Beruflich Dokumente
Kultur Dokumente
com
D
y
s
l
i
p
i
d
e
m
i
a
Cardiovascular Disease:
Why Is the Burden Still So Heavy?
C
ardiovascular disease accounted for 37% of all deaths in the
United States in 2003 (the latest year available), and more
than 71 million American adults are believed to have some
form of CVD.
1
The total US cost of cardiovascular and cerebrovas-
cular diseases in 2006 was estimated at more than $403 billion.
1
Efforts to prevent CVD have high priority and include the assess-
ment of risk and risk-reduction therapy.
Dyslipidemia and Cardiovascular
Risk Reduction: A Review Based
on the Evidence
There is an
urgent need
to improve
screening for
and management
of dyslipidemia
in primary care
What We Know About Dyslipidemia
Cardiovascular disease (CVD) is the leading cause of
death in the United States
Dyslipidemia, a leading risk factor for CVD and stroke,
includes high low-density lipoprotein cholesterol (LDL-C),
low high-density lipoprotein cholesterol (HDL-C), and
elevated triglyceride (TG) levels
Efforts to prevent CVD have a high priority and include
risk-reduction therapy
Learning Objectives
After completing this activity, participants should be
better able to:
Discuss current guidelines for the management
of dyslipidemia
Describe the results of recent clinical trials relevant
to the management of dyslipidemia
State lipid goals according to patients level of
cardiovascular risk
How should
muscle pain
complaints
be handled?
See page 39
CPCE38807. Home Study wkbk.Dyslip. Chapter.v7.qxp 9/4/2007 3:11 PM Page 23
Dyslipidemia, a leading risk factor for CVD and stroke, includes high LDL-C, low
HDL-C, and elevated TG levels. According to a survey conducted in 2003, almost half of
US adults had total cholesterol levels of 200 mg/dL or higher. Nearly 40% had borderline
high or higher LDL levels at or above 130 mg/dL,
1
while more than 20% had HDL below
the desired threshold of 40 mg/dL.
1
Risk Reduction Eff orts Fall Short
Failure to achieve lipid goals is a persistent problem,
2
although more patients appear to be
using lipid-lowering medications than ever before. The Lipid Treatment Assessment
Project (L-TAP) survey found that only 38% of patients diagnosed with dyslipidemia
reached National Cholesterol Education Program (NCEP)recommended targets for
LDL-C, despite treatment (Figure 1).
2
The reasons so many patients
do not reach treatment goals are
complex and involve both patients
and healthcare providers. Not all
clinicians follow the NCEP lipid
screening and intervention guide-
lines to the letter.
3,4
Many high-
risk patients are not assessed as the
guidelines recommend and there-
fore do not receive adequate treat-
ment.
3,4
Even after receiving a
diagnosis, counseling, and treat-
ment recommendations, many
patients do not adhere to lifestyle
modifications and medication
regimens for long.
3
Persistence with medication
is measured as the percentage of
patients who continue to take
their medication as prescribed
over a designated period. A
recent analysis of pharmacy
records to determine how many
patients persisted with statin
therapy found that overall per-
sistence dropped from 56% at 9
months to 35% at 12 months.
5
The fall-off in adherence was
seen across all subgroups of
patients: men, women, younger,
older, and patients who did or
did not pay directly for their
D
y
s
l
i
p
i
d
e
m
i
a
Dyslipidemia and Cardiovascular Risk Reduction:
A Review Based on the Evidence
24
Risk Groups
P
a
t
i
e
n
t
s
a
t
G
o
a
l
(
%
)
0
10
20
30
40
60
50
70
80
Overall Low risk High risk CHD
Figure 1. In the L-TAP survey, only 38% of patients with
dyslipidemia treated with lipid-lowering medications
reached NCEP LDL goals. The highest successrate (68% )
wasseen in low-risk patients. Only 37% of high-risk patients
achieved goals, and the successrate waslowest among
patientswith coronary heart disease (18% ). Pearson TA et al.
2
NCEP ATP III Risk Interpretations for Lipid Levels
* In clinical practice, HDL-C levels<40 mg/dL in men and <50
mg/dL in women are considered high risk.
Expert Panel
7
; ADA
8
; M osca L et al.
