High-density Lipoprotein Cholesterol Goal Research Articles

Lipid profiles and lifestyle habits of stroke survivors in the east coast region of peninsular Malaysia: Preliminary findings.

Background: Stroke survivors are at high risk for recurrent cardiovascular events if no prevention strategies are undertaken. Aim: This study aimed to investigate the fasting serum lipid profiles and lifestyle habits in stroke survivors, and the factors associated with suboptimal lipid profiles. Methods: A cross-sectional retrospective study was conducted in three public hospitals in Malaysia. Stroke survivors' data regarding the socio-demographic characteristics, clinical profiles, fasting serum lipid profiles, dietary adherence, and physical activity levels were acquired. Binary logistic regression was used to examine the factors associated with suboptimal lipid goals. Results: A total of 104 stroke survivors were recruited from patients attending the neurology and rehabilitation departments. Only 22% of the stroke survivors attained the targeted low-density lipoprotein cholesterol level (LDL-C < 1.8 mmol/L). Meanwhile, more than two thirds of patients achieved the targeted total cholesterol, triglyceride, and high-density lipoprotein cholesterol goals. Patients with a longer stroke duration (Adjusted odds ratio, AOR 3.33, 95% confidence intervals, CI: 1.09, 10.13, p = 0.034), elevated blood pressure (AOR 4.74, 95% CI: 1.65, 13.62, p = 0.004), chronic kidney disease (AOR 3.30, 95% CI: 1.05, 10.34, p = 0.041), abdominal obesity (AOR 3.14, 95% CI: 1.20, 8.21, p = 0.020), excessive energy intake (AOR 2.72, 95% CI: 1.07, 6.91, p = 0.036), and excessive saturated fatty acids intake (AOR 2.85, 95% CI: 1.02, 7.93, p = 0.045) were significantly associated with suboptimal lipid profiles. Conclusion: The lipid goals attainment was low, particularly the LDL-C levels among Malaysian stroke survivors. Greater efforts are warranted to fully utilise the lipid-lowering therapy and the lifestyle changes in these high-risk patients.

Achievement of treatment goals with canagliflozin in patients with type 2 diabetes mellitus: a pooled analysis of randomized controlled trials

Objective:To evaluate attainment of diabetes-related treatment goals with canagliflozin, a sodium glucose co-transporter 2 inhibitor, versus placebo in patients with type 2 diabetes mellitus (T2DM).Research design and methods:Data were pooled from four 26-week, placebo-controlled, Phase 3 studies of patients with T2DM (N = 2313). Goal attainment with canagliflozin 100 and 300 mg versus placebo was evaluated in the overall population, and in subgroups based on age and sex, at baseline and Week 26.Clinical trial registration:ClinicalTrials.gov NCT01081834, NCT01106677, NCT01106625, NCT01106690.Main outcome measures:Proportion of patients achieving hemoglobin A1C (A1C) <7.0% and ≤6.5%, systolic blood pressure (SBP) <140 and <130 mmHg, diastolic blood pressure (DBP) <90 and <80 mmHg, low-density lipoprotein cholesterol (LDL-C) <100 mg/dL (2.6 mmol/L), high-density lipoprotein cholesterol (HDL-C) ≥40 mg/dL (1.0 mmol/L), and the composite endpoint of A1C <7.0%, BP <130/80 mmHg, and LDL-C <100 mg/dL (2.6 mmol/L) at baseline and Week 26, and proportion with body weight reduction ≥5% at Week 26.Results:At baseline, similar proportions of patients met diabetes-related treatment goals across groups. At Week 26, a greater proportion of patients achieved A1C, SBP, DBP, and HDL-C goals with canagliflozin 100 and 300 mg compared with placebo. More patients achieved body weight reduction of ≥5% with canagliflozin 100 and 300 mg versus placebo at Week 26. Fewer patients had LDL-C <100 mg/dL (2.6 mmol/L) at Week 26 with canagliflozin 100 and 300 mg versus placebo. Canagliflozin 100 and 300 mg also provided better attainment of the composite endpoint of A1C <7.0%, BP <130/80 mmHg, and LDL-C <100 mg/dL (2.6 mmol/L) compared with placebo. Attainment of diabetes-related treatment goals was generally similar regardless of age and sex. Key limitations of this analysis include the selection of specific treatment targets that may not be reflective of all patient experiences, the non-prespecified, post hoc nature of the analysis, and the short duration of studies included in the pooled population.Conclusion:Canagliflozin was associated with better attainment of diabetes-related treatment goals compared with placebo, and was generally well tolerated at 26 weeks.

