain reaction (PCR+)-based tests for SARS-CoV-2 infection (n=8062) or received hospital-based International Classification of Diseases version-10 (ICD-10) codes for COVID-19 (n=1943) between February 1, 2020 and December 31, 2020. Population controls (n=217 730) and propensity score-matched controls (n=38 860) were also drawn from the UK Biobank during the same period. Proportional hazard models were used to evaluate COVID-19 for association with long-term (>1000 days) risk of MACE and as a coronary artery disease risk equivalent. Additional analyses examined whether COVID-19 interacted with genetic determinants to affect the risk of MACE and its components. The risk of MACE was elevated in COVID-19 cases at all levels of severity (HR, 2.09 [95% CI, 1.94-2.25]; P<0.0005) and to a greater extent in cases hospitalized for COVID-19 (HR, 3.85 [95% CI, 3.51-4.24]; P<0.0005). Hospitalization for COVID-19 represented a coronary artery disease risk equivalent since incident MACE risk among cases without history of cardiovascular disease was even higher than that observed in patients with cardiovascular disease without COVID-19 (HR, 1.21 [95% CI, 1.08-1.37]; P<0.005). A significant genetic interaction was observed between the ABO locus and hospitalization for COVID-19 (Pinteraction=0.01), with risk of thrombotic events being increased in subjects with non-O blood types (HR, 1.65 [95% CI, 1.29-2.09]; P=4.8×10-5) to a greater extent than subjects with blood type O (HR, 0.96 [95% CI, 0.66-1.39]; P=0.82). Hospitalization for COVID-19 represents a coronary artery disease risk equivalent, with post-acute myocardial infarction and stroke risk particularly heightened in non-O blood types. These results may have important clinical implications and represent, to our knowledge, one of the first examples of a gene-pathogen exposure interaction for thrombotic events.

Coronary Calcium Score and Stratification of Coronary Artery Disease Risk in Patients with Atherosclerotic and Non-Atherosclerotic Ischemic Stroke.

ResumoFundamento O acidente vascular encefálico isquêmico (AVEi) e a doença arterial coronariana (DAC) coexistem frequentemente e compartilham fatores de risco para doença aterosclerótica. Segundo a American Heart Association , os subtipos de AVEi podem ser considerados equivalentes de risco para DAC, mas a evidência para o AVEi não-aterosclerótico não está bem definida. Além disso, o escore de cálcio coronário (CAC) é um marcador preciso para estimar o risco de DAC. Entretanto, a distribuição do CAC pelos subtipos de AVEi ainda não foi bem caracterizada.Objetivos Comparar o CAC entre os grupos de AVEi ateroscleróticos e não ateroscleróticos, e determinar quais covariáveis estão associadas a CAC alto no AVEiMétodos Em um estudo transversal, incluímos todos os pacientes com AVEi, com idades entre 45 a 70 anos no momento do acidente vascular, consecutivamente admitidos em um hospital de reabilitação entre agosto de 2014 e dezembro de 2016, sem DAC prevalente. Todos os pacientes passaram por tomografia computadorizada (TC), para medir o CAC. CAC≥100 foi considerado alto risco de DAC. O nível de significância foi p<0,05.Resultados Dos 244 pacientes estudados (média de idade de 58,4±6,8 anos; 49% do sexo feminino), 164 (67%) apresentavam etiologia não-aterosclerótica. As proporções de CAC≥100 foram semelhantes entre os grupos ateroscleróticos e não-ateroscleróticos (33% [n=26] x 29% [n=47]; p= 0,54). Entre todos os pacientes com AVEi, apenas os de idade ≥60 anos foram associados independentemente a CAC≥100 (RC 3,5; 95% IC 1,7-7,1), ajustado para hipertensão, dislipidemia, diabetes, sedentarismo, e histórico familiar de DAC.Conclusão O AVEi aterosclerótico não apresentou risco maior de DAC quando comparado ao AVEi não-aterosclerótico de acordo com o CAC. Apenas a faixa etária ≥60 anos – mas não a etiologia - foi associada independentemente a CAC≥100. (Arq Bras Cardiol. 2020; 115(6):1144-1151)

Lipid Management in Chronic Kidney Disease: Systematic Review of PCSK9 Targeting.