9
T
A
B
L
E
1
Test Optimal
Borderline
High Risk
High
Risk
Very High
Risk
Total
cholesterol
<200 200-239 240
LDL-C <100 130-159 160-189 190
HDL-C 60 40-59 <40*
TG <150 150-199 200-499 500
CPCE38807. Home Study wkbk.Dyslip. Chapter.v7.qxp 9/4/2007 3:11 PM Page 24
medications.
5
By the end of the study, adherence was down to 34% for men, 18%
for women, 19% for patients aged younger than 65 years, and 41% for patients aged
65 years and older.
5
Another measure of medication adherence is the number of gap days between pre-
scription refills, which indicates if patients are taking medications inconsistently and
missing doses. The number of gap days between prescription refills was greater for
women than for men, indicating further that women were less likely than men to adhere
to therapy.
5
These findings may reflect that patients perceive CVD risk differently. Older
men, for example, may be more aware that they are at risk for heart disease and, there-
fore, more likely to take medications to reduce that risk.
5
Regrettably, most US women
do not understand that heart disease is the leading cause of death for women, and instead
believe breast cancer to be a greater health concern.
6
It i s clear that there i s an urgent need for pri mary care cli ni ci ans to i ncrease
thei r efforts to follow current gui deli nes and i mprove screeni ng for and manage-
ment of dysli pi demi a i n thei r pati ents. As part of these efforts, cli ni ci ans also need
to counsel thei r pati ents more effectively about the threat of CVD and to explai n
how i mportant i t i s to adhere to therapeuti c li festyle changes (TLCs) and prescri bed
medi cati on regi mens.
Risk Assessment Is the Critical First Step
The NCEP Adult Treatment Panel (ATP) III risk interpretations for each fasting lipid
parameter are shown in Table 1.
7
Levels of LDL-C between 100 and
129 mg/dL are considered to be
near or above optimal, indicating a
relatively low risk for CVD. Levels
of HDL-C below 40 mg/dL are
considered too low because they
are associated with a higher risk of
coronary heart disease (CHD).
7
Although the NCEP ATP III guide-
lines do not differentiate HDL
interpretation according to gender,
the American Diabetes Association
(ADA) and the American Heart
Association (AHA) make such a
distinction. Both of these organi-
zations advise that HDL-C levels
in women should be above
50 mg/dL, rather than above
40 mg/dL as in men.
8,9
When a fasting lipoprotein profile has been obtained, the next step is to evaluate the
main determinants of risk, as listed in Table 2. Patients at highest risk are those with a
history of CHD or who have risk factors equivalent to CHD.
7
25 www.practicingclinicians.com
D
y
s
l
i
p
i
d
e
m
i
a
NCEP ATP III Main Determinants of Risk
CHD or CHD risk equivalents:
Other clinical atherosclerotic disease (peripheral
arterial disease, peripheral vascular disease,
abdominal aortic aneurysm, symptomatic carotid
artery disease, or stroke)
Diabetes
Cigarette smoking
Hypertension (BP 140/90 mm Hg, or using
antihypertensive medication)
High LDL-C level (>130 mg/dL)
Low HDL-C level (<40 mg/dL)
Family history of premature CHD (male first-degree
relative aged <55 yearsor female first-degree relative
aged <65 years)
Age (men aged 45 years, women aged 55 years)
T
A
B
L
E
2
BP = blood pressure.
Expert Panel.
7
CPCE38807. Home Study wkbk.Dyslip. Chapter.v7.qxp 9/4/2007 3:11 PM Page 25
In patients who do not have existing CHD or a CHD risk equivalent, the next step is
to use a risk assessment tool to determine the Framingham risk score.
7
The Framingham
score estimates the patients risk of developing CHD over the next 10 years. An online
tool for estimating the Framingham risk is available at the NCEP Web site.
10
This calcula-
tor uses data from the Framingham Heart Study to estimate the 10-year risk of a hard
CHD event (myocardial infarction [ MI] or coronary death) in adults 20 years of age or
older who do not have heart disease, a risk equivalent, or diabetes. Other tools, including
online calculators, spreadsheet calculators, and calculator software for handheld devices,
are available at the NCEP Web site,
11
the Mobile Lipid Clinic Web site,
12
and the
Reynolds Risk Score Web site for calculating risk in women.