Frequency of Attainment of Low-Density Lipoprotein Cholesterol and Non–High-Density Lipoprotein Cholesterol Goals in Cardiovascular Clinical Practice (from the National Cardiovascular Data Registry PINNACLE Registry)

Studies have found that non-high-density lipoprotein cholesterol (non-HDL-C) is a superior marker for coronary heart disease compared to low-density lipoprotein cholesterol (LDL-C). Little is known about achievement of non-HDL-C goals outside clinical trials. Within a population of 146,064 patients with dyslipidemia in the PINNACLE Registry and a subgroup of 36,188 patients with diabetes mellitus (DM), we examined the proportion of patients and patient characteristics associated with having LDL-C, non-HDL-C, and both LDL-C and non-HDL-C levels at National Cholesterol Education Program goals. LDL-C, non-HDL-C, and both LDL-C and non-HDL-C goals in the overall cohort were achieved by 73%, 73.4%, and 68.9% patients, respectively. Significant predictors of meeting all 3 goals were age, male gender, statin, nonstatin, and combined statin plus nonstatin use. Patients with co-morbidities of hypertension, previous stroke or transient ischemic attack, peripheral arterial disease, myocardial infarction, and smoking were less likely to have LDL-C, non-HDL-C, and both LDL-C and non-HDL-C levels at National Cholesterol Education Program goal. In the overall cohort, patients with DM were less likely to meet non-HDL-C and both LDL-C and non-HDL-C goals. In the subgroup of patients with DM, predictors of meeting lipid goals were similar to the overall cohort. In conclusion, these data suggest contemporary treatment patterns by cardiologists successfully achieve lipid goals in most patients. Younger, female patients and those with atherosclerotic cardiovascular disease and risk factors, such as hypertension and DM, are less likely to achieve goals and may require more careful follow-up after statin initiation. Both LDL-C and non-HDL-C goals are achieved in <70% of patients, suggesting room for improvement if a goal-targeted individualized strategy is adopted.

Quality of diabetes care at outpatient clinic, sultan qaboos university hospital.

To assess the clinical care of type 2 diabetes mellitus (T2D) patients at Sultan Qaboos University Hospital (SQUH), a countrywide tertiary referral center in Muscat, Oman. . We performed a retrospective, observational, cross-sectional study using a total of 673 Omani T2D patients from the Diabetes and Family Medicine Clinics at SQUH. We collected patient data from June 2010 to February 2012 from the Hospital Information System (HIS). Patients had to be Omani, aged more than 18 years old, and have T2D with active follow-up and at least three visits within one year to be included in the study. Ninety-three percent of the patients (n=622) were on oral hypoglycemic drugs and/or insulin, and 70% were on statins. Patients' anthropometric data, biochemical investigations, blood pressure, and duration of diabetes were recorded from the HIS. . Using the recommended standards and guidelines of medical care in diabetes (American Diabetes Association and the American National Cholesterol Education Program III NCDP NIII standards), we observed that 22% of the patients achieved a HbA1C goal of <7%, 47% achieved blood pressure goal of <140/80mm Hg, 48% achieved serum low density lipoprotein cholesterol goal of <2.6mmol/L, 67% achieved serum triglycerides goal of <1.7 mmol/L, 59% of males and 43% of females achieved high density lipoprotein cholesterol goals (males>1.0; females >1.3mmol/L). Almost 60% of the patients had urinary microalbumin/creatinine ratio within the normal range. . The clinical outcomes of the care that T2D patients get at SQUH were lower than those reported in Europe and North America. However, it is similar to those reported in other countries in the Arabian Gulf.

Management of patients with ST-segment elevation or non-ST-segment elevation acute coronary syndromes in cardiac rehabilitation centers.