Cardiovascular disease is the leading cause of death in patients with chronic kidney disease (CKD) and CKD is considered a coronary artery disease risk equivalent. So far, statins have been the mainstay of primary and secondary prevention of cardiovascular disease in the general population. However, their benefit on outcomes is limited and controversial in CKD patients and new therapeutic approaches to reduce cardiovascular risk are needed. Monoclonal antibodies targeting proprotein convertase subtilisin/kexin 9 (PCSK9) reduce low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) in high-risk populations and cardiovascular events in secondary prevention. We now review the limitations of the current approach to lipid management in CKD and information on CKD patients from clinical trials of anti-PCSK9 monoclonal antibodies alirocumab and evolocumab. In CKD sub-group analysis, ODYSSEY COMBO I and ODYSSEY COMBO II studies demonstrated significant superiority of alirocumab on LDL-cholesterol lowering in comparison to placebo and ezetimibe, respectively, when added to statins, and case reports have shown efficacy in nephrotic syndrome. A detailed analysis of CKD subgroups in general population trials of anti-PCSK9 strategies addressing events is needed, given the limited efficacy of statins in CKD both in terms of lipid lowering and events, the high rate of statin non-compliance in these patients, and the high lipoprotein(a) levels. This information should guide the design of trials addressing the safety profile and efficacy on cardiovascular outcomes of PCSK9-targeted therapies in CKD patients.

Cardiovascular risk stratification in new-onset diabetes by qrisk2 risk score and conventional risk score within 3 months of diagnosis of diabetes

Aims: This study aims to assess the cardiovascular disease (CVD) risk by QRISK2 score and conventional risk score in new-onset diabetes without a history of heart disease or stroke, to find out if patients with diabetes have similar risk of coronary artery disease (CAD) as people with established CAD and to compare the conventional and QRISK2 score for the prediction of CVD. Materials and Methods: A cross-sectional study was conducted at Bhilai over 1 year in 183 newly detected diabetic patients (89 males and 94 females) aged 40–70 years. The probable risk factors were determined by cross-tabulation of cardiometabolic parameters with the 10-year cardiovascular risk level using the QRISK2-2016 and the conventional major risk markers. Results: The mean age in males was 53.5 ± 9.7 years and in females was 54.2 ± 10.1 signifying no gender differences. Mean body mass index in the most of the individuals in both sexes were either in the pre-obese or obese range. The mean value of high-density lipoprotein cholesterol (HDLc), low-density lipoprotein cholesterol (LDLc), non-HDLc, total cholesterol and HDLc (total cholesterol/HDLc) ratio was found to be higher in females than in the males. In the conventional risk group, 67.7% of individuals with new-onset diabetes were in high-risk category, 28.9% were in moderate-risk category and 3.2% in low-risk category. The QRISK2 score in new-onset diabetes was 68.8% in high-risk category, 31.1% were in moderate-risk category and none in the low-risk category. Conclusion: Risk stratification is essential for the primary prevention of CVD risks in patients with diabetes as patients with new-onset diabetes cannot be categorised as CAD risk equivalent.

Type of dyslipidemia and achievement of the LDL-cholesterol goal in chronic kidney disease patients at the University Hospital.

