National Cholesterol Education Program Goals Research Articles

Evaluating the need for free glycerol blanking for serum triglyceride measurements at Charlotte Maxeke Johannesburg Academic Hospital.

Background The accurate and precise measurement of triglycerides is important due to the adverse effects associated with hypertriglyceridaemia. Most laboratory methods are based on enzymatic hydrolysis of triglycerides with measurement of the total glycerol. An elevated free glycerol concentration may result in overestimation of triglyceride concentrations. The removal of free glycerol by blanking may therefore be of clinical importance. The aim of this study was to compare the glycerol blanking and non-glycerol blanking triglyceride methods. Methods This was a method comparison study of 1518 samples from both in-patients and out-patients at Charlotte Maxeke Johannesburg Academic Hospital. Triglycerides were measured in each sample using both the blanking and the non-blanking methods. Analytical performance was assessed based on the National Cholesterol Education Program (NCEP) goals. Clinical impact was assessed according to the NCEP Adult Treatment Program III (ATP III) risk classification. Results The method median was significantly higher in the non-blanking compared to the blanking method (1.33 vs. 1.12 mmol/L, p < 0.0001) in all patients. The average bias was above the total allowable error of 15% across all groups. There was a significant change in NCEP ATP III risk classification, with fewer patients classified as normal (67.6% vs. 74.6%, p < 0.0001) with the non-blanking method compared to the blanking method. Conclusions There was a significant error when glycerol blanking for triglyceride determination was not performed. The non-blanking triglyceride method overestimates triglyceride concentrations. This does not only exceed analytical performance goals, but also impacts on patient categorisation and clinical decision making in all patients.

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.

Intermittent Nondaily Dosing Strategies in Patients with Previous Statin-Induced Myopathy

To review the safety and efficacy of alternative intermittent statin dosing regimens in patients with previous intolerance due to myopathy. Literature was accessed through MEDLINE (1946 -December 2012) and EMBASE (1966-December 2012) using relevant MeSH and Emtree search terms, including statins, HMG Co-A reductase inhibitors, simvastatin, atorvastatin, lovastatin, fluvastatin, pravastatin, pitavastatin, rosuvastatin, myopathy, and myalgias. Web of Science (1955-December 2012) and the aforementioned databases were additionally searched using combinations of the following text words: statin intolerance, alternate dosing, nondaily dosing, weekly dosing, statin-induced myopathy, and intermittent statin dosing. References of identified articles were reviewed for additional citations. All identified English-language peer-reviewed publications were evaluated. Articles (excluding meeting abstracts) specifically addressing nondaily statin use in patients with previous statin-induced myopathy were reviewed. Although statins have achieved significant reductions in cardiovascular morbidity and mortality, as many as 10% of patients prescribed these therapies experience myopathies. Intermittent statin regimens ranging from every-other-day to once-weekly dosing have emerged in an attempt to maintain efficacy while moderating the incidence of adverse effects. The results reported in 10 publications investigating varying regimens with atorvastatin and/or rosuvastatin revealed that at least 70% of patients were able to tolerate an intermittent dosing strategy without a recurrence of previous treatment-limiting adverse effects. Although the degree of low-density lipoprotein cholesterol-lowering varied appreciably among studies (12-38%), the addition of a nondaily statin regimen facilitated attainment of National Cholesterol Education Program goals for some. Although areas of uncertainty remain, intermittent dosing (particularly with rosuvastatin and atorvastatin) in previously intolerant patients is a useful strategy to capitalize on the benefits of this therapy. Larger scale randomized trials are necessary to more clearly define the role of this strategy and the optimal choice of regimen.

