National Cholesterol Education Program Recommendations Research Articles

Reducing Lipid Panel Error Allowances to Improve the Accuracy of Cardiovascular Risk Stratification.

The standard lipid panel forms the backbone of atherosclerotic cardiovascular disease risk assessment. Suboptimal analytical performance, along with biological variability, could lead to erroneous risk assessment and management decisions. The current National Cholesterol Education Program (NCEP) performance recommendations have remained unchanged for almost 3 decades despite improvements in assay technology. We investigated the potential extent of risk misclassification when the current recommendations are met and explored the impact of improving analytical performance goals. We extracted lipid panel data for 8506 individuals from the NHANES database and used these to classify subjects into 4 risk groups as recommended by the 2018 US Multisociety guidelines. Analytical bias and imprecision, at the allowable limits, as well as biological variability, were introduced to the measured values to determine the impact on misclassification. Bias and imprecision were systematically reduced to determine the degree of improvement that may be achieved. Using the current performance recommendations, up to 10% of individuals were misclassified into a different risk group. Improving proportional bias by 1%, and fixing imprecision to 3% across all assays reduced misclassifications by up to 10%. The effect of biological variability can be reduced by taking the average of serial sample measurements. The current NCEP recommendations for analytical performance of lipid panel assays allow for an unacceptable degree of misclassification, leading to possible mismanagement of cardiovascular disease risk. Iteratively reducing allowable error can improve this.

Preventive Cardiology

Key Points The etiology of premature cardiovascular disease in children is multifactorial Hypocholesteremia Obesity/lack of physical activity Smoking The goals of preventive cardiology are to Prevent, identify, and treat potential atherosclerotic cardiac risk factors. Educate children and families on preventive strategies. Intervene early to decrease the burden of atherosclerotic heart disease in adult life. The American Heart Association and American Academy of Pediatrics have proposed a risk stratification and treatment algorithm for children at increased risk for premature coronary heart disease. The National Cholesterol Education Program recommends 2 separate approaches to managing hypercholesterolemia in children. Broad, population-based approach Iindividualized patient approach

Increased statin eligibility based on ACC/AHA versus NCEP guidelines for high cholesterol management in Chile

In 2013, the American College of Cardiology and the American Heart Association (ACC/AHA) jointly released new guidelines for cardiovascular risk assessment and cholesterol management that substantially modified the previous recommendations proposed by the National Cholesterol Education Program (NCEP) in 2001. The relative impact of these new guidelines on potential statin use has not been estimated in Latin American populations. To estimate and compare eligibility for statin therapy based on ACC/AHA and NCEP guidelines in adult Chilean population. Using data from the last National Health Survey (2009-2010 NHS), we conducted a cross-sectional analysis in a ​representative sample of the Chilean adult population and calculated the proportion of individuals that would receive statins under each set of guidelines. According to ACC/AHA guidelines, the population eligible for statin treatment increased from 21.7% (NCEP guidelines) to 33.2% (overall 53% increase). This effect was more pronounced among women (29.6% under ACC/AHA vs 15.6% under NCEP) and with those of advanced age (75% of the subjects >60 years of age compared with 46% under NCEP). The newly eligible group included more women and older subjects and individuals with lower LDL cholesterol levels. Compared with NCEP recommendations, the new ACC/AHA guidelines significantly increased the number of Chilean adults eligible for statin therapy. Full implementation of the new recommendations may have important public health implications in Chile and other Latin American countries, as more women and older subjects without cardiovascular disease would qualify for statin treatment.