Current data on the management of patients in cardiac rehabilitation (CR) after an acute hospital stay due to ST-segment elevation or non-ST segment elevation acute coronary syndromes (STE-ACS or NSTE-ACS) are limited. We aimed to describe patient characteristics, risk factor management, and lipid target achievement of patients in CR in Germany and compare the 2 groups. With respect to the risk factor pattern and treatment effects during a CR stay, there are important differences between STE-ACS and NSTE-ACS patients. Comparison of 7950 patients by STE-ACS or NSTE-ACS status in the Transparency Registry to Objectify Guideline-Oriented Risk Factor Management registry (2010) who underwent an inpatient CR period of about 3 weeks. STE-ACS patients compared to NSTE-ACS patients were significantly younger (60.5 vs 64.4 years, P < 0.0001), and had diabetes mellitus, hypertension, or any risk factor (exception: smoking) less often. At discharge, in STE-ACS compared to NSTE-ACS patients, the low-density lipoprotein cholesterol (LDL-C) <100 mg/dL goal was achieved by 75.3% and 76.2%, respectively (LDL-C <70 mg/dL by 27.7% and 27.4%), the high-density lipoprotein cholesterol goal of >50 mg/dL in women and >40 mg/dL in men was achieved by 49.3% and 49.0%, respectively, and the triglycerides goal of <150 mg/dl was achieved by 72.3% and 74.3%, respectively (all comparisons not significant). Mean systolic and diastolic blood pressure were 121/74 and 123/74 mm Hg, respectively (P < 0.0001 systolic, diastolic not significant). The maximum exercise capacity was 110 and 102 W, respectively (P < 0.0001), and the maximum walking distance was 581 and 451 meters, respectively (P value not significant). Patients with STE-ACS and NSTE-ACS differed moderately in their baseline characteristics. Both groups benefited from the participation in CR, as their lipid profile, blood pressure, and physical fitness improved.

Gender Difference in Statin Intervention on Blood Lipid Control among Patients with Coronary Heart Disease

The aim of this study was to clarify the current status in the effective control of dyslipidemia in Taiwanese women and men with coronary heart disease (CHD). A total 1584 patients with CHD (1188 men, aged 64.8 ± 11.6 years and 396 women, aged 69.0 ± 9.8 years) from 3486 patients who had atherosclerotic vascular disease and complete lipids measured values [total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), and low-density lipoprotein cholesterol (LDL-C)] were used for analysis. The waist, height, weight, and creatinine levels were higher in men than in women. The systolic blood pressure, TC, HDL-C, LDL-C, fasting blood glucose, and platelet were lower in men than in women. Men were more likely to achieve the target goal than women in TC < 160 mg/dL, LDL-C < 100 mg/dL, and TG < 150 mg/dL as well as to achieve HDL-C goal. A significant gap was found between the guidelines and clinical practice in statin intervention among these CHD patients, particularly for women. The strategy in control of dyslipidemia should consider gender difference.

Reducing Residual Risk in Secondary Prevention of Cardiovascular Disease

Prevention of cardiovascular disease (CVD) spans the human lifespan, including primordial, primary, and secondary prevention efforts. Extensive evidence from epidemiological, genetic, and animal studies confirms the central importance of elevated low-density lipoprotein (LDL) cholesterol (LDL-C) in atherosclerotic CVD events.1 The Cholesterol Treatment Trialists Collaboration provides per-person documentation from large-scale randomized clinical trials of the striking reduction in CVD events per 1 mmol (38.8 mg/dL) of LDL-C lowering with statins over a wide range of baseline LDL-C values.2,3 It is worth recalling that the major statin trials were not designed to determine the effectiveness of titration to LDL-C or even to non–high-density lipoprotein cholesterol goals by statins but were fixed-dose comparisons of various statins against placebo and then, more recently, large-dose statin therapy versus moderate-dose statin therapy. What is not so clear is whether we can intervene to reduce so-called residual risk further in secondary prevention patients optimally treated with statin therapy. A promising short list of proposed potential targets other than LDL includes efforts to promote smoking cessation and therapies to improve the prothrombotic and inflammatory state of the metabolic syndrome and to control elevated blood pressure.4 Article see p 1979 The article by Mora et al5 in this issue of Circulation is helpful in shedding light on this unresolved but important clinical problem. The investigators used data from a large-scale clinical trial of secondary prevention patients called Treating to New Targets (TNT). They evaluated risk factors for recurrent CVD events in those treated with intensive statin therapy (atorvastatin 80 mg/d) to address the challenges inherent in further risk reduction for those who had major cardiovascular events despite high-dose (atorvastatin 80 mg/d) statin therapy. The trial design of TNT included enrollment of participants with chronic coronary artery …

The impact of serum lipids on risk for microangiopathy in patients with type 2 diabetes mellitus

