National Cholesterol Education Project Research Articles

The prevalence of dyslipidemia in patients with spinal cord lesion in Thailand.

Objective. To assess the prevalence of dyslipidemia in 90 patients with spinal cord lesion (SCL) of duration greater than 2 years. The study was carried out from November 2007 to September 2008. Methods. Clinical history, physical examination, and lipid profiles were recorded and analyzed. Dyslipidemia was assessed using guidelines from the National Cholesterol Education Project Adult Treatment Panel III (ATP III). Results. The prevalence of dyslipidemia in at least one lipid parameter was 76.7%. The most frequent finding was low HDL-C (58.9%). Hypertriglyceridemia, hypercholesterolemia and high LDL-C were found in 28.9%, 26.7% and 21.1% of patients, respectively. The factors sex = male and age ≥45 years were associated with high LDL-C (P < 0.05 and P < 0.01). Patients who exercised less than 30 minutes per day had associated hypercholesterolemia (P < 0.01), hypertriglyceridemia (P < 0.01), and higher LDL-C (P < 0.05). Patients with BMI ≥23 kg/m2 had associated hypercholesterolemia and high LDL-C. Age was a significant determinant of high LDL-C. BMI was the most powerful and significant determinant of hypercholesterolemia and high LDL-C. Conclusion. SCL patients should have a regular lipid checkup, especially those patients having the following risk factors: males, age ≥45 years, BMI ≥23 kg/m2 and exercise duration <30 minutes per day.

Trans Fats in America: A Review of Their Use, Consumption, Health Implications, and Regulation

Trans fatty acids have long been used in food manufacturing due in part to their melting point at room temperature between saturated and unsaturated fats. However, increasing epidemiologic and biochemical evidence suggest that excessive trans fats in the diet are a significant risk factor for cardiovascular events. A 2% absolute increase in energy intake from trans fat has been associated with a 23% increase in cardiovascular risk. Although Denmark has shown it is possible to all but eliminate commercial sources of trans fats from the diet, total elimination is not possible in a balanced diet due to their natural presence in dairy and meat products. Thus, the American Heart Association recommends limiting trans fats to <1% energy, and the American Dietetic Association, the Institute of Medicine, US Dietary Guidelines, and the National Cholesterol Education Project all recommend limiting dietary trans-fat intake from industrial sources as much as possible. The presence of small amounts of trans fat in hydrogenated or partially hydrogenated oils/food products will likely cause many Americans to exceed their recommended maximum. This likelihood is exacerbated by the Food and Drug Administration labeling rules, which allow products containing <0.5 g trans fat per serving to claim 0 g trans fat. Many products with almost 0.5 g trans fat, if consumed over the course of a day, may approximate or exceed the 2 g maximum as recommended by American Heart Association, all while claiming to be trans-fat free. Accordingly, greater transparency in labeling and/or active consumer education is needed to reduce the cardiovascular risks associated with trans fats.

Relative risk of metabolic syndrome components in Nigerians: The adult treatment panel III definition

Background: The prevalence of metabolic syndrome is increasing in all populations worldwide and is associated with a substantially elevated risk of type 2 diabetes (5-fold) and of cardiovascular disease (2-3 fold). Metabolic syndrome is now established as a simple means of identifying individuals at increased risk of future cardiovascular disease and type 2 diabetes mellitus. Aim: To determine the prevalence of metabolic syndrome among adult Nigerians attending Family Medicine Clinics at two health facilities in Rivers State, Nigeria and to determine how much each diagnostic criterion contributed to the diagnosis of metabolic syndrome. Methods: Subjects were bled after an overnight fast, and venous blood obtained for lipid studies and fasting blood glucose estimation. Measurements were made to determine height, weight, waist circumference and blood pressure. The diagnosis of metabolic syndrome was based on the National Cholesterol Education Project: Adult Treatment Panel III (ATP III) definition. Results: The unadjusted and age-adjusted prevalence rates of metabolic syndrome at one centre were 19.8% and 20.9% respectively while they were 34.2% and 31.6% respectively at the other centre. The prevalence of low HDL-cholesterol was very high at both centres (78.3% at one centre and 92.1% at the other). Metabolic syndrome is most prevalent in females and older subjects. Conclusion: The prevalence of metabolic syndrome (19.8% and 20.9%, unadjusted and age-adjusted, respectively) were lower at one centre than the other (34.2% and 31.6%, unadjusted and age-adjusted, respectively). Despite the very high prevalence of low HDL-cholesterol, the relative risk for metabolic syndrome was not statistical significant (RR=6.73; 95% CI: 0.99-45.55). Key words: Metabolic syndrome, Prevalence, Adult Treatment Panel III, Adults, Nigeria