Prediabetes: A Prevalent and Treatable, but Often Unrecognized, Clinical Condition

Type 2 diabetes mellitus (T2DM) affects more than 8% of the United States population.1 The onset of T2DM is gradual, with most individuals progressing through a state of pre-diabetes which is defined as impaired fasting glucose (IFG; plasma glucose of 100–125 mg/dl or 5.6–6.9 mmol/l) and/or impaired glucose tolerance (IGT; plasma glucose of 140–199 mg/dl or 7.8–11.0 mmol/l 2h after an oral load of 75g dextrose) and/or hemoglobin A1C 5.7–6.4%.2 According to a study of a nationally representative sample (n =1,547), an estimated 35% of the United States population suffers from pre-diabetes: 19% have IFG only, 5% have IGT only, and 10% have both IFG and IGT.3 Although individuals can spend years in a pre-diabetic state, an expert American Diabetes Association (ADA) panel estimated that up to 70% will eventually progress to T2DM.4 However, not all individuals with pre-diabetes progress at the same rate. A meta-analysis of prospective cohort studies showed that the annual incidence of diabetes in people with IGT, IFG, or both was 6.1%, 7.0%, and 14.0% respectively.5 The diagnosis of pre-diabetes presents healthcare providers with an opportunity to identify patients at increased risk for T2DM and to implement interventions that can delay or prevent T2DM and its complications.4 Unfortunately, this opportunity is often unrecognized, as an analysis of a nationally representative sample of patients with pre-diabetes (n=584) concluded that only 31.7%, 33.4%, 25.9% had been counseled about exercise, diet, or both, respectively by a doctor or health professional.3 Possible reasons for not counseling patients include lack of reimbursement, lack of resources, lack of time, and lack of skill.6, 7 However, individuals who have been counseled by their health-care provider to adopt a healthy lifestyle reported greater adherence to weight control and diet modification and had lower low density lipoprotein (LDL) cholesterol, lower body mass index (BMI), and higher high density lipoprotein (HDL) cholesterol.8 Still, it is unclear whether counseling sessions by a primary care provider in the outpatient setting are correlated with improvements in fasting plasma glucose in patients with pre-diabetes compared to similar patients who have not been counseled. While there is some evidence to suggest lifestyle counseling may be associated with self-reported changes in lifestyle behavior in overweight and obese adults with pre-diabetes and diabetes,9 other data suggest that lifestyle intervention programs that have been implemented in the outpatient healthcare setting have had an insignificant impact on fasting plasma glucose.6 Nevertheless, according to ADA guidelines there is clear evidence to support providing medical nutrition therapy as needed to patients with pre-diabetes.10 Given the high prevalence of pre-diabetes, it is important to understand the basic underlying pathophysiology and how lifestyle interventions can be implemented in the clinical setting to reduce a patient’s risk for developing T2DM.

Fenofibric acid for hyperlipidemia

Introduction: 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (i.e., statins) are the mainstay of therapy for hyperlipidemia, as per the current National Cholesterol Education Program (NCEP) recommendation. However, the role of other agents, such as the fibrates, is continually being debated in the context of incremental risk reduction, especially in the setting of mixed dyslipidemia. Results from the ACCORD Trial have further added to the confusion. Fibrates also have a role to play in familial hyperlipidemias and in hypertriglyceridemia. Fenofibric acid is one of the newly approved forms of fenofibrate with enhanced bioavailability and was recently approved by the Food and Drug Administation (FDA) for the treatment of various types of hyperlipidemia, in conjunction with statins.Areas covered: This article reviews the role of fenofibric acid in the context of results from recent randomized trials on fenofibrate, including the ACCORD Trial. It discusses the current status of fenofibric acid in the management of dyslipidemia, especially in combination with statins, and also addresses the comparative efficacy and safety profile of this new molecule against other agents in its class.Expert opinion: fenofibric acid in combination with low- to moderate-dose statins is an effective and safe option in the treatment of mixed dyslipidemia, although the long-term effects on cardiovascular risk reduction need to be explored further.