Comparative Effectiveness and Toxicity of Statins Among HIV-Infected Patients

dyslipidemia is common and is often treated with 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins). Little is known about the comparative effectiveness of statins among human immunodeficiency virus (HIV)-infected patients. This study compared the effectiveness and toxicity of statins among HIV-infected patients in clinical care. we conducted a retrospective cohort study of patients starting their initial statin medications at 2 large HIV clinics (N = 700). The primary observation was change in lipid levels during statin therapy. Secondary observations included whether individualized National Cholesterol Education Program (NCEP) goals for low density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (non-HDL-C) levels were reached, and toxicity rates. We used linear regression to examine change in lipid levels, controlling for baseline lipid values and demographic and clinical characteristics. We conducted secondary analyses using propensity scores to address confounding by indication. the most commonly prescribed statins were atorvastatin (N = 303), pravastatin (N = 280), and rosuvastatin (N = 95). One year after starting a statin therapy, patients who received atorvastatin or rosuvastatin had significantly greater decreases in total cholesterol, LDL-C, and non-HDL-C than patients on pravastatin. The likelihood of reaching NCEP goals for LDL-C levels was higher with the use of rosuvastatin (OR 2.1; P = .03) and atorvastatin (odds ratio [OR], 2.1; P = .001) compared with that of pravastatin. The likelihood of reaching NCEP goals for non-HDL-C levels was higher for rosuvastatin (OR 2.3; P = .045) but not atorvastatin (OR, 1.5; P = .1) compared with pravastatin. Toxicity rates were similar for all 3 statins: 7.3% for atorvastatin, 6.1% for pravastatin, and 5.3% for rosuvastatin. our findings suggest that atorvastatin and rosuvastatin are preferable to pravastatin for treatment of HIV-infected patients with dyslipidemia, due to greater declines in total cholesterol, LDL-C, and non-HDL-C, with similar lower toxicity rates.

Outcomes of a Multidisciplinary Partnership to Improve Cardiac Wellness: An Opportunity for Pharmacists

To describe the results of an initiative to create awareness of coronary heart disease and provide education regarding cardiovascular (CV) risk and cholesterol (lipid) management in a community-based senior population. A multidisciplinary partnership composed of governmental agencies, a member of the pharmaceutical industry, a college of pharmacy, and several community-based health care practitioners collaborated in the program. Prospective CV risk assessment, educational interventions, and follow-up. Community centers providing wellness and activity programs for ambulatory seniors. Ambulatory senior adults who were active participants in senior center programs were invited to participate in a series of health screenngs at a center-based health fair. Those who met specific evidence-based qualifying criteria were enrolled in the program. Changes in CV risk profile, specifically, total cholesterol, low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), triglycerides (TG), blood glucose levels; and attainment of National Cholesterol Education Program (NCEP) lipid goals of the Adult Treatment Panel III. Initial screening of 501 patients for eligibility allowed 273 patients to qualify and enroll in the program. A total of 112 (41.0%) participants returned for the year 2 follow-up, leaving a loss to follow-up of 161 patients. Compared with baseline, reductions occurred in total cholesterol (206.8 mg/dL vs.182.9 mg/dL), LDL-C (122.2 mg/dL vs. 105.5 mg/dL), HDL-C (51.5 mg/dL vs. 49.6 mg/dL), TG (164.8 mg/dL vs. 136.4 mg/dL), and blood glucose (115 mg/dL vs. 106.3 mg/dL); the number of patients with less than two risk factors decreased from 43 (38.4%) to 28 (25.0%) and those with two or more risk factors increased from 69 (61.6%) to 84 (75.0%); the number of patients at NCEP (lipid) goal increased from 57 (50.9%) to 80 (71.4%). For senior adults participating in the program, improvements occurred in both the lipid profiles and the number of patients at their NCEP (lipid) goal, although the number of seniors with > or = two risk factors increased from 69 (61.6%) to 84 (75.0%). A multidisciplinary partnership for improving the CV health and awareness of an ambulatory senior population is a unique opportunity for pharmacists to provide wellness services for seniors.

Prevalence of Low Low-Density Lipoprotein Cholesterol With Elevated High Sensitivity C-Reactive Protein in the U.S.: Implications of the JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) Study

We assessed the prevalence of low-density lipoprotein-cholesterol (LDL-C) <130 mg/dl with elevated high-sensitivity C-reactive protein (hsCRP) in the National Health And Nutrition Examination Survey (NHANES), weighted to be representative of the general U.S. population. Rosuvastatin therapy in the JUPITER (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) study reduced cardiovascular events among older adults with LDL-C <130 mg/dl and hsCRP > or =2 mg/l. Using 1999 to 2004 NHANES data, we categorized men age > or =50 years and women age > or =60 years by fasting LDL-C and hsCRP levels, excluding individuals with prevalent coronary heart disease, coronary heart disease equivalent (including diabetes), and other JUPITER exclusions. A total of 3.9 million men age > or =50 years and 2.6 million women age > or =60 years meeting JUPITER eligibility criteria had fasting LDL-C <130 mg/dl and hsCRP > or =2 mg/l. In addition, 6.7 million older adults with elevated hsCRP > or =2 mg/l have LDL-C levels that exceed their National Cholesterol Education Program goals. Extrapolating JUPITER eligibility to NHANES, an estimated 6.5 million additional adults could be potential candidates to initiate statin therapy.

