Target Low-density Lipoprotein Cholesterol Values Research Articles

Inclisiran Usage in Very High-Risk Patients with Dyslipidemia Resistant to Statins and Ezetimibe Therapy

Background. Complications of systemic atherosclerosis (myocardial infarction, ischemic stroke) are the main causes of mortality and disability in the modern world. The relevance of this problem is determined by its scale: the number of deaths from cardiovascular disease has gradually increased from 12.1 million in 1990 to 18.6 million in 2019 and is on the rise. Today, the standard treatment regimen for dyslipidemia includes statins and ezetimibe. For patients who do not achieve the required lipid lowering, intensification of therapy with a relatively new group of drugs – PCSK9 inhibitors – is available. The aim. To study the effectiveness of inclisiran in the complex therapy of dyslipidemia in patients with very high cardiovascular risk. Materials and methods. The study design was a series of clinical cases, the data of which are described for comparison in dynamics. On the basis of the Department of Cardiometabolic Diseases of the Ukrainian Children’s Cardiac Center, a group of 7 patients with very high cardiovascular risk who did not achieve the target lipid parameters on standard therapy with rosuvastatin and ezetimibe was selected. Results. All the patients in the study group of very high cardiovascular risk with dyslipidemia resistant to standard combination treatment who took inclisiran as part of complex lipid-lowering therapy achieved a significant reduction in total cholesterol, but more importantly, they reached the target low-density lipoprotein cholesterol values. We did not find any side effects when using inclisiran. Conclusions. The present series of clinical cases demonstrates high efficacy of inclisiran as part of complex lipid-lowering therapy in patients with very high cardiovascular risk, who have a combination of coronary heart disease and type 2 diabetes mellitus. These results suggest the possibility of wider use of inclisiran in patients with very high cardiovascular risk to reduce cardiovascular morbidity and mortality.

Establishing Apolipoprotein-B and non-high-density-lipoprotein-C goals in Indian population: A Cross-sectional study

BackgroundDefining lipid goals solely on low-density lipoprotein-cholesterol (LDL-C) levels in Indian population may cause misclassification due to high prevalence of hypertriglyceridemia and small dense LDL-C particles. International guidelines now recommend Apoliporotein-B (Apo-B) and non-high-density lipoprotein-cholesterol (non-HDL-C) levels as alternative targets. In this study, we used a cross-sectional representative population database to determine Apo-B and non-HDL-C cut-offs corresponding to identified LDL-C targets and compared them to international guidelines. MethodsA community-based survey carried out in urban Delhi and adjacent rural Ballabhgarh provided lipid values for 3047 individuals. The Spearman correlation coefficient was used to evaluate the degree of relationship between Apo-B and LDL-C and non-HDL-C. Cut-off values for Apo-B and non-HDL-C were established using receiver operator curve analysis correlating with guideline-recommended LDL-C targets. ResultsSpearman's rank correlations between Apo-B and LDL-C (0.82) and non-HDL-C and LDL-C (0.93) were significant (p < 0.05). Proposed corresponding cut-off values for LDL-C of 55, 70,100,130 and 160 mg/dl for Apo-B and non-HDL-C in our population were 75.3, 75.5, 91.3, 107.6, 119.4 mg/dL and 92.5,96.5, 123.5, 154.5, 179.5 mg/dL respectively. However, in those with triglycerides >150 mg/dl the corresponding Apo-B and non-HDL-C values were 85.1, 92.7, 103.5, 117.5 and 135 mg/dL and 124.5, 126.5, 147.5, 167.5 and 190.5 mg/L respectively. ConclusionBased on this study we provide Apo-B and non-HDL cut-offs corresponding to target LDL-C values in Indian patients with and without high triglycerides. It is noted that in individuals with triglycerides ≥ 150 mg/dl, the Apo-B levels are much higher than the values recommended by guidelines.