BackgroundFew large-scale, real-world studies have assessed the relative associations of lipid fractions with diabetic microvascular events. The main objective of this study was to evaluate the association of the lipid profile components, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), and non-high density lipoprotein cholesterol (non-HDL-C) with microvascular complications (MVCs) in type 2 diabetes mellitus (T2DM) patients.MethodsThis observational cohort study queried the HealthCore Integrated Research Database (HIRDSM) for newly-diagnosed (Index Date) 18-64-year-old patients with diabetes mellitus between 01/01/2005-06/30/2010. Inclusion required ≥12 months pre-index continuous health plan eligibility and ≥1 pre-index lipid profile result. Patients with polycystic ovary syndrome and prior MVCs were excluded. Incident complications were defined as the earliest occurrence of diabetic retinopathy, peripheral neuropathy, and/or nephropathy post-index. Cox proportional models and Kaplan-Meier (KM) curves were used to evaluate associations among variables.ResultsOf the patients (N = 72,267), 50.05 % achieved HDL-C, 64.28 % LDL-C, 59.82 % TG, and 56.79 % non-HDL-C American Diabetes Association goals at baseline. During follow-up (mean, 21.74 months), there were 5.21 microvascular events per 1,000 patient-months. A 1-mg/dL increase in HDL-C was associated with 1 % decrease in any MVC risk (P < .0001), but for LDL-C, TG, and non-HDL-C, 1-mg/dL increase resulted in increases of 0.2 % (P < .0001), 0.1 % (P < 0.001) and 0.3 % (P < 0.001) in MVC risk. Patients achieving HDL-C goals had a 11 % lower risk of MVC versus non-achievers (RR 0.895, [95 % CI, 0.852-0.941], P < .0001). Similarly, TG goal attainment was associated with a lowered risk for any MVC (RR 0.849, [95 % CI, 0.808-0.892], P < .0001). Evaluation of KM survival curves demonstrated no significant difference in the risk of MVCs between patients achieving vs. not achieving LDL-C goals, but did demonstrate a difference in MVC risk between patients achieving vs. not achieving non-HDL-C goals.ConclusionThis study demonstrates significant independent associations among lipid fractions and risk for microangiopathy. These findings suggest that attaining established ADA goals for HDL-C, TG, and non-HDL-C may reduce risk for microvascular events among patients with diabetes.

Institutional, provider, and patient correlates of low-density lipoprotein and non–high-density lipoprotein cholesterol goal attainment according to the Adult Treatment Panel III guidelines

The aim of this analysis was to identify the proportion of coronary heart disease (CHD) patients achieving guideline-recommended low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) goals and to identify correlates of dual goal attainment. We analyzed patient, provider, and facility characteristics for 21,801 CHD patients in one Veterans Affairs Hospitals Network. Low-density lipoprotein cholesterol goal attainment was 80%, but optional LDL-C goal attainment was 41%. Of patients with triglycerides ≥200 mg/dL, 51% attained both LDL-C and non-HDL-C goals. Correlates of higher dual goal attainment included older age (65-74 years: odds ratio [OR] 1.47, 95% CI 1.28-1.69), diabetes (OR 1.33, 95% CI 1.16-1.53), obesity (OR 1.25, 95% CI 1.04-1.50), a higher number of primary care visits (OR 1.04, 95% CI 1.04-1.05), and mild increase in illness severity of patients in provider's panel (OR 1.20, 95% CI 1.0008-1.46), whereas African American patients were less likely to achieve dual lipid goals (OR 0.63, 95% CI 0.48-0.82). Receipt of care from physician (vs nonphysician) or specialist (vs primary care) provider, number of patients in provider's panel, and percentage of patients in provider's panel with diagnosis of hyperlipidemia were not associated with dual goal attainment. A large proportion of CHD patients attained LDL-C goal, but optional LDL-C goal attainment was low. Patients with elevated triglycerides had poor attainment of dual LDL-C and non-HDL-C goals, suggesting a treatment gap. Factors associated with dual goal attainment may identify interventions needed to improve future guideline adherence.