BackgroundChronic kidney disease (CKD) has been defined as a coronary artery disease risk equivalent. Therefore, the current guideline has been recommended for CKD patients to reach and maintain a low-density lipoprotein-cholesterol (LDL-C) goal of less than 100 mg/dL. However, the data regarding the achievement of LDL-C goal in these patients is lacking.ObjectiveThis study was conducted to evaluate the types of dyslipidemia affecting patients with CKD stages 3 and 4 and to determine whether these patients achieved LDL-C goal.MethodsWe performed a retrospective chart review of patients with CKD stage 3 or 4 and dyslipidemia who were followed-up at Siriraj Hospital between October 2011 and September 2012.ResultsIn total, 150 patients with CKD stage 3 or 4 and dyslipidemia were recruited. The mean age was 72±10 years, and the body mass index was 25.6±4 kg/m2; 60% had CKD stage 3 with an estimated glomerular filtration rate of 34±12 mL/min/1.73 m2, and 54% had type 2 diabetes. The percentage of patients with hypercholesterolemia was 78%, hypertriglyceridemia 54%, and low high-density lipoprotein-C 36%. Of these, 52% had mixed hyperlipidemia. Statin treatment was prescribed to 87% of the patients, of which only 31.3% achieved the LDL-C goal according to the National Cholesterol Education Program and the European Society of Cardiology/European Atherosclerosis Society recommendations. Patients who did not achieve the LDL-C goal had a higher cholesterol level at diagnosis and higher prevalence of type 2 diabetes and stroke than those who achieved it.ConclusionTwo-thirds of CKD patients with hyperlipidemia had mixed hyperlipidemia. Despite the high frequency of statin treatment, only one-third of patients with CKD achieved the LDL-C goal. Thus, a developmental plan for the management of dyslipidemia in patients with CKD should be implemented to increase their achievement of the LDL-C goal.

Status Of Dyslipidemia Management With Statins, In In-Patients With Known Coronary Artery Disease Confirmed By Angiographic Findings

Aim: To determine the status of dyslipidemia management with statins in In-patients with known Coronary Artery Disease (CAD) confirmed by angiographic findings. Methods: This study has been conducted in a corporate cardiac centre at Visakhapatnam, Andhra Pradesh. This study is a retrospective analysis of data collected from the electronic medical records in terms of age, sex, CAD status, associated risk factors, statin usage, and lipid parameters. Results: Among a sample of 92 known CAD in-patients, 81.5% achieved LDL-C goal of <100 mg/dl as recommended by Third Report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III [ATP III] for CAD and CAD risk equivalents. Success rates among males and females are 79.7% and 85% respectively. 78.2% of 69 patients on Atorvastatin, 85% of 20 patients on Rosuvastatin and 100% of 3 patients on Simvastatin achieved LDL-C goal. If the target LDL-C level is kept at <70 mg/dl as defined as optional goal for very high risk CAD and CAD risk equivalents, the success rate is only 31.5%. Conclusion: The Success rates for achieving LDL-C goals (<100mg/dl) is satisfactory in this facility. But the major concern in this study is even with desired LDL-C levels 61% of these in-patients suffered with a recurrent CAD leaving an opportunity to reconsider the target LDL-C to still lower levels (<70 mg/dl) which is mentioned just as an optional for very high risk candidates in NCEP ATP-III guidelines.

Chronic Kidney Disease as a Coronary Artery Disease Risk Equivalent

Chronic kidney disease (CKD) is associated with accelerated cardiovascular disease (CVD) risk and a higher CVD event rate. Substantial data from prospective cohort studies support the concept that dialysis patients as well as those with advanced stage (stages 3-5) CKD are associated with an increased risk for all-cause and cardiovascular mortality. The risk for coronary artery disease (CAD) increases exponentially with declining kidney function, i.e., stage 3 or higher CKD. Indeed, CVD accounts for more than 50% of deaths in patients with CKD. CKD patients are more likely to die of CVD than to progress to end stage kidney disease. This increase in CV risk is commonly attributed to co-existence of numerous traditional and nontraditional risk factors for the development of CVD that frequently accompany reduced kidney function. Therefore, CKD itself is now considered an independent CVD risk factor and a coronary artery disease (CAD) equivalent for all-cause mortality. All patients at risk for CAD should be evaluated for kidney disease. Treatments used for management of established CAD might have similar benefits for patients with concomitant CKD.