A Message from the Laboratory Community to the National Cholesterol Education Program Adult Treatment Panel IV

The National Cholesterol Education Program (NCEP)5. Adult Treatment Panel IV (ATP IV) is poised to release its guidelines on the detection, evaluation, and treatment of high blood cholesterol in adults for comments by the scientific and medical communities. We briefly summarize the current status of lipid and lipoprotein testing in the US. Since its inception in 1985, the NCEP has recognized the value of accurate and precise lipid and lipoprotein testing for the effective implementation of its mission to lower morbidity and mortality from coronary heart disease in the US by reducing the percentage of Americans with high blood cholesterol. The NCEP Laboratory Standardization Panel and the Working Group on Lipoprotein Measurement were established to assess the status of lipid and lipoprotein testing, develop means to improve these measurements, and create analytical performance goals to meet clinical needs. This program provided a comprehensive approach to the measurement of total cholesterol, triglycerides, HDL cholesterol (HDL-C) and LDL cholesterol (LDL-C). The recommendations developed by this panel and working group were based on data and information generated by the CDC Lipid Standardization Program. The latter program also helped in implementing the NCEP recommendations by providing for standardization of lipid measurements performed for patient care and ensuring accurate measurements in research studies (1, 2). The resulting improvements in the accuracy and precision of these laboratory measurements allowed the effective implementation of NCEP guidelines and enabled the monitoring of its success (3, 4). In the 1980s and 1990s, clinical laboratories measured HDL-C by precipitating apolipoprotein B containing lipoproteins and assaying the cholesterol component of HDL in the supernatant. LDL-C concentrations were estimated with the Friedewald calculation (5). Laboratory methods have evolved over the past 2 decades, and according to a recent College of American Pathologists (CAP) survey, nearly all clinical …

Dietary Intake of Participants With Peripheral Artery Disease and Claudication

We compared the dietary intake of participants with peripheral artery disease (PAD) and claudication with diet recommendations of the National Cholesterol Education Program (NCEP) and dietary reference intake values recommended by the Institute of Medicine (IOM) of the National Academy of Sciences. Forty-six participants consumed a mean macronutrient composition of 17% protein, 51% carbohydrate, and 30% fat. Compared to the NCEP and IOM recommendations, few participants met the recommended daily intake for sodium (0%), vitamin E (0%), folate (13%), saturated fat (20%), fiber (26%), and cholesterol (39%). Participants with PAD and claudication have poor nutrition, with diets particularly high in saturated fat, sodium, and cholesterol, and low in fiber, vitamin E, and folate intakes. Participants should be encouraged to reduce consumption of dietary fat, saturated fat, cholesterol, and sodium and to increase fiber and vitamin intakes to meet recommendations of the NCEP and IOM.

Evaluation of the Lipid Panel on the Abaxis Piccolo Xpress to Determine Its Potential as a Point-of-Care Instrument in a Nonlaboratory Setting

Cardiovascular disease is the largest cause of mortality in Australia, accounting for 34% and 39% of male and female deaths, respectively. Hyperlipidemia is a modifiable risk factor for cardiovascular disease. The National Cholesterol Education Program (NCEP) has published recommendations for analytical performance targets for lipid analysis. These guidelines set targets for allowable bias, imprecision, and total analytical error. We evaluated the lipid panel on the Piccolo Xpress point-of-care instrument (Abaxis, Union City, Calif) for the measurement of total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride levels. All 3 tests concurred with NCEP recommendations for bias and total analytical error. Imprecision was acceptable for total cholesterol and triglycerides, but HDL cholesterol exceeded the recommendations. However, this differs from the HDL cholesterol precision analysis performed by Abaxis that produced precision results within the NCEP guidelines. This may better reflect the true imprecision of the Piccolo Xpress owing to the much higher number of replicate tests performed compared with our study, which was limited by the number of disks available. Results of this study suggest that the Abaxis Piccolo Xpress is a suitable point-of-care instrument to use in nonlaboratory settings for lipid analysis.