Low- and high-density lipoprotein cholesterol goal attainment in dyslipidemic women: The Lipid Treatment Assessment Project (L-TAP) 2

Low- and high-density lipoprotein cholesterol goal attainment in dyslipidemic women: The Lipid Treatment Assessment Project (L-TAP) 2

Low- and high-density lipoprotein cholesterol goal attainment in dyslipidemic women: The Lipid Treatment Assessment Project (L-TAP) 2

Differences between women and men have been documented for both diagnostic testing and treatment in cardiology. This analysis evaluates whether low-density lipoprotein cholesterol (LDL-C) success rates according to current guidelines and high-density lipoprotein cholesterol (HDL-C) levels differ by gender in the L-TAP 2 population. Patients aged > or =20 years with dyslipidemia on stable lipid-lowering therapy were assessed in 9 countries between September 2006 and April 2007. Low-density lipoprotein cholesterol goal attainment by cardiovascular risk level and region and determinants of low HDL-C were compared between genders. Of 9,955 patients (45.3% women) evaluated, women had a significantly lower overall LDL-C success rate than men (71.5% vs 73.7%, P = .014), due entirely to the difference in the high-risk/coronary heart disease (CHD) group (LDL-C goal <100 mg/dL, 62.6% vs 70.6%, P < .0001) Among CHD patients with > or =2 additional risk factors, only 26.7% of women and 31.5% of men (P = .021) attained the optional LDL-C goal of <70 mg/dL. High-density lipoprotein cholesterol was <50 mg/dL in 32.2% of women and <40 mg/dL in 26.8% of men (P < .0001), including 38.2% of women and 29.8% of men in the high risk/CHD group (P < .0001). Predictors of low HDL-C in women included diabetes, smoking, waist circumference, and hypertension. Cholesterol treatment has improved substantially since the original L-TAP a decade ago, when only 39% of women attained their LDL-C goal. However, high-risk women are undertreated compared to men, and a substantial opportunity remains to reduce their cardiovascular risk.

Results of retrospective chart review to determine improvement in lipid goal attainment in patients treated by high-volume prescribers of lipid-modifying drugs.

There is a primary focus in cholesterol management on the elevated low-density lipoprotein cholesterol (LDL-C) component of dyslipidemia and a secondary focus on the other components of dyslipidemia, such as low high-density lipoprotein cholesterol (HDL-C), high triglycerides (TGs), and high non-HDL-C. This was a physician practice analysis to examine the real-world therapeutic management of patients diagnosed with hyperlipidemia and/or hypercholesterolemia according to the guidelines of the National Cholesterol Education Program (NCEP) Adult Treatment Panel Third Report (ATP III) and the American Heart Association (AHA). Additionally, the number of patients who should be diagnosed with mixed hyperlipidemia instead of hyperlipidemia or hypercholesterolemia was estimated. A total of 600 high-volume prescribers of lipid-modifying drugs were identified in 6 metropolitan areas using the IMS Health prescription database. A total of 101 physician prescribers (about 17%) agreed to participate in the study and had the necessary medical records available. The participating prescribers were asked to identify all patients aged between 18 and 79 years who were seen in their practice in the last 2 years having a diagnosis of hyperlipidemia (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 272.4) and/or hypercholesterolemia (ICD-9-CM code 272.0). ICD-9-CM code 272.2 (mixed hyperlipidemia) was purposely excluded from the criteria for patient chart selection in order to estimate the prevalence of mixed hyperlipidemia in patients previously diagnosed with hyperlipidemia and/or hypercholesterolemia. A random number generator was used to select 25 patient medical records from each office. A common instrument was used to collect data on patient demographics; clinical history; comorbid disease states; laboratory test results, including liver function; and 4 values for serum cholesterol (total cholesterol, LDL-C, HDL-C, TG). Total cholesterol was recorded to permit calculation of non-HDL-C. Data collection via patient chart abstraction occurred from March 2004 through August 2004, performed by a staff member in each physician practice who had been trained for this purpose. Drug prescribing was identified from the patient chart. For the physician practice assessment portion of the project, we used patient charts if there was a complete (total cholesterol, TG, HDL-C, and LDL-C) lipid profile for baseline and follow-up, and a minimum of 6 weeks between baseline and follow-up values. At follow-up, the proportion of patients meeting goal lipid values according to the guidelines for LDL-C was 68%, 63% for HDL-C, 59% for TG, and 68% for non-HDL-C. Only 32% of patients met all 3 goals (LDL-C, HDL-C, and TG). The average time between the baseline and follow-up lipid profile was 3.7 years, with a median of 2.9 years, and a minimum of 6 weeks and a maximum of 42 years. Compared with baseline, the most recent follow-up lipid assessment for HDL-C goal attainment showed improvement by an absolute 6%, from 57% to 63% of patients. TG goal attainment improved an absolute 18% (from 41% to 59%), LDL-C goal attainment improved an absolute 45% (from 23% to 68%), non-HDL-C goal attainment improved an absolute 46% (from 22% to 68%), and the combined goals of LDL-C, HDL-C, and TG improved from 8% of patients at baseline to 32% at follow-up. Of the 2,119 patients in the study population, 1,784 (84%) at the time of chart review had been prescribed at least 1 lipid-modifying medication: 1,552 (87%) a single lipid-modifying medication and 232 (13%) combination therapy. The hydroxymethylglutaryl (HMG) coenzyme-A reductase class (statins) accounted for 89% of the monotherapy regimens. Of the patients with baseline LDL-C, HDL-C, and TG readings, 40% could have been diagnosed as having mixed hyperlipidemia, defined as having (a) baseline LDL-C greater than their NCEP ATP III goal and (b) either baseline TG of >150 mg/dL or a baseline HDL-C of <40 mg/dL for males or <50 mg/dL for females. Of the 40% of patients estimated to have mixed hyperlipidemia, 69% were prescribed lipid-modifying monotherapy, 18% were prescribed combination drug therapy, and 14% were not prescribed drug therapy. Attainment of therapeutic goals for serum lipids improved from baseline to follow-up, but approximately one third of patients did not achieve individual lipid goals and two thirds of patients did not attain goal for all 3 targets (LDL-C, HDL-C, and TG).