Isolated Nonspecific ST-Segment and T-Wave Abnormalities in a Cross-Sectional United States Population and Mortality (from NHANES III)

Most clinicians regard isolated, minor, or nonspecific ST-segment and T-wave (NS-STT) abnormalities to be incidental, often transient, and benign findings in asymptomatic patients. We sought to evaluate whether isolated NS-STT abnormalities on routine electrocardiograms (ECGs) are associated with increased risk of cardiovascular mortality (CM) and all-cause mortality (AM) in a cross-sectional United States population without known coronary artery disease. We included all adults 40 to 90 years of age without known coronary artery disease or risk equivalent based on history and laboratory values, enrolled in the NHANES III from 1988 to 1994, with electrocardiographic data available, and a total follow-up period of 59,781.75 patient-years. NS-STT abnormalities were defined by Minnesota Coding. Subjects were excluded if their mortality data were missing or if they had major electrocardiographic abnormalities, heart rate >120 beats/min, nonsinus rhythm, cardiac infarction/injury score ≥ 20 on ECG, left ventricular hypertrophy by Minnesota Codes 3.1 and 3.3, or patient-reported history coronary artery disease, congestive heart failure, stroke, diabetes, or peripheral arterial disease. The remaining 4,426 subjects were stratified by presence or absence of NS-STT abnormalities. Mortality was judged based on International Classification of Diseases, Tenth Revision coding linked to the National Death Index. Cox proportional hazard ratio was used for multivariate analysis, showing that CM (hazards ratio 1.71, 95% confidence interval 1.04 to 2.83, p = 0.04) and AM (hazards ratio 1.37, 95% confidence interval 1.03 to 1.81, p = 0.02) were significantly higher in the isolated NS-STT abnormalities group. In conclusion, isolated NS-STT abnormalities on ECG were associated with a higher incidence of CM and AM in this large nationally representative cross-sectional cohort without known coronary artery disease or coronary artery disease risk equivalents.

Reconsidering low-dose aspirin therapy for cardiovascular disease: a study protocol for physician and patient behavioral change

BackgroundThere are often disparities between current evidence and current practice. Decreasing the gap between desired practice outcomes and observed practice outcomes in the healthcare system is not always easy. Stopping previously recommended or variably recommended interventions may be even harder to achieve than increasing the use of a desired but under-performed activity. For over a decade, aspirin has been prescribed for primary prevention of cardiovascular disease and for patients with the coronary artery disease risk equivalents; yet, there is no substantial evidence of an appropriate risk-benefit ratio to support this practice. This paper describes the protocol of a randomized trial being conducted in six primary care practices in the Denver metropolitan area to examine the effectiveness of three interventional strategies to change physician behavior regarding prescription of low-dose aspirin.MethodsAll practices received academic detailing, one arm received clinician reminders to reconsider aspirin, a second arm received both clinician and patient messages to reconsider aspirin. The intervention will run for 15 to 18 months. Data collected at baseline and for outcomes from an electronic health record will be used to assess pre- and post-interventional prescribing, as well as to explore any inappropriate decrease in aspirin use by patients with known cardiovascular disease.DiscussionThis study was designed to investigate effective methods of changing physician behavior to decrease the use of aspirin for primary cardiovascular disease prevention. The results of this study will contribute to the small pool of knowledge currently available on the topic of ceasing previously supported practices.Trial RegistrationClinicalTrials.gov: NCT01247454

Are the Recommended Blood Pressure Goals in High‐Risk Patients Based on Outcome Data or Opinion?