Seasonal Variation in Lipids in Patients Following Acute Coronary Syndrome on Fixed Doses of Pravastatin (40 mg) or Atorvastatin (80 mg) (from the Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis In Myocardial Infarction 22 [PROVE IT-TIMI 22] Study)

Previous studies have shown seasonal variation in lipids. To understand whether this variation exists in patients with acute coronary syndromes receiving statins, we examined data from the PROVE IT-TIMI 22 Study. At baseline, no significant difference in low-density lipoprotein (LDL) cholesterol was observed when stratified by season. However, a statistically significant difference in high-density lipoprotein cholesterol between winter (37 mg/dl) and summer (39 mg/dl) was observed (p <0.001) at baseline. On treatment, median LDL cholesterol was 102 mg/dl in winter versus 96 mg/dl in summer (p <0.001) for the pravastatin group and 68 mg/dl in winter versus 62 mg/dl in summer (p <0.001) for the atorvastatin group. Median high-density lipoprotein cholesterol was 43 mg/dl in summer versus 41 mg/dl in winter in the pravastatin group and 42 mg/dl in summer versus 39 mg/dl in winter in the atorvastatin group (p <0.001). More patients achieved LDL cholesterol <100 mg/dl in summer at 56% versus 47% in winter in the pravastatin group (p <0.001) and 89% versus 87% in winter for the atorvastatin group (p = 0.11). Achievement of LDL cholesterol <70 mg/dl was also higher in summer than winter. In conclusion, this was the first evidence of seasonal variability in cholesterol in patients with acute coronary syndromes treated with statins. This variability affected achievement of National Cholesterol Education Program goals and may affect management decisions based on season of collection.

Benefits of the MEDPED treatment support program for patients with familial hypercholesterolemia

Patients with heterozygous familial hypercholesterolemia (FH) patients often have difficultly achieving National Cholesterol Education Program (NCEP) goals. Herein we present an evaluation of a centrally located, nationwide treatment support program that remotely attempted to educate and guide FH patients by monitoring their serum low-density lipoprotein (LDL) cholesterol levels and giving appropriate treatment recommendations through mail contact. All subjects were FH patients registered with the Make Early Diagnosis to Prevent Early Deaths (MEDPED) program. In this descriptive evaluation, we compared self-reported lipid levels in 386 FH patients participating in our treatment support program with 295 non-participants who had responded to questionnaires. Participants were recruited into the treatment support program if they had not reached their LDL cholesterol goal after at least 1 year of follow-up and were unable to receive specialized lipid care due to location. Participants who continued for a longer term in the treatment support program achieved greater total cholesterol reductions (14%) than the comparison group (7%, P=.004). Reductions in total and LDL cholesterol were highly correlated with more aggressive use of statin medications (P <.0001). These results demonstrate the potential benefits and limitations of a centralized program operating remotely to encourage appropriate treatment of severe hypercholesterolemia.

Rosuvastatin reduces non–high-density lipoprotein cholesterol and lipoprotein remnants in patients with dysbetalipoproteinemia (Fredrickson type III hyperlipoproteinemia)