Validation of reported physical activity for cholesterol control using two different physical activity instruments

The National Cholesterol Education Program recommends increasing physical activity to improve cholesterol levels and overall cardiovascular health. We examined whether US adults who reported increasing their physical activity to control or lower blood cholesterol following physician's advice or on their own efforts had higher levels of physical activity than those who reported that they did not. We used data from the National Health and Nutrition Examination Survey 2003-2004, which implemented two physical activity assessment instruments. The physical activity questionnaire (PAQ) assessed self-reported frequency, intensity, and duration of leisure-time, household, and transportation-related physical activity in the past month. Physical movement was objectively monitored using a waist accelerometer that assessed minute-by-minute intensity (counts of movement/minute) during waking time over a 7-day period. We adjusted our analysis for age, gender, race/ethnicity, educational attainment, and body mass index. Participants who reported increasing physical activity to control blood cholesterol had more PAQ-assessed physical activity and more accelerometer-assessed active days per week compared to those who did not. However, there were no significant differences in cholesterol levels between comparison groups. These findings suggest that self-report of exercising more to control or lower cholesterol levels among US adults might be valid.

Validation of the MEDFICTS Dietary Assessment Questionnaire in a Diverse Population

The National Cholesterol Education Program (NCEP) recommends MEDFICTS, a rapid screening instrument for dietary fat, to assess adherence to the Adult Treatment Panel (ATP) III Therapeutic Lifestyle Changes (TLC) diet (score <40 points indicates intake of <7% of energy from saturated fat, <30% of energy from total fat, and <200 mg dietary cholesterol/day). MEDFICTS has only been validated in small, select populations and its utility in diverse clinical settings is unknown. To evaluate the ability of MEDFICTS to identify individuals who are nonadherent to a TLC diet in an ethnically diverse population that includes both English- and Spanish-speakers. MEDFICTS was administered concurrently with the Gladys Block Food Frequency Questionnaire to participants (n=501; mean age 48+/-13.5 years; 36% nonwhite; 66% female) in the National Heart, Lung, and Blood Institute Family Intervention Trial for Heart Health (FIT Heart) at the baseline screening visit. Reliability and validity analyses were conducted overall and by sex, age, and race/ethnicity. MEDFICTS score correlated significantly with percentage of energy from saturated fat (r=0.52, P<0.0001), percentage of energy from total fat (r=0.31, P<0.0001), and milligrams per day of dietary cholesterol (r=0.54, P<0.0001). Sensitivity of MEDFICTS to correctly identify TLC diet adherence was 85.7% and did not differ significantly by sex, age, or race/ethnicity. Specificity of MEDFICTS to correctly identify nonadherence to the TLC diet was low (56.9%) and significantly worse for women than men (48.4% vs 72.9%; P<0.0001), but did not differ significantly in older vs younger participants or among white, black, or Hispanic participants. Our data suggest that sex-specific recalibration of MEDFICTS may improve specificity and clinical utility.

Abstract 2372: Validity of the MEDFICTS Dietary Assessment Questionnaire in a Diverse Population

Background: The National Cholesterol Education Program (NCEP) recommends MEDFICTS, a rapid dietary fat screening instrument, for assessment of adherence to the Adult Treatment Panel (ATP) III Therapeutic Lifestyle Change (TLC) diet (Score &lt; 40 points = &lt; 7% of calories from saturated fat, &lt;30% of calories from total fat, and &lt;200mg dietary cholesterol/day). MEDFICTS has only been validated in small, select populations and its utility in diverse clinical settings is unknown. The purpose of this study was to evaluate the ability of MEDFICTS to identify individuals non-adherent to a TLC diet against a gold standard in an ethnically diverse population. Methods: MEDFICTS was administered concurrently with the Gladys Block Food Frequency Questionnaire to participants (n=470; 35% non-white; 66% female; mean age 48.1 ± 13.6y) in the NHLBI F amily I ntervention T rial for Heart Health ( F.I.T. Heart ) at the baseline screening visit. Correlation, agreement, sensitivity and specificity analyses were conducted overall and by sex, age, and race/ethnicity. Results: MEDFICTS score correlated significantly with % calories from saturated fat (r=.51, p&lt;.0001), % calories from total fat (r=.30, p&lt;.0001), and mg/day dietary cholesterol (r=.53, p=&lt;.0001). Categorical agreement between MEDFICTS score &lt;40 and Gladys Block on TLC diet adherence was poor overall (κ = 0.07) and for individual TLC components: &lt;7% calories from saturated fat (κ=.12), &lt;30% calories from total fat (κ=.16), &lt;200mg dietary cholesterol per day (κ=.34). Sensitivity of MEDFICTS to correctly identify TLC diet adherence was 84% and did not differ significantly by sex, age, or race/ethnicity. Specificity of MEDFICTS to correctly identify non-adherence to TLC diet was low (57%) and was significantly worse for females than males (48% vs. 74%; p&lt;.0001), but did not differ significantly in older vs. younger participants or among whites and non-whites. Conclusion: The NCEP ATP III MEDFICTS dietary assessment questionnaire performed poorly as a screening tool to correctly identify patients non-adherent to a TLC diet. Our data suggest a re-calibration of the instrument to improve specificity may increase its clinical utility.