Baseline Achievement of Lipid Goals and Usage of Lipid Medications in Patients With Diabetes Mellitus (from the Veterans Affairs Diabetes Trial)

The American Diabetes Association has established lipid goals for patients with diabetes. Although diabetic populations historically have poor low-density lipoprotein (LDL) cholesterol goal adherence, little is known about adherence to triglyceride and high-density lipoprotein (HDL) cholesterol goals. To determine the degree of lipid goal attainment among patients with diabetes, and to characterize the patterns of lipid medication use, we evaluated the baseline data from 1,742 enrollees of the national Veterans Affairs Diabetes Trial. Using current American Diabetes Association lipid guidelines, we calculated the proportion of participants achieving a LDL cholesterol level <100 mg/dl, triglyceride level <150 mg/dl, and HDL cholesterol level >40 mg/dl in men (>50 mg/dl in women). We also performed a descriptive analysis of the use of lipid medications in this population. The baseline LDL cholesterol level was 111 +/- 63 mg/dl, triglyceride level was 213 +/- 277 mg/dl, and HDL cholesterol was 36 +/- 10 mg/dl. At enrollment, 44% of veterans met the LDL cholesterol goal, 58% met the triglyceride goal, and 16% met the HDL cholesterol goal, but only 6% met all 3 goals. Of the 1,742 enrollees, 2/3 were receiving lipid therapy, with statins (58%) the most commonly used drug. Combination lipid therapy was used by 11% of enrollees. Although the enrollees of the Veterans Affairs Diabetes Trial demonstrated better adherence to the American Diabetes Association's LDL cholesterol goal than other diabetic populations recently studied, more aggressive and directed lipid medication use is needed to treat the overall lipid profile better.

Guidelines for lowering lipids to reduce coronary artery disease risk: a comparison of rosuvastatin with atorvastatin, pravastatin, and simvastatin for achieving lipid-lowering goals

Both the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III and the Second Joint Task Force of European Societies guidelines have established low-density lipoprotein (LDL) cholesterol goals for lipid-lowering treatment to reduce the risk of coronary artery disease. Data from 3 trials that compared rosuvastatin 10 mg (n = 389) with atorvastatin 10 mg (n = 393) and 2 trials that compared rosuvastatin 10 mg (n = 226) with pravastatin 20 mg (n = 252) and simvastatin 20 mg (n = 249) were pooled separately to compare the achievement of LDL cholesterol goals over 12 weeks of treatment in hypercholesterolemic patients. Noncomparative pooling of rosuvastatin 10 mg results from all 5 trials (n = 615) showed that 80% achieved NCEP ATP III goals and 81% achieved the European goal of <3.0 mmol/L. Compared with atorvastatin 10 mg, significantly more patients treated with rosuvastatin 10 mg achieved their ATP III (76% vs 53%) and European (82% vs 51%) goals (p <0.001). Also, in comparisons with simvastatin 20 mg and pravastatin 20 mg, 86% of patients treated with rosuvastatin 10 mg achieved ATP III goals, compared with 64% of simvastatin-treated patients and 49% of pravastatin-treated patients (p <0.001). The proportions of patients who achieved the European goal were 80%, 48%, and 16% for rosuvastatin 10 mg, simvastatin 20 mg, and pravastatin 20 mg, respectively, in this comparison (all p <0.001). A total of 71% of patients treated with rosuvastatin 10 mg who had triglyceride levels ≥200 mg/dL met both their LDL cholesterol and their non–high-density lipoprotein cholesterol goals.