Dysbetalipoproteinemia is an uncommon genetic disorder characterized by accumulation of plasma remnant lipoproteins, severe mixed dyslipidemia, elevated apolipoprotein E levels, accelerated atherosclerosis, and premature cardiovascular disease. To evaluate the efficacy and safety of rosuvastatin in patients with dysbetalipoproteinemia. Following a 6-week washout, 32 patients with dysbetalipoproteinemia received rosuvastatin 10 mg, rosuvastatin 20 mg, and pravastatin 40 mg, each for 6 weeks in a randomized, double-blind, three-way crossover design. Patients subsequently entered an 18-week open-label phase in which the rosuvastatin dosage could be increased from 20 mg to a maximum of 40 mg at 6 weekly intervals to reach National Cholesterol Education Program goals for non-high-density lipoprotein cholesterol (non-HDL-C) and optimal triglyceride (TG). Fibrates (except gemfibrozil) could be added if patients were not at goal on rosuvastatin 40 mg. The primary efficacy variable was percent change from baseline in non-HDL-C during the double-blind phase. The prespecified efficacy criterion was for the 95% confidence interval (CI) of non-HDL-C to lie entirely below -25% for any rosuvastatin dose. Following drug washout, median total cholesterol was 8.86 mmol/L, non-HDL-C 7.61 mmol/L, and TG 5.69 mmol/L. After 6-week treatment, median change in non-HDL-C was -48.2% (95% CI -56.7% to -45.6%) for rosuvastatin 10 mg, -56.4% (95% CI -61.4% to -48.5%) for rosuvastatin 20 mg, and -35.1% (95% CI -41.6% to -29.6%) for pravastatin 40 mg. Rosuvastatin increased HDL-C and apolipoprotein A-I and substantially reduced total, very low-, intermediate-, and low-density lipoprotein cholesterol and TG, and corresponding apolipoproteins. Efficacy was maintained in the open-label phase, with reduction in non-HDL-C of -61.5%, -62.8% and -65.8% at weeks 24, 30 and 36, respectively. All treatments were well tolerated. Rosuvastatin 10 and 20 mg favorably modify the dyslipidemia of patients with dysbetalipoproteinemia.

Niacin Extended-Release/Simvastatin

Niacin extended-release (ER)/simvastatin is a once-daily, fixed-dose combination of the HMG-CoA reductase inhibitor simvastatin and an ER formulation of niacin (a B-complex vitamin). In healthy volunteers who were given niacin ER/simvastatin 2000 mg/40 mg, niacin exposure was similar to that with niacin ER 2000 mg, while simvastatin exposure was increased compared to that with simvastatin 40 mg. In patients with elevated non-high-density lipoprotein cholesterol (non-HDL-C) but with low-density lipoprotein cholesterol (LDL-C) at or below the National Cholesterol Education Program (NCEP) goal after a > or = 2-week simvastatin 20 mg/day run-in period (SEACOAST I), 24 weeks of niacin ER/simvastatin 1000 mg/20 mg or 2000 mg/20 mg per day reduced median plasma non-HDL-C levels to a significantly greater extent than simvastatin 20 mg/day. In patients with elevated non-HDL-C and LDL-C at any level after a > or = 2-week simvastatin 40 mg/day run-in period (SEACOAST II), 24 weeks of niacin ER/simvastatin 1000 mg/40 mg or 2000 mg/40 mg per day was noninferior to simvastatin 80 mg/day in reducing median plasma non-HDL-C levels. Compared with simvastatin monotherapy, there was no significant difference in reduction in plasma LDL-C levels with niacin ER/simvastatin in SEACOAST I, and the noninferiority criterion for LDL-C was not met in SEACOAST II. However, plasma HDL-C levels increased more and triglyceride levels were lowered more than with simvastatin monotherapy (SEACOAST I and II). Niacin ER/simvastatin was generally well tolerated, with flushing being the most common adverse reaction.

Achievement of National Cholesterol Education Program Goals by Patients With Dyslipidemia in Rural Ambulatory Care Settings

The Third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program provides guidelines for managing dyslipidemia; however, studies from large centers find that most dyslipidemic patients fail to achieve management goals. Few data exist on lipid management in rural settings. To determine the proportion of rural dyslipidemic patients achieving ATP III goals, records of 461 patients were reviewed from 4 practices. Only 54% of the patients with dyslipidemia achieved ATP III goals. Patients with diabetes or with a family history of premature coronary heart disease were less likely to achieve ATP III goals (odds ratio 0.56; 95% confidence interval, 0.38-0.84 and odds ratio 0.42; 95% confidence interval, 0.25-0.71, respectively). Patients taking statins were more likely to achieve goals (odds ratio 3.23; 95% confidence interval, 2.13-4.89). These results indicate that a significant proportion of patients with dyslipidemia in rural practices do not achieve management goals. Strategies to improve lipid management in rural practices are needed.