The effect of achieving guideline-based target low-density lipoprotein cholesterol levels on mortality in transcatheter aortic valve implantation patients with coronary artery disease

Objectives: The aim of this retrospective study was to evaluate the effects of bringing low-density lipoprotein cholesterol (LDL-C) values to levels in line with guideline recommendations on long-term mortality in patients with a known history of coronary artery disease (CAD), undergoing transcatheter aortic valve implantation (TAVI), and long-term pre-treatment with statins. Methods: This is a retrospective and observational study of patients undergoing TAVI at a tertiary heart center with a history of CAD and long-term statin therapy. Ninety-nine patients were included in the study. The relationship between LDL-C levels in accordance with the guidelines and 5-year mortality was determined by regression analysis. Results: When the study population was divided into 2 groups with and without 5-year mortality, LDL-C values were found to be significantly higher in the mortality group (120 mg/dL vs. 93.9 mg/dL, p &amp;lt; 0.001). Parameters associated with the development of 5-year mortality were evaluated with univariate and multivariate logistic regression analysis. LDL-C ≥ 100 mg/dL (OR: 6.59, 95% CI: 2.17-20.01) and LDL-C ≥ 70 mg/dL (OR:3.88, 95% CI: 1.16-12.93) parameters were determined as independent predictors of mortality independent of other parameters. Conclusions: The most important result obtained in this study is that achieving the LDL-C level targets specified in the guidelines significantly reduces the in-hospital and 5-year mortality rates in patients with a previous history of CAD and statin use and undergoing TAVI. Although all patients included in the study used statins, the mortality rate was significantly higher in patients who did not reach the target LDL-C value.

Intensification of lipid-lowering therapy in very high-risk patients: potential of combination with PCSK9 inhibitors

Aim. To assess the efficacy and safety of 6-month combined lipid-lowering therapy with a PCSK9 inhibitor in patients with very high cardiovascular risk (CVR).Material and methods. This prospective, open-label, single-center exploratory research study with active treatment included 5 outpatients with very high CVR. So, 80% of patients had prior coronary artery disease, 20% peripheral arterial disease, and 60% old myocardial infarction. The key inclusion criterion was the failure to achieve the target low-density lipoprotein cholesterol (LDL-C) &lt;1,4 mmol/l with high-intensity statin monotherapy at the maximal tolerated doses or combination therapy with ezetimibe. On a regular basis, all included patients took atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/day, or pitavastatin 2-4 mg/day. In addition, 2 patients received a statin in combination with ezetimibe 10 mg/day. Patients were followed up for 6 months as follows: every 2 weeks, with a lipid profile monitoring, subcutaneous injections of alirocumab at a dose of 150 mg/ml were performed. Additionally, clinical and laboratory indicators of the safety of therapy were evaluated.Results. After 6 months, with the combined lipid-lowering therapy with alirocumab, a decrease in median LDL-C from 4,3 (4,11-4,67) to 1,27 (1,06-1,47) (p=0,001) mmol/l, total cholesterol from 6,1 (6-7) to 3,7 (3,5-3,9) (p=0,018) mmol/l, atherogenic index from 3,2 (3-3,26) to 0,8% (0,8-1,5) (p=0,001). There was no significant decrease in median triglycerides and an increase in median high-density lipoprotein cholesterol. Six-month lipid-lowering therapy with a PCSK9 inhibitor had no adverse events and made it possible to achieve a maximum decrease in LDL-C by an average of 75,4% already by 4 months of treatment in actual clinical practice.Conclusion. Six-month combined lipid-lowering therapy with alirocumab 150 mg subcutaneously every 2 weeks in very high-risk patients allows the majority of patients to achieve target LDL-C values.

Efficiency of high-intensity therapy with rosuvastatin for secondary prevention of cardiovascular complications in patients with a very high risk