Treatment of hypertension to specific blood pressure (BP) goals is controversial, and the exact goal BP for different clinical populations at high risk for cardiovascular disease (CVD) is hotly debated. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) specifically recommended a goal BP of 130 ⁄80 mm Hg for patients with chronic kidney disease (CKD) or diabetes mellitus (DM). The national kidney foundation (Kidney Disease Outcomes Quality Initiative [KDOQI]) guidelines also recommend a goal BP of 130 ⁄80 mm Hg in patients with CKD and DM and a goal BP of 125 ⁄75 mm Hg in CKD patients with proteinuria >1000 mg ⁄d. More recent, the American Heart Association (AHA) and the European Society of Hypertension ⁄European Society of Cardiology recommended a goal BP of 130 ⁄80 mm Hg in all patients with coronary artery disease (CAD) or CAD risk equivalents, including patients with carotid artery disease, peripheral arterial disease, abdominal aortic aneurysm, and patients with high risk for CVD with a Framingham 10-year risk score >10%. In addition, the AHA also recommended a BP 120 ⁄80 mm Hg in patients with CAD and left ventricular dysfunction. The rationale behind these recommendations in patients with CKD is that these patients are considered to be the ‘‘highest-risk’’ group for CVD. Although patients with CKD have a many-fold increased risk of CVD, there has not been a controlled trial demonstrating superior CVD prevention by lowering BP to the recommended 130 ⁄80 mm Hg goal. So where does this recommendation come from? A recent meta-analysis was conducted to assess whether lower BP targets ( 135 ⁄85) are associated with reduction in mortality and morbidity as compared with standard BP targets of 140–160 ⁄ 90–100 mm Hg. Interestingly, no trials comparing different systolic BP (SBP) targets were found. Seven trials (22,089 patients) comparing different diastolic BP (DBP) targets were included. Primary outcomes were myocardial infarction, stroke, congestive heart failure, major cardiovascular (CV) events, and endstage renal disease. Secondary outcomes were achieved mean SBP and DBP and withdrawals due to adverse effects. Despite a greater achieved reduction in SBP and DBP, the ‘‘lower targets’’ did not improve mortality, myocardial infarction, stroke, congestive heart failure, or end-stage renal disease. Specifically a sensitivity analysis in diabetic patients and in patients with CKD also did not show a reduction in any of the mortality and morbidity outcomes with lower targets as compared with standard targets. Treating patients to lower BP targets does not reduce mortality or morbidity. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study of 4733 diabetics with hypertension echoes the findings of this meta-analysis. Despite a difference of 14 mm Hg in SBP, the primary end points (non-fatal myocardial infarction, nonfatal stroke, or CV death) were not improved by more aggressive BP reduction after nearly 5 years of follow-up. Stroke risk was, however, significantly lower in the intensive BP group (P=.01). Critics of this study have pointed out that although From the Department of Medicine, Hypertension Program, University of Pennsylvania School of Medicine, Philadelphia, PA Address for correspondence: Debbie L. Cohen, MD, Renal Division, University of Pennsylvania School of Medicine, 210 White Building, Philadelphia, PA 19104 E-mail: cohendl@mail.med.upenn.edu

Framingham Risk Score Inadequately Predicts Cardiac Risk in Young Patients Presenting with a First Myocardial Infarction

Introduction: The Framingham Risk Score (FRS) is a well-validated epidemiologic tool used to assess the risk for a first cardiac event. Because young patients presenting with a first myocardial infarction (MI) tend to have less significant risk profiles compared with older patients, we hypothesized that FRS may underestimate cardiac risk in these patients. Materials and Methods: We studied 1267 patients between January 2002 and November 2007 presenting with a first MI. Patients with pre-existing diabetes mellitus and vascular disease were excluded. FRS was calculated for each patient. Patients were divided based on their age: group A (&lt;40 years), group B (40 to 64 years) and group C (≥65 years). Results: The mean age was 54.7 ± 11 years, 88.4% of the patients were males. Younger patients were more likely to be assigned with lower scores. Based on FRS, 63.0%, 29.3% and 14.2% of group A, B and C patients were classified as low risk (10-year risk for cardiac events&lt;10%) respectively, P &lt;0.001. The sensitivity of FRS in identifying at least intermediate risk subjects (10-year risk for cardiac events &gt;10%) was 37.0% in group A vs 85.8% in group C (P &lt;0.001). The incidence of newly diagnosed diabetes mellitus was higher in younger patients (12.0% vs 13.2% vs 7.1 % in groups A, B and C respectively, P = 0.027). Conclusions: FRS inadequately predicts cardiac risk in young patients presenting with a first MI. This could be because a significant proportion of these young patients have undiagnosed diabetes mellitus, a coronary artery disease risk equivalent. Key words: Diabetes mellitus, Young myocardial infarction

Diabetes as a coronary artery disease risk equivalent: before a change of paradigm?