Validity of the Framingham point scores in the elderly: Results from the Rotterdam study

The National Cholesterol Education Program recommends assessing 10-year risk of coronary heart disease (CHD) in individuals free of established CHD with the Framingham Point Scores (FPS). Individuals with a risk >20% are classified as high risk and are candidates for preventive intervention. We aimed to validate the FPS in a European population of elderly subjects. Subjects free of established CHD at baseline were selected from the Rotterdam study, a population-based cohort of subjects 55 years or older in The Netherlands. We studied calibration, discrimination (c-index), and the accuracy of high-risk classifications. Events consisted of fatal CHD and nonfatal myocardial infarction. Among 6795 subjects, 463 died because of CHD and 336 had nonfatal myocardial infarction. Predicted 10-year risk of CHD was on average well calibrated for women (9.9% observed vs 10.1% predicted) but showed substantial overestimation in men (14.3% observed vs 19.8% predicted), particularly with increasing age. This resulted in substantial number of false-positive classifications (specificity 70%) in men. In women, discrimination of the FPS was better than that in men (c-index 0.73 vs 0.63, respectively). However, because of the low baseline risk of CHD and limited discriminatory power, only 33% of all CHD events occurred in women classified as high risk. The FPS need recalibration for elderly men with better incorporation of the effect of age. In elderly women, FPS perform reasonably well. However, maintaining the rational of the high-risk threshold requires better performing models for a population with low incidence of CHD.

Hypertriglyceridemia

Hypertriglyceridemia is a commonly encountered lipid abnormality frequently associated with other lipid and metabolic derangements. The National Cholesterol Education Program recommends obtaining a fasting lipid panel in adults over the age of 20. The discovery of hypertriglyceridemia should prompt an investigation for secondary causes such as high fat diet, excessive alcohol intake, certain medications, and medical conditions (eg, diabetes mellitus, hypothyroidism). In addition, patients should be evaluated for other components of the metabolic syndrome. These include abdominal obesity, insulin resistance, low high-density lipoprotein (HDL), high triglyceride, and hypertension. Hypertriglyceridemia is classified as primary hypertriglyceridemia when there are no secondary causes identified. Primary hypertriglyceridemia is the result of various genetic defects leading to disordered triglyceride metabolism. It is important to treat hypertriglyceridemia to prevent pancreatitis by reducing triglyceride levels to <500 mg/dL. Furthermore, lowering triglycerides while treating other dyslipidemias and components of the metabolic syndrome will reduce coronary events. However, it is controversial how much isolated hypertriglyceridemia correlates directly with coronary artery disease and further studies are needed to clarify whether treatment for this condition leads to meaningful clinical outcomes. Therapeutic lifestyle changes (TLC) are the first line of treatment for hypertriglyceridemia. These changes include a low saturated fat, carbohydrate-controlled diet, combined with alcohol reduction, smoking cessation, and regular aerobic exercise. High doses of omega-3 fatty acids from fish and fish oil supplements will lower triglyceride levels significantly. When patients do not reach their goals by TLC, drug therapy should be started. In cases of isolated hypertriglyceridemia, fibrates are initially considered. When elevated low-density lipoprotein levels accompany hypertriglyceridemia, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors are preferred. In patients with low HDL levels and hypertriglyceridemia, extended release niacin can be considered. A combination of the medicines may be necessary in recalcitrant cases.