According to the latest international and Russian guidelines for the treatment of dyslipidemias, statins are defined as the main group of drugs that significantly reduce the level of low-density lipoprotein cholesterol (LDL-C) effectively prevent atherosclerotic cardiovascular diseases (CVD) and complications and can slow down the progression of atherosclerosis. The principle “the lower LDL-C, the better” is especially relevant in categories of patients with very high and extreme cardiovascular risk, and therefore, in order to achieve target LDL-C values (≤1.4 is optimal ≤1.0) in this category of patients, high-intensity lipid-lowering therapy should be used. Rosuvastatin remains the most effective statin. Its use makes possible to achieve target lipid values at the starting dose of treatment, enhances adherence to treatment, and also reduces the frequency of side effects associated with the use of high doses of other statins. In addition, the proven ability of rosuvastatin to reduce the volume of atherosclerotic plaque, by reducing the level of pro-inflammatory cytokines and C-reactive protein, normalizing endothelial function, antiplatelet action, that is, rosuvastatin, in addition to its powerful lipid-lowering effect, has anti-inflammatory and anti-ischemic effects. Also, rosuvastatin can be successfully used in the presence of comorbidities, including chronic kidney disease and chronic heart failure. Taking into consideration the urgency of the fight against the COVID-19 pandemic (coronavirus Disease 2019), which covered 220 countries, due to the lack of effective etiotropic drugs, the possibility of using statins, including rosuvastatin, for the treatment of comorbid patients with COVID-19, was evaluated.

Familial Hypercholesterolemia in the Arabian Gulf Region: Clinical results of the Gulf FH Registry.

Background and aimsFamilial hypercholesterolemia (FH) is a common autosomal dominant disorder that can result in premature atherosclerotic cardiovascular disease (ASCVD). Limited data are available worldwide about the prevalence and management of FH. Here, we aimed to estimate the prevalence and management of patients with FH in five Arabian Gulf countries (Saudi Arabia, Oman, United Arab Emirates, Kuwait, and Bahrain).MethodsThe multicentre, multinational Gulf FH registry included adults (≥18 years old) recruited from outpatient clinics in 14 tertiary-care centres across five Arabian Gulf countries over the last five years. The Gulf FH registry had four phases: 1- screening, 2- classification based on the Dutch Lipid Clinic Network, 3- genetic testing, and 4- follow-up.ResultsAmong 34,366 screened patient records, 3713 patients had suspected FH (mean age: 49±15 years; 52% women) and 306 patients had definite or probable FH. Thus, the estimated FH prevalence was 0.9% (1:112). Treatments included high-intensity statin therapy (34%), ezetimibe (10%), and proprotein convertase subtilisin/kexin type 9 inhibitors (0.4%). Targets for low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol were achieved by 12% and 30%, respectively, of patients at high ASCVD risk, and by 3% and 6%, respectively, of patients at very high ASCVD risk (p <0.001; for both comparisons).ConclusionsThis snap-shot study was the first to show the high estimated prevalence of FH in the Arabian Gulf region (about 3-fold the estimated prevalence worldwide), and is a “call-to-action” for further confirmation in future population studies. The small proportions of patients that achieved target LDL-C values implied that health care policies need to implement nation-wide screening, raise FH awareness, and improve management strategies for FH.

Abstract P029: Non-high Density Lipoprotein Is A Residual Risk For The Progression Of Endothelial Dysfunction In Patients With Well Controlled Low-density Lipoprotein Cholesterol: Multicenter Prospective Study FMDJ Study

Introduction: Recently, several guidelines suggest the usefulness of non-high density lipoprotein cholesterol (non-HDLC) as a secondary treatment target for CVD prevention, next to low-density lipoprotein cholesterol (LDLC). However, its effect on endothelial dysfunction have not been fully clarified. The objective of this multicenter-prospective-observational study, FMD-J Study, is to evaluate whether non-HDLC is a residual risk for the progression of endothelial dysfunction in patients with hypertension. Hypothesis: Non-HDLC is a residual risk for the progression of endothelial dysfunction in patients with hypertension. Methods: 633 treated hypertensive patients (mean age 62±9 years) in the FMD-J study were followed for 3 years. Endothelial function was evaluated by the change of flow mediated vasodilation (FMD). Multivariate regression analysis adjusted for established coronary heart disease (CHD) risk factors (sex, age, BMI, systolic blood pressure, heart rate, fasting blood glucose, high density lipoprotein cholesterol, baseline FMD, current smoking, treatment of diabetes, and treatment of dyslipidemia) was performed to evaluate whether LDLC and non-HDLC were associated with the change of FMD. We also performed secondary analysis to evaluate whether non-HDLC is associated with progression of endothelial dysfunction in patients with well controlled LDLC level according to their CHD risk. CHD risk was evaluated by Suita score, which is established risk score to assess the 10-year risk of CHD for the Japanese population. (High-risk: 56≦Suita score, Mid-risk: 41≦Suita score≦55, Low-risk: Suita score≦40) Target controlled LDLC levels according to CHD risk were defined as follows; High-risk: LDLC&lt;70 mg/dl, Mid-risk: LDLC&lt;100 mg/dl, Low-risk: LDLC&lt;70 mg/dl. Results: Mean change of FMD after 3 years was 0.07±2.97% and mean Suita score was 46.4±8.9. Overall, both higher LDLC and non-HDLC was significantly associated with impairment of FMD. (Adjusted 1SD increase of LDLC; β: -0.26±0.11, P=0.02, Adjusted 1SD increase of non-HDLC; β: -0.25±0.11, P=0.03 ). In secondary analysis, 97 patients’ LDLC reached target LDLC level according to CHD risk. Among LDLC controlled group, higher non-HDLC was significantly associated with impairment of FMD. (Adjusted 1SD increase of non-HDLC; β: -0.75±0.13, P=0.02). However, among 536 patients whose LDLC did not reach target LDLC value, non-HDLC was not associated with the change pf FMD. (Adjusted 1SD increase of non-HDLC; β: -0.15±0.12, P=0.20). Conclusions: Non-HDLC may be a residual risk for the progression of endothelial dysfunction in patients with hypertension, especially in hypertensive patients with well controlled LDLC.