Effect of Rosuvastatin Compared with Other Statins on Lipid Levels and National Cholesterol Education Program Goal Attainment for Low-Density Lipoprotein Cholesterol in a Usual Care Setting

To compare, in a usual care setting, the effects of rosuvastatin and other 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) on lipid levels and on goal attainment of low-density lipoprotein cholesterol (LDL) levels from the National Cholesterol Education Program (NCEP) third report of the Adult Treatment Panel (ATP III). Retrospective, longitudinal, cohort study. Managed care medical and pharmacy claims and laboratory database. A total of 8251 patients starting treatment with rosuvastatin, atorvastatin, simvastatin, pravastatin, lovastatin, or fluvastatin from August 1, 2003-September 30, 2004, excluding those who received dyslipidemic therapy in the previous 12 months. Patients with at least one pretreatment and posttreatment lipid level were followed until their initial statin was changed or they reached the end of benefit eligibility or the study period. Percent changes in lipid levels were calculated, and adjusted changes in LDL and goal attainment were evaluated by regression techniques. Absolute and percent reductions in LDL, triglyceride, and total cholesterol levels were significantly greater with rosuvastatin than with other statins (all p<0.05 except for triglyceride reduction vs atorvastatin). After adjustment for age, sex, and baseline LDL, percent LDL reductions still were significantly greater with rosuvastatin than with other statins (p<0.05). Changes in high-density lipoprotein cholesterol were not significant. Goal attainment was higher with rosuvastatin than with other statins after adjustment for age, sex, baseline LDL, risk status, dose, and duration of therapy (p<0.05). Dose-stratified analysis showed that LDL goal attainment was significantly higher with rosuvastatin 10 mg than with atorvastatin 10 or 20 mg. Rosuvastatin was more effective than other statins in reducing LDL, triglyceride (except vs atorvastatin), and total cholesterol levels. Significantly more patients taking rosuvastatin than patients taking other statins attained their LDL goals.

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

The United States' National Cholesterol Education Program (NCEP) Adult Treatment Panel III and the Canadian Working Group on Hypercholesterolemia and Other Dyslipidemias (CWG) have each issued guidelines for the treatment of dyslipidemia. The present analysis compared the percentage of patients reaching target lipid levels according to NCEP and CWG guidelines among participants of the NCEP Evaluation ProjecT Utilizing Novel E-technology (NEPTUNE) II, a survey performed in the United States. American physicians who were high prescribers of lipid-modifying medications (n=376) each enrolled 10 to 20 consecutive patients from February to September 2003. Medical information, laboratory measurements and treatment plans associated with a single office visit were entered into a personal digital assistant and uploaded to a central database via the Internet. Under both sets of guidelines, treatment success was strongly related to risk category (P<0.001). Treatment goal achievement in the low-risk (zero or one risk factor) and moderate-risk (two or more risk factors) categories was not substantially different between NCEP and CWG guidelines; however, in the high-risk category (coronary artery disease [CAD] and risk equivalents [RE]), CWG treatment goals were met less frequently than NCEP goals. NCEP combined low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol treatment goals were met by 39% of hypertriglyceridemic patients (27% in the CAD + CAD RE category). CWG combined low-density lipoprotein cholesterol and total cholesterol/high-density lipoprotein cholesterol ratio treatment goals were met by 38% of hypertriglyceridemic patients (19% in the CAD + CAD RE category). These data indicate substantial underachievement of treatment goals by patients at high risk under both the CWG and NCEP guidelines. The lower frequency of treatment success in high-risk patients according to the CWG definition indicates that more aggressive treatment is needed to reach CWG goals.

Implications of changing national cholesterol education program goals for the treatment and control of hypercholesterolemia

Implications of changing national cholesterol education program goals for the treatment and control of hypercholesterolemia

Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia

Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia

Evaluation of the VITROS® chemistry products dHDL slides for direct measurement of high density lipoprotein cholesterol