Not Much Evidence for Specific LDL Targets

The National Cholesterol Education Program recommends titrating lipid-lowering therapy to reduce LDL cholesterol to very low levels. For example, the goal is less than 70 mg/dL in people at very high risk for cardiovascular events. Because the strength of the evidence supporting the recommendation has been …

Should all patients with metabolic syndrome be treated with statins?

The metabolic syndrome is a constellation of cardiovascular risk factors that include atherogenic dyslipidemia, elevated blood pressure, abdominal/truncal obesity, and glucose intolerance. Current National Cholesterol Education Program (NCEP) recommendations for specific treatment of the metabolic syndrome are centered on therapeutic lifestyle changes. A recent publication from the NCEP Adult Treatment Panel III suggests pharmacologic intervention for parameters of metabolic syndrome, including dyslipidemia, hypertension, and hyperglycemia, to prevent cardiovascular disease, based on risk category. This review looks at the clinical trial evidence to support the use of statins in metabolic syndrome.

Comparative Safety of Atorvastatin 80 mg Versus 10 mg Derived from Analysis of 49 Completed Trials in 14,236 Patients

Atorvastatin has been shown to reduce coronary events and revascularization procedures in patients with multiple risk factors for coronary heart disease. Recent studies with atorvastatin 80 mg support the overall safety of this dose during long-term treatment. However, physicians appear reluctant to use high doses of statins. A retrospective analysis of pooled data from 49 clinical trials of atorvastatin in 14,236 patients treated for an average period of 2 weeks to 52 months was conducted. The study compared the safety of atorvastatin 10 mg (n = 7,258), atorvastatin 80 mg (n = 4,798), and placebo (n = 2,180) and included analyses on treatment-associated adverse events; nonserious and serious adverse events related to the musculoskeletal, hepatic, and renal systems; the incidence of elevations of creatine kinase >10 times the upper limit of normal (ULN); and hepatic transaminases >3 times ULN. Percentages of patients experiencing > or =1 adverse event were similar across all 3 groups. Withdrawals due to treatment-related adverse events were observed in 2.4%, 1.8%, and 1.2% of patients in the atorvastatin 10 mg, atorvastatin 80 mg, and placebo groups, respectively. Serious adverse events were rare and seldom led to treatment withdrawal with any dose. Treatment-associated myalgia was observed in 1.4%, 1.5%, and 0.7% of patients in the atorvastatin 10 mg, atorvastatin 80 mg, and placebo groups, respectively. No cases of rhabdomyolysis were reported in any group. Persistent elevations in hepatic transaminases >3 times ULN were observed in 0.1%, 0.6%, and 0.2% of patients in the atorvastatin 10 mg, atorvastatin 80 mg, and placebo groups, respectively. The incidence of treatment-associated adverse events for atorvastatin 80 mg was similar to that of atorvastatin 10 mg and placebo. In conclusion, the results of this analysis support the positive safety profile of atorvastatin at the highest dose.