Current guidelines consider diabetes per se as a coronary artery disease (CAD) risk equivalent. We aimed at investigating the contribution of baseline coronary atherosclerosis to the risk of diabetic patients for future vascular events. Prospective cohort study. Vascular events were recorded over 4 years in 750 consecutive patients undergoing coronary angiography for the evaluation of stable CAD. From our patients, 244 had neither type 2 diabetes (T2DM) nor significant CAD (i.e. coronary stenoses >or=50%) at the baseline angiography, 50 had T2DM but not significant CAD, 342 did not have T2DM but had significant CAD, and 114 had both T2DM and significant CAD. Nondiabetic patients without significant CAD had an event rate of 9.0%. The event rate was similar in T2DM patients without significant CAD (8.0%, P = 0.951), but higher in nondiabetic patients with significant CAD (24.9%, P<0.001). Patients with T2DM and significant CAD had the highest event rate (43.0%). Importantly, T2DM patients without significant CAD had a significantly lower event rate than nondiabetic patients with significant CAD (P = 0.008). T2DM per se is not a CAD risk equivalent. Moderate-risk diabetic patients without significant CAD and very high-risk diabetic patients with significant CAD add up to a grand total of high-risk diabetic patients, this is why diabetes seems to be a CAD risk equivalent in many epidemiological studies.

Infrarenales Aortenaneurysma

Abdominal aortic aneurysms (AAA) confer a substantial healthcare burden in the Western world. Surgical or endovascular therapy is indicated in patients with a maximum diameter exceeding 5.5 cm. Patients with smaller AAA must undergo a specific ultrasound surveillance program aimed at avoiding exposure to an increased risk of rupture once their AAA exceeds the threshold for active treatment. Based on improved understanding of the pathophysiology of AAA, recent years provided initial insight into potential medical treatment options. The presence of AAA is currently regarded a coronary artery disease risk equivalent. ACE inhibitors, statins and JNK-inhibitors were shown to have the potential to slow down progression. Since cigarette smoking is the main risk factor for both the development and progression of AAA, smoking cessation remains a key goal. Further prospective studies will assess the clinical efficacy of various promising drug treatment approaches aimed at slowing disease progression of small AAA and after endovascular therapy.

Erectile dysfunction as a coronary artery disease risk equivalent

The conditions that predispose patients to erectile dysfunction are substantially similar to the coronary artery disease risk factors, including diabetes mellitus, hypertension, hyperlipidemia, obesity, sedentary lifestyle, depression, age, and smoking. Because of these shared risks and overlapping pathophysiologic mechanisms, we designed this pilot study to address the hypothesis that the presence of coronary artery calcium, a known indicator of increased cardiac risk, is associated with erectile dysfunction. A prospective registry enrolled 9150 men who underwent multidetector computed tomography. Subjects supplied baseline data regarding demographic variables, coronary risk factors, and erectile dysfunction symptoms or lack thereof. The 2 groups then underwent computed tomography to screen for the presence or absence of coronary artery calcium. Subjects with erectile dysfunction were older, had higher triglyceride levels, had higher blood pressures, and were more likely to have measurable coronary artery calcification than men without erectile dysfunction (79% vs 58%, P < .001). Erectile dysfunction is significantly associated with abnormal coronary artery calcification and, like peripheral arterial disease, might warrant consideration as a coronary artery disease risk equivalent.