PCSK9 inhibitors for in-hospital treatment of patients with acute coronary syndrome and severe lipid metabolism disorders

Aim. To assess the efficacy and safety of PCSK9 inhibitor alirocumab as part of a combination lipid-lowering therapy in patients with acute coronary syndrome (ACS).Material and methods. This prospective, open-label, single-center activetreatment study included 13 patients hospitalized due to ACS. The main inclusion criterion was nonachievement of target low-density lipoprotein cholesterol (LDL-C) values (&lt;1,4 mmol/L) with high-intensity statin therapy prior to ACS. During the first 30 days after ACS, all patients received therapy with atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/day in combination with alirocumab 150 mg/ml (Praluent) administered by subcutaneous injection. Lipid and biochemical profiles were monitored. The first injection of the PCSK9 inhibitor was performed on days 3-5 of hospitalization, the second — after 2 weeks.Results. On admission, the median LDL-C was 4,3 [3,5;5,3] mmol/L. A day after administration, there was a decrease in LDL-C by 41,9% (median 2,5 [1,8;3,2] mmol/L; p=0,001) without a negative effect on high-density lipoproteins (HDL-C) (median 1,2 [0,8;1,4] mmol/L; p=0,270). Before the next injection, LDL-C decreased by another 8% (median 2,3 [1,1;4,1] mmol/L). A day after the second injection, a decrease in LDL-C from the baseline values was 69,8% (median 1,3 [0,7;1,5] mmol/L; p=0,010). Strengthening lipid-lowering therapy with a PCSK9 inhibitor within 30 days after ACS did not lead to clinical and biochemical deterioration.Conclusion. The use of subcutaneous 150-mg injections of alirocumab 2 times a week 30 days after ACS in patients who did not reach target LDL-C values with statin therapy, leads to a 69% decrease in LDL-C from baseline values and is safe.

Lipid-Lowering Therapy Guidelines

The major guidelines for lipid-lowering therapy (LLT) have been revised recently. Although “higher cardiovascular risk-aggressive LLT with greater absolute clinical benefit” is the main idea underlying all guidelines, there are some differences in the details among them. The US guidelines recommend pharmacological LLT based on a patient’s risk category, independently of their low-density lipoprotein-cholesterol (LDL-C) level. However, the European and Korean guidelines consider the patient’s risk category and LDL-C at the same time. Lifestyle modifications are suggested in parallel in all guidelines. The newest US guidelines have characteristically revived target LDL-C values in some patient groups and indications for non-statin drugs (ezetimibe and PCSK9 inhibitors), whereas the European and Korean guidelines have maintained target LDL-C values as usual. It is universally accepted that statins are the first-line agent. Adding ezetimibe, bile acid sequestrants, or PCSK9 inhibitors is recommended as a second line treatment. Appreciating the trend and background of the newest LLT guidelines will be essential to maximize cardiovascular prevention in patients. (Korean J Med 2019;94:396-402)