Background We evaluated the new VITROS direct high density lipoprotein cholesterol (dHDL) slide assay, based on the precipitation of apolipoprotein B-containing lipoproteins by phosphotungstic acid/magnesium chloride (PTA/MgCl 2). Methods We determined linearity, within-run and between-run imprecision for the VITROS dHDL slide assay, and compared it to the RANDOX two-step PTA/MgCl 2 method for 300 fresh sera. Moreover, triglyceride and cholesterol interference were tested. Results The VITROS dHDL slide assay was linear from 0 to 3.13 mmol/l. Within-run and between-run imprecision were 1.6%, 1.8%, 3.3% and 3.2% for target values at 1.00 and 1.40 mmol/l, respectively. For 300 fresh serum samples, the linear regression equation between the VITROS dHDL slide assay ( y) and the RANDOX PTA/MgCl 2 2 method ( x) was: y (mmol/l) = 0.934 x + 0.043 (CI = 0.916–0.952 for slope and 0.017–0.069 for intercept) . The bias of the VITROS assay compared to the RANDOX PTA/MgCl 2 method was less than 5% for HDL cholesterol concentrations used for medical decision (1.04 and 1.50 mmol/l). Total error remained below 13% for triglyceride and LDL cholesterol concentrations below 6.6 mmol/l. Conclusion The VITROS dHDL slide assay is rapid, linear over a broad range of concentrations, and satisfies the National Cholesterol Education Program goals for precision and accuracy.

Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia

Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia

Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia

Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia

Implications of Changing National Cholesterol Education Program Goals for the Treatment and Control of Hypercholesterolemia

Modifications to the National Cholesterol Education Program (NCEP) guidelines lowered optional low-density lipoprotein cholesterol (LDL-C) treatment goals. We evaluated the implications of widely adopting these optional goals in clinical practice. We performed a cross-sectional study using 1999 to 2002 data from 3,281 U.S. adults aged 20 to 79 years participating the National Health and Nutrition Examination Survey. The primary outcomes were the proportions of adults whose fasting LDL-C levels exceeded NCEP recommended and optional targets from 2001 and 2004. We used survey weights to estimate the size of the U.S. population exceeding targets. We examined outcomes for 4 coronary disease risk subgroups described by the NCEP. Low-density lipoprotein cholesterol values exceeded 2001 NCEP goals for 30.0% of adults, and 35.8% had levels above optional 2004 goals. An estimated 24,900,000 individuals (14.2%) exceeded 2001 thresholds for drug therapy, 46,200,000 (26.3%) exceeded optional 2001 thresholds for drug therapy, and 56,500,000 (32.2%) were above the optional 2004 thresholds for drug therapy. For lower, moderate, moderately high, and high-risk groups, 13.4%, 44.2%, 58.8%, and 71.8%, respectively, exceeded 2001 NCEP goals; 13.4%, 15.7%, 87.4%, and 96.0% of these groups exceeded optional 2004 thresholds for drug therapy. In 1999 to 2002, LDL-C levels commonly exceeded 2001 NCEP goals, especially for moderately high and high-risk individuals, and cholesterol-lowering medications were underused. Optional goals promulgated by the NCEP in 2001 and 2004 moderately increased the number of adults with LDL-C above their goal, and greatly increased the number of low, moderately high, and high-risk adults who exceeded LDL-C thresholds, for cholesterol-lowering medication.

Clinical profile and outcomes of diabetic and nondiabetic patients in cardiac rehabilitation

Patients with diabetes mellitus have increased risk of cardiovascular disease; however, there are limited data addressing cardiac rehabilitation in these patients. This study assessed the effectiveness of participation in cardiac rehabilitation on clinical outcomes after myocardial infarction and/or revascularization procedures in diabetic and nondiabetic patients. Analysis on 1505 patients completing a minimum of 7 weeks of a 12-week cardiac rehabilitation program included fasting lipid profile and glucose, body mass index, and metabolic equivalent time in patients with diabetes (n = 292) and without diabetes (n = 1213). There were significant improvements in total cholesterol, low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) in each group after cardiac rehabilitation. Diabetic women and nondiabetic men had the greatest improvement in HDL-C, with an improvement of 4.9% in diabetic women (P = .02) and an improvement of 4.1% in nondiabetic men (P < or = .0001). On completion of cardiac rehabilitation, both diabetic and nondiabetic patients were at National Cholesterol Education Program Adult Treatment Panel III goals in total cholesterol, LDL-C, HDL-C, and triglycerides at a higher rate. However, patients with diabetes did not reach National Cholesterol Education Program goals for HDL-C, total cholesterol, and triglycerides as effectively as nondiabetic patients. Exercise capacity improved by 28.1% in diabetic patients after cardiac rehabilitation (P < .0001). Improvement in outcomes in the patients with diabetes occurred without significant change in body mass index. These results suggest that participation in a comprehensive cardiac rehabilitation program integrates care of patients with chronic conditions such as diabetes to achieve comparable cardiac risk factor reduction as achieved with nondiabetic patients.