Erectile dysfunction as a coronary artery disease risk equivalent

Erectile dysfunction as a coronary artery disease risk equivalent

Expanding roles for atorvastatin

Atherosclerosis, especially when manifested as coronary artery disease (CAD), continues to be the number one cause of mortality and morbidity in developed nations and will soon become so in developing countries. Survivors of an acute heart attack have an increased risk of illness and death that is 1.5-15 times greater than in the general population. Sudden death occurs in myocardial infarction (MI) survivors at a rate 4-6 times greater than in the general population. After an initial recognized MI, 25% of male and 38% of female survivors die within 1 year. Within 6 years after a recognized MI, 18% of men and 35% of women will have a second MI, 7% of men and 6% of women will suffer sudden death, and 22% of men and 46% of women will be disabled with heart failure. Aggressive secondary prevention, therefore, is the key to containing and reversing the "malignant" natural history of CAD, since patients with CAD or CAD risk equivalents are already in the "high risk" category according to the Adult Treatment Panel III (ATP III) of the National Cholesterol Education rogram (NCEP). Treatment of dyslipidemia, especially the reduction of low-density lipoprotein (LDL) cholesterol levels to below 100 mg/dl, was recommended by the 2001 NCEP-ATP Guidelines. In 2004, based on the increasing evidence from several major clinical trials between 2001 and 2004, the NCEP-ATP reaffirmed its LDL goal of < 100 mg/dl in patients with CAD or coronary disease risk equivalents (including multiple risk factors), with an optional LDL goal of < 70 mg/dl in very-high-risk patients (including patients with established coronary heart disease plus other highrisk conditions) Findings from major studies, such as the Treating to New Targets (TNT) study, the Scandinavian Simvastatin Survival Study (4S), the Collaborative Atorvastatin Diabetes Study (CARDS), the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial and, more recently, the Lipid-Lowering Arm of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT-LAA), lend support to the idea that greater LDL cholesterol lowering than that achieved with standard doses of statins may be warranted in patients with CAD and metabolic syndrome, CAD and diabetes, CAD and congestive heart failure, and CAD and renal insufficiency. On the other hand, additional lipid reduction may also be warranted in patients with risk factors such as diabetes, hypertension or a history of stroke, but without manifest CAD and despite relatively normal cholesterol levels. These newer indications for statins, atorvastatin in particular, as part of more aggressive secondary and primary prevention, are reviewed in this paper.

Diabetes Is Not Treated as a Coronary Artery Disease Risk Equivalent

Observational studies (1–3) have suggested that the risk of mortality is equivalent for patients with myocardial infarction (MI) without previous diabetes and for diabetic patients without previous MI. Because vascular risk-reduction targets are based on a patient’s future risk, clinical practice guidelines (4–9) recommend that the same or lower blood pressure and lipid targets be applied to diabetic patients as would be applied for secondary prevention following MI. Patients newly diagnosed with diabetes and those with first MIs enter a high-risk category for subsequent coronary events. Therefore, if diabetes were treated as a coronary artery disease risk equivalent, we would expect that both groups of patients should have similar increases in utilization of antihypertensive and lipid-lowering medications following their index events. The study used administrative health databases from Ontario, Canada, including hospital discharge abstracts, physician service claims, and records from the government drug insurance program, which covers all prescriptions filled for individuals aged ≥65 years. Individuals are linked between databases via an anonymous identification number. The study also used the Ontario Diabetes Database, a validated registry of all individuals with diabetes, derived from these administrative databases (10). All individuals with no history of MI or diabetes were identified, and two cohorts were assembled: those …

Combination therapy in the management of complex dyslipidemias.

Patients with dyslipidemias continue to be undertreated in both the primary and secondary prevention settings. Many patients have therapeutic needs that exceed simple reductions in low-density lipoprotein levels using statins. This review discusses the need for comprehensive management of all abnormalities in a given patient's lipoprotein profile and for the use of combinations of anti-lipidemic medications, when indicated. The majority of high-risk patients with manifestations of atherosclerotic disease or who have a coronary artery disease risk equivalent are not meeting their various lipoprotein targets. There is considerable reluctance to titrate statins and to use combinations of anti-lipidemic medications in patients not reaching their various lipoprotein targets. Combinations of anti-lipidemic medications can be specifically tailored to address abnormalities in multiple lipoprotein fractions. Recent clinical trials clearly demonstrate that combination therapy is well tolerated and facilitates lipoprotein goal attainment. Therapeutic approaches that incorporate the use of multiple anti-lipidemic medications should be more widely adopted in order to increase the number of patients able to meet their lipoprotein goals and to produce more substantially reduced risks for acute cardiovascular events.