Real-life LDL-C treatment goals achievement in patients with heterozygous familial hypercholesterolemia in the Czech Republic and Slovakia: Results of the PLANET registry

Background and aimsDespite the high prevalence of familial hypercholesterolemia (FH) and available effective lipid-lowering therapy, most of the individuals with this disorder remain undiagnosed and undertreated. The aim of the PLANET registry was to assess the real-life attainment of low-density lipoprotein cholesterol (LDL-C) therapeutic target level in patients with heterozygous FH, to characterize prescribed lipid-lowering therapy with assessment of its efficiency according to the attainment of the target LDL-C level, and to characterize cardiovascular events observed in this patient population again in relation to LDL-C target level attainment. MethodsPLANET registry was designed as a non-interventional, retrospective, cross-sectional, multicentre disease registry for adult patients with heterozygous FH in the Czech Republic and Slovakia. ResultsOverall, 1755 patients were enrolled at 32 sites specialized in FH treatment. 15.4% of patients attained the target LDL-C value. The proportion of patients with LDL-C goal achievement increased to 17.3% in the subgroup of patients receiving high-intensity statin therapy (54.6% of study population). Out of 55 patients receiving inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9), 61.8% reached the LDL-C treatment goal. Of all cardiovascular events reported, 14.0% occurred in patients attaining the LDL-C goal, while it was 86.0% in the not-at-target group. It was documented (p=0.004) that the longer is the patient in care at the specialized FH centre, the higher is the probability that he/she will attain the target LDL-C level. ConclusionsAlthough target LDL-C level attainment remains relatively low, the likelihood of LDL-C goal attainment increases with duration of specialized care.

A consensus statement on lipid management after acute coronary syndrome.

In patients admitted for acute coronary syndrome (ACS), the guidelines of the European Society of Cardiology give a Class I, Level A recommendation for the prescription of high-intensity statins to be initiated as early as possible, regardless of the low-density lipoprotein cholesterol (LDL-C) level. Although statins are widely prescribed after ACS, the intensity of therapy and the proportion of patients achieving target LDL-C values are often not in line with recommendations due to a lack of compliance with guidelines by the physicians, a lack of compliance with treatment or poor tolerance by patients, and poor dose adaptation. In this context, a group of French physicians came together to define strategies to facilitate and improve the management of lipid-lowering therapy after ACS. This paper outlines the scientific rationale for the use of statins at the acute phase of ACS, the utility of ezetimibe, the measurement of LDL-C during the course of ACS, the opportunities for detecting familial hypercholesterolaemia and the results of the consensus for the management of lipid-lowering therapy, illustrated in two decision-making algorithms.

Implementation of a new guideline in cardiovascular secondary preventive care: subanalysis of a randomized controlled trial.

BackgroundCardiovascular secondary preventive recommendations are often not reached. We investigated whether a nurse-led telephone-based follow-up could improve the implementation of a new guideline within a year after its release.MethodsIn February 2013, a new secondary preventive guideline for diabetic patients was released in the county of Jämtland, Sweden. It included a changed of the low-density lipoprotein cholesterol (LDL-C) target value from <2.5 mmol/L to <1.8 mmol/L. In the Nurse-Based Age-Independent Intervention to Limit Evolution of Disease (NAILED) trial, patients with an acute coronary syndrome, stroke, or transient ischemic attack were randomized to secondary preventive care with nurse-based telephone follow-up (intervention) or usual care (control). Patient data were obtained from the NAILED trial to study the implementation of the new LDL-C guideline by comparing telephone follow-up with usual care. The Mann–Whitney U-test was used for continuous variables, and Person’s χ2 test was used for categorical variables to assess between-group differences.ResultsOut of the 1267 patients that entered the study period, 101 intervention and 100 control patients with diabetes fulfilled the inclusion criteria and completed the study period. Before the guideline change, 96 % of the intervention patients and 70 % of the control patients reached the target LDL-C value (p < 0.001). After the guideline change, the corresponding respective proportions were 65 % and 36 % (p < 0.001). The main reason that intervention patients did not achieve the target LDL-C value was that they received full-dose treatment; for control patients, the main reason was that medication was not adjusted, for an unknown reason.ConclusionsOne year after a change in the cardiovascular secondary preventive guideline, nurse-based telephone follow-up performed better than usual care to implement the new recommendation.Trial registrationISRCTN registry; ISRCTN96595458 (date of registration 10 July 2011) and ISRCTN23868518 (date of registration 13 May 2012).