Metabolic Changes in Protease Inhibitor-Naive Patients Treated for 1 Year With Lopinavir/Ritonavir

To the Editor: Certain metabolic complications are common in HIV-positive patients treated with antiretroviral therapy. These alterations, especially hypercholesterolemia, could increase the cardiovascular risk (CVR), as measured by the Framingham risk score (FRS). Lopinavir coformulated with ritonavir (LPV/r) is an effective and potent protease inhibitor (PI) with a high genetic barrier, which can produce hypercholesterolemia, hypertriglyceridemia, and insulin resistance.1 To assess the CVR, using the FRS in patients treated with LPV/r, we designed a prospective, open-label, 1-arm study lasting 12 months. Seventy-three (71.2% male) consecutive PI-naive patients were included in the study and received treatment with LPV/r combining a nucleoside/nucleotide backbone. Exclusion criteria were PI-experienced, pregnant, or breast-feeding patients; those receiving concomitant treatments with investigational drugs or with agents that might have potential major interactions with LPV/r; and, finally, patients younger than 18 years of age. The inclusion period was from January 2001 to January 2002. The route of HIV transmission among the 73 included patients was heterosexual intercourse in 39.4%, injection drug abuse in 38.0%, homosexual intercourse in 19.7%, vertical transmission in 1.4%, and others (unknown) in 1.4%. The concurrent antiretroviral therapy was lamivudine in 41.8%, zidovudine in 24.3%, stavudine (d4T) in 11.4%, tenofovir in 11.4%, didanosine in 8.1%, and abacavir in 2.7%. Patients were evaluated clinical and analytically at baseline and every 3 months thereafter. Patients had the following baseline characteristics: duration of HIV infection for 62.9 ± 65.7 months, CD4 T-lymphocyte count of 263 ± 263 cells/μL, CD4 T-lymphocyte percentage of 14.2 ± 9.6%, and plasma HIV-1 RNA level of 415,512 ± 960,152 copies/mL. Initially, the average CVR factor was 1.7 ± 0.9. The number of risk factors per patient was 0 CVR in 5 patients (6.8%), 1 in 24 patients (32.9%), 2 in 32 patients (53.8%), 3 in 11 patients (15.1%), 4 in 0 patients, and 5 in 1 patient (1.4%). The salient CVR was smoking (72.6%). Other common CVRs were age (men older than 45 years of age) in 15.1% of patients and hypertension in 11.1% of patients. The family heart disease history showed that 2.7% of the fathers of patients had ischemic heart disease, and the figure was 4.1% in the case of the mothers of patients. None of the patients had diabetes. Taking into account all CVRs, the FRS was initially 4.4 ± 6.9. At baseline, the levels of cholesterol, high-density lipoprotein (HDL) cholesterol (HDLc), low-density lipoprotein (LPL) cholesterol (LDLc), triglycerides (TGs), and glucose were 165.0 ± 49.4 mg/dL, 35.5 ± 13.6 mg/dL, 99.2 ± 41.6 mg/dL, 160.9 ± 89.0 mg/dL, and 93.1 ± 12.7 mg/dL, respectively. The immunologic, virologic, and metabolic data at the end of the study (12 months) are shown in Table 1. We found a significant increase in total cholesterol, HDLc, and LDLc. TGs also showed an increase that was not significant. No cases of diabetes were diagnosed. LPV/r was discontinued in 19 cases: 12 of them because of side effects (diarrhea and/or digestive alterations in 10 cases) and 5 because of loss to follow-up. Twenty-eight patients were treated for dyslipemia, of whom 25 were treated only with diet and 3 were treated with diet and specific lipid-lowering drugs. Statins were used in 3 to achieve the National Cholesterol Education Project (NCEP) Adult Treatment Panel III (ATPIII) goals. We found no significant increase in the CVR, using the FRS. Accordingly at baseline, the CVR was 4.4; however, after 12 months on the LPV/r-based regimen, the CVR stood at 6.3. This increase was not significant (P = 0.059).TABLE 1: Patients' Data at Baseline and 12 Months of Follow-UpWe know that d4T can induce dyslipemia.2 To assess if the lipid profile could change when the backbone included d4T in an LPV/r-based regimen, the patients were divided into 2 groups: a d4T group and a non-d4T group. Twelve and 45 patients, respectively, completed the treatment for 12 months in each group. No significant difference was found between the 2 groups in the lipid profile. In conclusion, correct management of metabolic complications permits the use of LPV/r without a significant increase in CVR. In fact, the use of LPV/r is recommended in a PI-based regimen in different guidelines for treating antiretroviral-naive patients.3-5 Although a PI-based regimen can produce dyslipemia, correct management of modifiable CVR factors, such as a smoking habit, hypertension, or diabetes, is equally essential. In this series, more than 70% of patients were smokers. Maria José Galindo, MD, PhD* José Verdejo, MD† Miguel Gonzalez-Muñoz, PhD‡ Ana Ferrer, MD* Rosa Polo, MD, PhD§ *Infectious Diseases Department Hospital Clinico Universitario Valencia, Spain †Internal Medicine Service Hospital Madrid Torrelodones Madrid, Spain ‡Department of Immunology Hospital Carlos III Madrid, Spain §National Plan of AIDS Madrid, Spain