13
The final step is to determine the patients NCEP ATP III risk category. According to the
Framingham risk score and other important risk factors, the patient may be considered to
be at low risk, moderate risk, moderately high risk, high risk, or very high risk of a cardio-
vascular (CV) event.
14
Each risk category is described in Table 3. The category very high risk
has been suggested for patients who have established CVD plus 1 of the following
14
:
Multiple risk factors (especially diabetes)
A severe and poorly controlled risk factor (eg, persistent cigarette smoking)
Multiple risk factors indicating metabolic syndrome
Acute coronary syndrome
Metabolic Syndrome
in Risk Assessment
Metabolic syndrome encompasses
a cluster of abnormalities, includ-
ing dyslipidemia, that increase the
risk of developing CVD and dia-
betes. Several organizations have
proposed definitions for the meta-
bolic syndrome; the 2 most recent
proposals are summarized in
Table 4.
15,16
The AHA/National
Heart, Lung, and Blood Institute
(NHLBI) and International
Diabetes Foundation (IDF) defini-
tions are similar and focus on abdominal or central obesity (as indicated by increased
waist circumference), dyslipidemia, hypertension, and elevated blood glucose levels as
central criteria.
15,16
The AHA/NHLBI definition requires the presence of 3 or more cri-
teria for a diagnosis of metabolic syndrome.
16
The IDF definition requires the presence
of central obesity (defined as waist circumference above ethnicity-specific thresholds) as
an essential component, in addition to 2 or more of the factors listed.
15
The metabolic syndrome is more common in older age groups. Data from 8814 men
and women at least 20 years of age who participated in the Third National Health and
Nutrition Examination Survey (NHANES III) between 1988 and 1994 were assessed to
estimate the prevalence of the metabolic syndrome as defined by the NCEP ATP III.
17
D
y
s
l
i
p
i
d
e
m
i
a
Dyslipidemia and Cardiovascular Risk Reduction:
A Review Based on the Evidence
26
NCEP ATP III Risk Categories
Expert Panel
7
; Grundy SM et al.
14
T
A
B
L
E
3
Risk Category Criteria
Low risk 0-1 risk factor
Moderate risk 2 risk factors; 10-year risk <10%
Moderately
high risk
2 risk factors; 10-year risk 10% -20%
High risk
CHD or CHD risk equivalents, or 2
risk factorswith a 10-year risk >20%
Very high risk
Established CVD plus1 of 4
additional factors
CPCE38807. Home Study wkbk.Dyslip. Chapter.v7.qxp 9/4/2007 3:11 PM Page 26
Prevalence overall increased from 6.7% at ages 20 to 29 years to a peak of 43.5% at ages
60 to 69 years, which can be extrapolated to mean that approximately 47 million US
adults have the metabolic syndrome.
17
Although prevalence differed little between men
and women in the different age groups, there were gender differences by ethnic group.
NCEP Guidelines in a Nutshell
Primary care clinicians can take 3 essential steps to help their patients reap the greatest
possible benefit from lipid-lowering efforts:
Identify individuals at increased risk of CHD and CV events
Start appropriate treatment in a timely manner
Monitor treatment to ensure that it enables patients to achieve and maintain
goals for lipid control
One of the challenges clinicians face is targeting treatment to have the greatest impact
despite limitations of time and other resources. Patients who are at high risk stand to
gain the greatest benefits from dyslipidemia treatment. Therefore, it is important to iden-
tify patients who have a 10-year Framingham risk score >20%, plan a treatment strategy
to reach their lipid goals, and monitor their progress on treatment.
Even in patients with a 10% risk score, CVD risk is still considerable. These patients
may start with TLCs, but most will need the addition of lipid-lowering medications to
reach goal. Patients who are at lower levels of risk should also be informed about health
conditions and risks that may develop, as well as the measures they can take to avoid
CVD in the future. This information may help motivate patients to follow through and
possibly prevent adverse outcomes.
27 www.practicingclinicians.com
D
y
s
l
i
p
i
d
e
m
i
a
Metabolic Syndrome Def initions: AHA/NHLBI and IDF
WC = waist circumference. * Or receiving treatment for thislipid abnormality.
100