Cardiovascular secondary prevention in high-risk patients: a randomized controlled trial sub-study.

BackgroundEnhanced cardiovascular secondary preventive follow-up is needed to improve adherence to recommended low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) levels. Patients with diabetes mellitus (DM) or chronic kidney disease (CKD) have a high risk of recurrent events. Secondary prevention is therefore essential in these patients.MethodsPatients with acute coronary syndrome, stroke, or transient ischemic attack were randomized to nurse-based telephone follow-up (intervention) or usual care (control). LDL-C and BP were measured at 1 month (baseline) and 12 months post-discharge. Intervention patients with above-target values at baseline received medication titration to achieve treatment goals. Values measured for control patients were given to the patient’s general practitioner for assessment.ResultsThe final analyses included 225 intervention and 215 control patients with DM or CKD. Among patients with above-target baseline values, the following 12-month values were recorded for intervention and control patients, respectively: LDL-C, 2.2 versus 3.0 mmol/L (p < 0.001); and median systolic BP (SBP), 140 versus 145 mmHg (p = 0.26). Among patients with above-target values at baseline, 52.3 % of intervention patients reached target LDL-C values at 12 months versus 21.3 % of control patients (absolute difference of 30.9 %, 95 % CI 16.1 to 43.8 %), and there was a non-significant trend of more intervention patients reaching target SBP (49.4 % versus 36.8 %; absolute difference of 12.6 %, 95 % CI −1.7 to 26.2 %).ConclusionsCardiovascular secondary prevention with nurse-based telephone follow-up was more effective than usual care in improving LDL-C levels 12 months after discharge for patients with DM or CKD.Trial registrationISRCTN registry; ISRCTN96595458 (date of registration 10 July 2011) and ISRCTN23868518 (date of registration 13 May 2012).Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-015-0115-0) contains supplementary material, which is available to authorized users.

Benefit of Early Statin Therapy in Patients With Acute Myocardial Infarction Who Have Extremely Low Low-Density Lipoprotein Cholesterol

We investigated whether statin therapy could be beneficial in patients with acute myocardial infarction (AMI) who have baseline low-density lipoprotein cholesterol (LDL-C) levels below 70 mg/dl. Intensive lipid-lowering therapy with a target LDL-C value <70 mg/dl is recommended in patients with very high cardiovascular risk. However, whether to use statin therapy in patients with baseline LDL-C levels below 70 mg/dl is controversial. We analyzed 1,054 patients with AMI who had baseline LDL-C levels below 70 mg/dl and survived at discharge from the Korean Acute MI Registry between November 2005 and December 2007. They were divided into 2 groups according to the prescribing of statins at discharge (statin group n = 607; nonstatin group n = 447). The primary endpoint was the composite of 1-year major adverse cardiac events, including death, recurrent MI, target vessel revascularization, and coronary artery bypass grafting. Statin therapy significantly reduced the risk of the composite primary endpoint (adjusted hazard ratio [HR]: 0.56; 95% confidence interval [CI]: 0.34 to 0.89; p = 0.015). Statin therapy reduced the risk of cardiac death (HR: 0.47; 95% CI: 0.23 to 0.93; p = 0.031) and coronary revascularization (HR: 0.45, 95% CI: 0.24 to 0.85; p = 0.013). However, there were no differences in the risk of the composite of all-cause death, recurrent MI, and repeated percutaneous coronary intervention rate. Statin therapy in patients with AMI with LDL-C levels below 70 mg/dl was associated with improved clinical outcome.