HDL in atherosclerosis: actor or bystander?

Despite dramatic improvement in treatments for reducing risk for coronary heart disease (CHD), it is still the leading cause of mortality in the developed world. In the past decade, a major improvement in reducing low-density lipoprotein (LDL) cholesterol has been achieved with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins). This approach has been shown to be beneficial in both primary and secondary prevention of CHD. On the other hand, while a reduced high-density lipoprotein (HDL) cholesterol level is an independent CHD risk factor, no HDL cholesterol goal has yet been established. The Helsinki Heart Study and the Veterans Affairs High-density Lipoprotein Intervention Trial documented that increasing HDL cholesterol with gemfibrozil significantly decreases coronary events or stroke in CHD patients either with elevated non-HDL cholesterol or normal LDL cholesterol levels plus low HDL cholesterol. Investigations with statins have focused on their efficacy not only in significantly decreasing total cholesterol, LDL cholesterol, and triglyceride levels but also in increasing HDL cholesterol concentrations. The two different classes of drugs (statins and fibrates) have different effects on the various HDL subspecies. As new members of these drug classes and other novel drugs are emerging, there is interest in clarifying whether HDL is only a bystander (an indicator for other CHD risk factors) or it has an active role in the development of CHD. If HDL has an active role, there is a need to determine if any HDL subspecies are protective. It is now clear that HDL plays a pivotal role in cellular cholesterol efflux via the interaction of apolipoprotein A-I with the ATP binding cassette transporter A-1. Thereafter the cholesterol is esterified by lecithin:cholesterol acyltransferase; HDL is remodeled by cholesterol ester transfer protein (CETP) and hepatic lipase. The cholesterol in HDL can either be transferred to apolipoprotein B-containing particles via CETP or delivered directly to the liver with the help of scavenger receptor B1.

Use of simvastatin treatment in patients with combined hyperlipidemia in clinical practice. For the Simvastatin Combined Hyperlipidemia Registry Group.

To describe and understand current care of simvastatin-treated patients with combined hyperlipidemia in routine clinical practice. A 6-month prospective observational study. Demographics, simvastatin dosage, cardiac risk factors, and lipid profile were collected from August 1997 to December 1998 at 20 sites (230 patients) across the United States. Overall mean percentage of reduction in total cholesterol levels was 27% (P<.001), low-density lipoprotein cholesterol (LDL-C) was 35% (P<.001), and triglyceride values was 28% (P<.001). Among those patients with low baseline high-density lipoprotein cholesterol (HDL-C) values (<0.91 mmol/L [<35 mg/dL]) (N = 49), there was a 17% increase in HDL-C (P< or =.001); 35% of these patients achieved National Cholesterol Education Program HDL-C goal (ie, < or =0.91 mmol/L [> or =35 mg/dL]). Coronary heart disease (CHD) patients were given significantly higher initial doses (mean, 15.1 mg) compared with non-CHD patients (mean, 11.5 mg) (P< or =.001). Overall, 74% of patients achieved LDL-C goal (52% on starting dose, 22% after 1 titration). Among those patients who were not at goal and had a follow-up lipid profile result available, only 1 patient (2%) was at the maximum dose (80 mg); 69% were receiving 20 mg or less. Approximately 63% of patients with CHD, 80% of patients with 2 or more risk factors, and 91% of patients with fewer than 2 risk factors achieved LDL-C goal. Multiple factors contribute to LDL-C goal achievement in a usual care setting. A significant opportunity exists to increase the number of patients who achieve LDL-C goal by appropriate dose titration and/or give patients a higher initial dose of simvastatin.