Childhood Metabolic Syndrome and Its Components in Premature Adrenarche

Premature pubarche (PP), the main clinical manifestation of premature adrenarche (PA), has been associated with insulin resistance and dyslipidemia in selected populations. Our aim was to determine the prevalence of childhood metabolic syndrome (cMBS) and to study its components in prepubertal Northern European girls with PA. We conducted a cross-sectional study on 63 prepubertal girls with PA (32 with PP = PP-PA, 31 without PP = nonPP-PA) and 80 healthy age-matched control girls. A standard 2-h oral glucose tolerance test with insulin sampling was performed. Plasma lipids and serum SHBG were analyzed, and blood pressure and weight-for-height were recorded. cMBS was defined by modified criteria of the U.S. National Cholesterol Education Project Adult Treatment Panel III and the World Health Organization. The study was performed at University Hospital. The mean weight-for-height (P = 0.002) and the prevalence of cMBS by the modified Adult Treatment Panel III (24 vs. 10%) and World Health Organization definitions (16 vs. 5%) (P < 0.05 for both) were higher in the PA than control girls. The weight-for-height adjusted serum insulin concentrations during the oral glucose tolerance test were elevated in the whole PA group, whereas the fasting insulin concentrations were increased and SHBG was decreased only in the PP-PA subgroup. The weight-for-height adjusted blood pressure, lipid, or glucose levels did not differ between the study groups. Prepubertal Northern European PA girls have increased prevalence of cMBS mainly due to being overweight and their hyperinsulinism. Among the PA children, the nonPP-PA girls have milder metabolic changes than the PP-PA girls.

A Guideline-Driven Assessment of Need for Cardiovascular Disease Risk Intervention in Persons With Chronic Paraplegia

Nash MS, Mendez AJ. A guideline-driven assessment of need for cardiovascular disease risk intervention in persons with chronic paraplegia. Objective To examine percentages of persons with chronic paraplegia who qualify for lipid-lowering therapeutic lifestyle intervention (TLI) as assessed by authoritative guidelines. Design Cross-sectional. Setting Academic medical center. Participants Forty-one subjects (mean age ± standard deviation, 34±11y) with motor-complete paraplegia (American Spinal Injury Association grade A or B) at T6-L1 levels for greater than 2 years. Interventions Not applicable. Main Outcome Measures Percentages of subjects qualifying for TLI were independently assessed and then compared using National Cholesterol Education Project Adult Treatment Panel (ATP) II (1994) and ATP III (2002) Guidelines. Results A total of 34.1% of subjects qualified for intervention based on the ATP II Guidelines and 63.4% based on ATP III (χ12 test=4.53; 2-tailed, P=.003). Seventy-six percent (31/41) of study participants had high-density lipoprotein cholesterol levels below the high-risk criterion of 40mg/dL established by ATP III. Almost one third of subjects had hypertension, and 34.1% satisfied criteria for diagnosis of the metabolic syndrome. Conclusions A high percentage of young, apparently healthy people with chronic paraplegia are at risk for cardiovascular disease and qualify for lipid-lowering TLI. Updated guidelines of the ATP III have increased the urgency for early risk assessment and intervention.