Low Density Lipoprotein Cholesterol Target Goal Attainment Rate in Korean Patients with Diabetes

Hypertension, dyslipidemia, and smoking are all factors that increase the risk of cardiovascular disease in patients with type 2 diabetes [1]. Among them, one of the most important risk factors is dyslipidemia. Among lipoproteins, low density lipoprotein cholesterol (LDL-C) level is the most important predicting factors for cardiovascular disease, and many large-scale studies have been ongoing for many years to determine the target value for LDL-C treatment [2]. Since the risk of cardiovascular disease in type 2 diabetes patients is higher than that in healthy, the target LDL-C value in diabetes patients has been emphasized as being even more important than other metrics [3]. When the recommended LDL-C treatment goals of the 2003 Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP) and the 2008 American Diabetes Association (ADA) released consensus with the American College of Cardiology (ACC) [4] and the dyslipidemia treatment goal guidelines in accordance with the 2011 European Society of Cardiology (ESC) and the European Society of Arteriosclerosis (ESA) were examined, recent trends generally call for more aggressive LDL-C reduction than what has been seen in previous guidelines particularly in the patient group with the highest risk, where an LDL-C target value less than 70 mg/dL is encouraged [5]. Based on the ESC and the ESA guidelines, cardiovascular disease, severe chronic kidney disease, and target organ damage are all included in the highest risk factors for the diabetes group. Even when diabetes is the only risk factor, the target value for LDL-C is recommended to be less than 70 mg/dL [5]. The LDL-C treatment target values have gradually been getting more aggressive all over the world. Although the changes in these values are aggressive, there is no set guideline for LDL-C treatment target values in Koreans, specifically Koreans who have diabetes. There are also very few studies that show the actual level of success of dyslipidemia treatment according to this guideline or how effectively the treatment target value is achieved (achievement rate). Hwang et al. [6] performed a study on diabetes patients over 18 years of age who were receiving treatment for hyperlipidemia. Research was conducted on the difference between the achievement rate of actual treatment target value of LDL-C and recognition rate of target values by medical personnel (expected achievement rate). Among the patients who had received treatment, 35.9% (approximately 1/3 of the total participants) reached the actual LDL-C target value, while that the expected achievement rate was reported in 70.6% of the total participants. In addition, even when lipid levels did not reach the target value, 65.3% of patients were receiving the same statin dosage as when the treatment was started. The authors felt that these results were due to a lack of recognition of the target lipid values by the medical personnel. So, in order to decrease the risk of cardiovascular disease in Korean diabetes patients and in order for LDL-C treatment goals to be reached, they proposed that the recognition standards of the medical personnel be changed [6]. A limitation to this study is that they did not consider whether participants performed any sort of diet or exercise, and drug compliance was also not considered. In actual clinical practice, it could easily be seen that lipid levels did not reach the target values, and clinicians were able to provide adequate care. In particular, in diabetes patients at relatively high risk for cardiovascular disease, statin dosage is increased, being able to reach the target value is the most feasible basis. In the future, even when patients receive treatment, prospective studies regarding the difficulty to reach the lipid target value (due to the low success rate) are required. In addition, during dyslipidemia treatment, statin drug therapy is not the only treatment method used; diet management and exercise are often combined with the treatment process. Additional studies on other positive effects, the need for education, and effectiveness of these treatments will be very helpful in the treatment of dyslipidemia.

Exploring the gap between National Cholesterol Education Program guidelines and clinical practice in secondary care: results of a cross-sectional study involving over 10 000 patients followed in different specialty settings across Italy

To evaluate implementation of low-density lipoprotein cholesterol (LDL-C) control recommendations in secondary care and explore key points in the decisional workup. In a nationwide survey of secondary-care outpatients (n=11,124), we studied prevalence/predictors of (1) LDL-C value availability; (2) ongoing treatment with statins; (3) achievement of US National Cholesterol Education Program III target LDL-C values. Agreement between US National Cholesterol Education Program III risk category and physicians' personal risk assessments was also studied. LDL-C values were available for 78% evaluable patients; 71% of the patients with dyslipidema were undergoing treatment with statins; 34% patients undergoing treatment had target LDL-C values. At regression analysis, non-availability of LDL-C values was predicted by absence of diabetes, presence of normotension, and advancing age; lack of statins treatment by female sex, diabetes, overweight and northern location (southern location predicted treatment); non-achievement of target LDL-C values by age, diabetes, attending a diabetic clinic, cigarette smoking, history of cardiovascular disease, and taking less than six pills per day. Physicians provided underestimates of patients' risk (39% high-risk patients were rated as intermediate-risk patients and a further 10% as low-risk patients). Suboptimal prevention practice seems to be associated with various factors acting at different levels within the complex process running from individual risk-level ascertainment to LDL-C target achievement. Multicomponent interventions that target the different key steps need to be considered.