Statins and cognitive function in the elderly

To examine the association of statin drug use on cognitive and MRI change in older adults. Participants in the Cardiovascular Health Study, a longitudinal study of people age 65 or older, were classified into three groups determined by whether they were taking statin drugs on a continuous basis, intermittently, or not at all. The untreated group was further divided into categories based on National Cholesterol Education Program recommendations for lipid-lowering treatment. Participants with prevalent or incident clinical TIA or stroke or with baseline Modified Mini-Mental State Examination (3MS) scores at or below 80 were excluded. Outcomes examined included rate of change on the 3MS over an average observational period of 7 years, along with changes in MRI white matter grade and measures of atrophy. Three thousand three hundred thirty-four participants had adequate data for analysis. At baseline, the untreated group in which lipid-lowering drug treatment was recommended were slightly older, less likely to be on estrogen replacement, and had higher serum cholesterol and lower 3MS scores than the statin-treated group. The rate of decline on the 3MS was 0.48 point/year less in those taking statins compared with the untreated group for which treatment was recommended (p = 0.069) and 0.49 point/year less in statin users compared with the group in which lipid-lowering treatment was not recommended (p = 0.009). This effect remained after controlling for serum cholesterol levels. One thousand seven hundred thirty participants with baseline 3MS scores of > 80 underwent cranial MRI scans on two occasions separated by 5 years. There was no significant difference in white matter grade change or atrophy measures between groups. Statin drug use was associated with a slight reduction in cognitive decline in an elderly population. This relationship could not be completely explained by the effect of statins on lowering of serum cholesterol.

The Relationship between Non-HDL Cholesterol and Other Lipid Parameters in Japanese Subjects

Plasma non-HDL cholesterol (HDL-C) concentration that is simply estimated from plasma total cholesterol and HDL-C concentrations, without the influence of plasma triglyceride concentration, has been included as a therapeutic target for hypertriglyceridemic patients in the most recent National Cholesterol Education Program (NCEP) recommendations. In the present study, we estimated plasma non-HDL-C concentration in Japanese subjects to clarify the correlation of plasma non-HDL-C to other plasma lipid concentrations, and to evaluate the NCEP recommendation. Plasma non-HDL-C concentration has a positive correlation with low-density lipoprotein cholesterol (LDL-C) and triglyceride concentrations. From our analysis, 140 mg/dl of plasma LDL-C concentration, which is the level for the diagnosis of hyper-LDL cholesterolemia, corresponds to 169 mg/dl of non HDL-C concentration. The relationship between plasma non-HDL-C and LDL-C concentrations in Japanese subjects is quite similar to that described in the NCEP guideline. Thus, we suggest that non-HDL-C is a useful risk marker in Japan, as recommended by the NCEP.

Follow-up lipid tests and physician visits are associated with improved adherence to statin therapy

The National Cholesterol Education Program recommends regular physician follow-up and lipid testing to promote adherence with lipid-lowering medications. The objective of this study was to determine whether lipid tests and physician visits after treatment initiation are indeed associated with adherence to statin therapy. A retrospective cohort study was conducted among 19 422 enrolees in a US managed care plan who initiated treatment with a statin between October 1999 and August 2001. Computerised pharmacy, medical and laboratory records were used to study the patterns and predictors of adherence with lipid-lowering therapy for up to 3 years. Adherence was assessed in 3-month intervals with patients considered 'adherent' if > or = 80% of days were covered by lipid-lowering therapy. In the first 3 months, 40% of patients had follow-up lipid tests and only 21% had dyslipidaemia visits (14% had both). Those receiving such care were substantially more likely to be adherent in subsequent intervals. Compared with those without follow-up, the relative odds of adherence were 1.42 and 1.27 for patients with one or more lipid test and one or more dyslipidaemia visit, respectively (95% confidence intervals [CI] 1.33, 1.50 and 1.16, 1.39). Patients who received a follow-up visit and lipid test were 45% more likely to be adherent (95% CI 1.34, 1.55). Similar associations were observed when lipid tests and dyslipidaemia visits occurred later in therapy. Early and frequent follow-up by physicians--especially lipid testing--was associated with improved adherence to lipid-lowering therapy. A randomised prospective study is needed to determine whether this relationship is causal.

Problems With the National Cholesterol Education Program Recommendations for Cholesterol Analytical Performance

Problems With the National Cholesterol Education Program Recommendations for Cholesterol Analytical Performance