The Role of High-Density Lipoprotein Cholesterol in the Prevention and Possible Treatment of Cardiovascular Diseases

Despite significant progress in the management of atherosclerosis and its resultant complications, cardiovascular disease remains the principal cause of death in the world. The National Cholesterol Education Project Adult Treatment Panel III (NCEP ATP III) recognizes low levels of high-density lipoprotein cholesterol (HDL) as a risk factor for coronary heart disease (CHD) and high levels of HDL as a risk-reducing factor; however, the elevation of HDL as a specific therapeutic target for the prevention and treatment of CHD has yet to be accepted on the same level as low-density lipoprotein (LDL)-reducing therapies. Current HDL elevators including nicotinic acid, fibric acid derivatives, peroxisome proliferator activated receptor (PPAR) agonists and statins also affect other lipid constituents which make interpretation of the clinical trials of these drugs difficult in teasing out the independent effect of HDL elevation. Ample laboratory investigation suggests that HDL elevation would reduce atherosclerotic burden through multiple independent mechanisms. In this review, we explore HDL biology, its potential mechanisms in the treatment of atherosclerotic disease, and promising new drugs with HDL-raising activity.

Dyslipidemia and the Risk of Incident Hypertension in Men

Evidence suggests that hypertension may share a similar pathophysiology with cardiovascular disease (CVD). Thus, dyslipidemia, a strong predictor of CVD, may also predict incident hypertension. We analyzed 3110 men free of hypertension, CVD, and cancer from the Physicians' Health Study, who provided baseline blood samples from which we measured total cholesterol (TC) and HDL cholesterol (HDL-C), and calculated non-HDL-C and the TC/HDL-C ratio. We categorized each lipid parameter into quintiles and considered National Cholesterol Education Project clinical cut points. Other risk factor information was provided from self-reports on the baseline questionnaire. Incident hypertension was defined as either the initiation of antihypertensive treatment, self-reported systolic blood pressure > or =140 mm Hg, or diastolic blood pressure > or =90 mm Hg. Over a mean follow-up of 14.1 years, 1019 men developed hypertension. In Cox proportional hazards models adjusted for lifestyle and clinical risk factors, men in the highest quintile of TC, non-HDL-C, and TC/HDL-C ratio had increased risks of developing hypertension of 23%, 39%, and 54%, respectively, compared with participants in the lowest quintile. Furthermore, men in the highest quintile of HDL-C had a 32% decreased risk of developing hypertension compared with those in the lowest quintile. Models using National Cholesterol Education Project cut points demonstrated similar associations with hypertension. Models excluding men with diabetes and obesity maintained an independent association between baseline lipids and hypertension. These prospective cohort data suggest that dyslipidemias may lead to the subsequent development of hypertension. Thus, plasma lipids may be useful in the identification of men at risk for hypertension.

A Randomized Trial of the Efficacy and Safety of Fenofibrate versus Pravastatin in HIV-Infected Subjects with Lipid Abnormalities: AIDS Clinical Trials Group Study 5087

There is a paucity of information on the safety and efficacy of lipid-lowering therapy for dyslipidemia associated with human immunodeficiency virus (HIV) and antiretroviral therapy. Our objective was to determine whether fenofibrate and pravastatin were equivalent for the treatment of combined dyslipidemia in HIV as measured by a composite of the National Cholesterol Education Project (NCEP) goals based on absolute values for low-density lipoprotein (LDL), triglycerides (TG), and high-density lipoprotein (HDL) and to compare the safety of these agents through 48 weeks. This was a randomized, open-label trial with subjects assigned to fenofibrate 200 mg (n = 88) or pravastatin 40 mg (n = 86) daily. Subjects who failed to reach the NCEP composite goal on monotherapy by week 12 received both drugs. The composite goal at week 12 was achieved in 1% of fenofibrate and 5% of pravastatin subjects. At week 16, 69/88 subjects on fenofibrate added pravastatin (FP) and 67/86 subjects on pravastatin added fenofibrate (PF). At week 48, 7% FP subjects and 3% PF subjects achieved the composite goal. Median changes in LDL/HDL/TG/non-HDL were -8/+5/-144/+50 and -14/+2/-66/+34 mg/dl in subjects receiving FP and PF, respectively. There were few adverse events and no rhabdomyolysis reported. Combination therapy with fenofibrate and pravastatin for HIV-related dyslipidemia provides substantial improvements in lipid parameters and appears safe, but is unlikely to achieve all NCEP targets for lipid levels.