Implication of the New Low-Density Lipoprotein Goals in Dyslipidemia Management of Patients With Acute Coronary Syndrome

To assess the ability of patients with an acute coronary syndrome (ACS) to meet the recommended low-density lipoprotein cholesterol (LDL-C) goal of 100 mg/dL and optional aggressive lowering to 70 mg/dL. Patients diagnosed as having ACS who had lipid levels measured within 24 hours of admission from January 1, 1998, through December 31, 2002, were assessed for the ability to meet the 2 target LDL-C levels. Patients were considered to have ACS if they were diagnosed as having myocardial infarction, had significant disease on angiography, or had a history of coronary artery disease. Patients were classified into 1 of 4 groups on the basis of the degree of LDL-C lowering required to meet the 2 different goals: less than 33%, 33% to 39%, 40% to 49%, and 50% or more. Patients with myocardial infarction who had lipid sampling performed more than 24 hours after admission were excluded. The mean plus-or-minus SD LDL-C level was 111 plus-or-minus 43 mg/dL in the 1322 patients who met criteria for ACS and had LDL-C levels assessed. On the basis of a target LDL-C value of less than 100 mg/dL, 43% of patients were at goal and did not require treatment, and only 2.5% had an LDL-C level that required a 50% or greater reduction to meet goal. In contrast, using the newer LDL-C target of 70 mg/dL, 85% patients required treatment, and 23% of patients required a 50% or greater decrease in LDL-C level and therefore were likely to require more than 1 lipid-lowering agent. Decreasing the LDL-C target to less than 70 mg/dL substantially increases the number of patients with ACS who would require treatment. A significant proportion of patients will require a reduction in LDL-C level of 50% or more, which is not easily achievable with current lipid-lowering monotherapy.

Hyperlipidemia after heart transplantation: Report of a 6-year experience, with treatment recommendations

Mean plasma lipid values in 100 patients who survived >3 months after heart transplantation increased significantly at 3 months over pretransplantation values: total cholesterol from 168 ± 7 to 234 ± 7 mg/dl, low density lipoprotein (LDL) cholesterol from 111 ± 6 to 148 ± 6 mg/dl, high density lipoprotein (HDL) cholesterol from 34 ± 1 to 47 ± 1 mg/dl and triglycerides from 107 ± 6 to 195 ± 10 mg/dl. There were no significant increases after this time. The LDL cholesterol values remained ≥130 mg/dl in 64% of patients and triglyceride values remained ≥200 mg/dl in 41% of patients 6 months after postoperative dietary instructions.Beginning in 1985, select patients whose total cholesterol values remained >300 mg/dl despite 6 months of dietary intervention were treated with lovastatin given alone in a high dose (40 to 80 mg/day) or in combination with another hypolipidemic agent. Four of the five patients so treated developed rhabdomyolysis; two of the four had acute renal failure. Beginning in 1988, a second protocol—lovastatin at 20 mg/day as monotherapy—was used in patients who despite dietary intervention had total cholesterol > 240 mg/dl (mean follow-up 13 months). In the 15 patients so treated, mean total cholesterol decreased from 299 ± 10 mg/dl before treatment with lovastatin to 235 ± 9 mg/dl during treatment (21% reduction, p < 0.001) and mean LDL cholesterol was reduced from a baseline value of 190 ± 10 to 132 ± 12 mg/dl during treatment (31% reduction, p < 0.001).In this study, lovastatin at a dose of ≤29 mg/day as monotherapy was a well tolerated, effective treatment for hyperlipidemia after heart transplantation. It did not result in rhabdomyolysis and required no alteration in immunosuppressive therapy. However, the dose should not exceed 20 mg/day and combination therapy with either gemfibrozil or nicotinic acid should be avoided, even if the target LDL cholesterol value is not reached.