Usefulness of in-hospital prescription of statin agents after angiographic diagnosis of coronary artery disease in improving continued compliance and reduced mortality

Despite well-documented clinical benefit of the use of statins in patients with coronary artery disease (CAD) and even mild lipid elevations, studies have documented the presence of a significant “treatment gap” between those patients in whom treatment is indicated and those patients who actually receive it. It has been proposed that a prescription for statin therapy given to indicated patients at the time of initial angiographic diagnosis of CAD has the potential to improve long-term medication compliance, but this requires further evaluation. We prospectively followed 600 patients with angiographically demonstrated CAD (diameter stenosis ≥70%) who met the National Cholesterol Education Project (NCEP) guidelines for statin therapy for an average of 3.0 years (range 2.0 to 4.6). Patients were an average of 65 years of age, 78% were men, 77% presented initially with acute ischemic syndrome, and 64 (10.7%) died during follow-up. Overall, 105 patients (18%) were discharged from the initial hospitalization with a statin prescription. At long-term follow-up, the number of patients taking statins had increased to 47%. However, long-term statin compliance was significantly higher among patients initially discharged with a statin prescription than those who were not (77% vs 40%; p <0.0001). Additionally, those patients discharged with a statin prescription had significantly reduced mortality rate at long-term follow-up (5.7% vs 11.7%; p = 0.05). Cox hazard regression analysis, controlling for all known clinical baseline variables, confirmed the absence of a prehospital discharge statin prescription to be an independent predictor of increased mortality (hazard ratio 2.4) with a statistical trend (p = 0.06). Thus, this study demonstrates that after angiographic diagnosis of CAD, prescription of appropriate statin therapy at the time of hospital discharge improves long-term statin compliance and may significantly enhance survival.

Lipid-lowering diets: putting guidelines into practice.

The incidence of cardiovascular disease is four to five times greater in people with diabetes than in people without diabetes. Lipid disorders, along with elevated blood pressure, cigarette smoking, and abdominal obesity, are major risk factors for people with diabetes. All adults with diabetes should be screened for blood lipid levels including triglycerides, cholesterol, and high-density lipoprotein (HDL) cholesterol. The low-density lipoprotein (LDL) cholesterol should be measured more routinely in people with diabetes than suggested in the National Cholesterol Education Project (NCEP) guidelines. No single diet is best for persons with diabetes. Sometimes a lower fat, higher carbohydrate diet is more acceptable, and other times a lower carbohydrate, higher monounsaturated fatty acid (MUFA) diet is preferred. The decision regarding the level of fat in the diet is based both on patient preference as well as serial measurements of metabolic control. Changing eating habits regarding lipids is a gradual process and can best be accomplished when introduced in a staged approach.

Cholesterol 'War': Dietitians, Physicians Team Up

MORE AND MORE physicians are turning to the counsel of dietitians to help their patients reduce serum cholesterol concentrations. The trend is largely due to the recommendations of the National Cholesterol Education Project, a consortium of more than 40 health and medical organizations formed by the National Heart, Lung, and Blood Institute, Bethesda, Md. The project's 1988 report advocates diet as the cornerstone of prevention and treatment of hypercholesterolemia, and specifically recommends the counsel of a registered dietitian if the patient is unable to bring his or her cholesterol concentration within healthy levels after 3 months of dietary therapy (<i>Arch Intern Med</i>. 1988;148:36-69). Approximately 84 million people in the United States are believed to have cholesterol levels above 5.15 mmol/L (200 mg/dL), the uppermost limit in the opinion of many experts for "desirable blood cholesterol." A large percentage of these people could control their cholesterol level through diet, yet simply

Hyperlipidemia and Diabetes: The Role of Dietary Fats

The role of diet in the prevention and treatment of hyperlipidemia is extremely important. Both elevated cholesterol and diabetes mellitus are risk factors for coronary heart disease, the leading cause of death in adults with diabetes. All health professionals working with diabetic patients must be familiar with the recommendations from the National Cholesterol Education Project and know general dietary guidelines to assist their patients in adopting lower fat eating styles. Dietitians should develop an awareness of the controversial research questions being asked. The role of total fat, cholesterol, saturated fat, monounsaturated fat, polyunsaturated fat, and carbohydrate in the diet will be explored. Implications for practice for dietitians as well as other health professionals will be suggested.