Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines

Results of new statin trials: Should the low-density lipoprotein cholesterol treatment guidelines be revised?

In December 2002, the National Cholesterol Education Program published its third expert panel report on the detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Since then, many new studies suggest that a more aggressive approach should be taken in cholesterol therapy. Based on these new clinical trials, the National Cholesterol Education Program published recommended modifications to the Adult Treatment Panel III guidelines in July 2004. There is good evidence to support the proposed modifications to Adult Treatment Panel III, but there is still much uncertainty in many patient subsets. More evidence is necessary to clarify if current treatment guidelines and low-density lipoprotein cholesterol goals are optimal for all patients within each risk category. These guidelines, and the proposed modifications, should be used as a tool to guide therapy that should be tailored to fit the overall risk assessment and needs of the individual patient.

Diabetic dyslipidaemia: insights for optimizing patient management

BACKGROUND

Lipid abnormalities in people with diabetes are likely to play an important role in the development of atherogenesis. These lipid disorders include potentially atherogenic quantitative (increased triglyceride levels and decreased high-density lipoprotein-cholesterol [HDL-C] levels) and qualitative abnormalities of lipoproteins (changes in lipoprotein size, increase in triglyceride content of low-density lipoprotein (LDL) and HDL, glycation of apoproteins and increased susceptibility of LDL to oxidation). Guidelines from the two main diabetes organizations, the International Diabetes Federation and the American Diabetes Association, recommend the aggressive management of diabetic dyslipidaemia to reduce the risk of cardiovascular disease (CVD). Statins are the first choice pharmacological therapy to address diabetic dyslipidaemia due to their effectiveness at lowering LDL-C levels in patients with diabetes. Fibrates (peroxisome proliferator-activated receptor [PPAR]alpha ligands) target another aspect of dyslipidaemia by lower ing triglycerides (to a greater extent than statins) and raising HDL-C levels, especially when baseline levels are low. The PPARgamma agonist, pioglitazone appears to affect lipid metabolism by decreasing plasma triglycerides, increasing HDL-C and decreasing the number of small, dense atherogenic LDL particles.

SCOPE

This paper provides a review of the current literature (based on searches of MEDLINE and EMBASE from 1985 to 2005, inclusive) supporting the recommendations for the management of dyslipidaemia among patients with type 2 diabetes, including new strategies involving drug combinations that achieve good glycaemic and lipidaemic control that could potentially reduce the morbidity and mortality associated with type 2 diabetes.

Prolonged-Release Nicotinic Acid

Prolonged-release (PR) nicotinic acid (niacin) [Niaspan] is an oral, once-daily formulation of the lipid-modifying drug designed to produce less vasodilatory flushing than crystalline immediate-release (IR) nicotinic acid and less hepatotoxicity than previous sustained-release formulations of nicotinic acid.PR nicotinic acid appears to retain the same level of efficacy as crystalline IR nicotinic acid and be better tolerated than older nicotinic acid formulations. Nicotinic acid has beneficial effects on all traditional blood lipid and lipoprotein fractions and is the most effective agent for increasing high-density lipoprotein (HDL)-cholesterol (HDL-C) and reducing lipoprotein(a). The effects of PR nicotinic acid are often additive when used in combination with HMG-CoA reductase inhibitors (statins), making it a useful addition when lipid goals are not achieved with the usual statin monotherapy or when additional correction of a specific lipid abnormality is required. PR nicotinic acid also slows atherosclerotic progression and even appears to produce regression of atherosclerosis in patients on stable statin therapy. PR nicotinic acid is a logical drug choice for treating atherogenic dyslipidaemia commonly associated with type 2 diabetes mellitus and the metabolic syndrome, and has been shown to be effective in patients with diabetes without adversely affecting glycaemic control in the majority of patients. The incidence of vasodilatory flushing with PR nicotinic acid is lower than with IR nicotinic acid and it decreases substantially over time as tolerance develops. To date, there has been no clinically significant hepatotoxicity observed with PR nicotinic acid. Therefore, once-daily PR nicotinic acid appears to maximise the potential benefits of nicotinic acid, while minimising any historical tolerability or safety concerns.

Risk factors for atherosclerotic vascular disease

Several controlled interventional trials have shown the benefit of anti-hypertensive and hypolipidaemic drugs for the prevention of coronary heart disease (CHD). International guidelines for the prevention of CHD agree in their recommendations for tertiary prevention and recommend lowering the blood pressure to below 140 mm/90 mm Hg and low density lipoprotein (LDL)-cholesterol to below 2.6 mmol/l in patients with manifest CHD. Novel recommendations for secondary prevention are focused on the treatment of the pre-symptomatic high-risk patient with an estimated CHD morbidity risk of higher than 20% per 10 years or an estimated CHD mortality risk of higher than 5% per 10 years. For the calculation of this risk, the physician must record the following risk factors: sex, age, family history of premature myocardial infarction, smoking, diabetes, blood pressure, total cholesterol, LDL-cholesterol, high-density lipoprotein (HDL)-cholesterol, and triglyceride. This information allows the absolute risk of myocardial infarction to be computed by using scores or algorithms which have been deduced from results of epidemiological studies. To improve risk prediction and to identify new targets for intervention, novel risk factors are sought. High plasma levels of C-reactive protein has been shown to improve the prognostic value of global risk estimates obtained by the combination of conventional risk factors and may influence treatment decisions in patients with intermediate global cardiovascular risk (CHD morbidity risk of 10%-20% per 10 years or CHD mortality risk of 2%-5% per 10 years).

Prevention of Stroke in Patients with Diabetes mellitus and the Metabolic Syndrome

The basic principles of stroke prevention are the same in patients with diabetes and/or the metabolic syndrome as in those without. Blood-pressure lowering is highly effective in both primary and secondary prevention of stroke in diabetics, and there is no evidence to suggest that the benefits of lipid-lowering therapy are any less. Antiplatelet agents are effective in secondary prevention and may be indicated in asymptomatic diabetic patients, who have a substantially increased risk of acute vascular events. Uncertainty over optimal management of patients with diabetes, and possibly of those with metabolic syndrome, relates more to the thresholds for initiation of treatment. The decision to initiate treatment should depend on the balance between the absolute risk of potentially preventable events and the risks of any complications of treatment. The absolute risks of ischaemic stroke and acute coronary events are significantly increased in diabetics in population-based cohort studies and the recommended thresholds for instigating blood pressure lowering and lipid lowering are therefore lower than in the general population. Optimization of strategies to prevent vascular complications must be a priority, given the rapid rises in the incidence and prevalence of type 2 diabetes and the metabolic syndrome in most populations across the globe.

Kardiovaskuläre Risikoabschätzung – PROCAM und neue Algorithmen der Stratifizierung / Assessment of Cardiovascular Risk – PROCAM and New Algorithms

The absolute risk for myocardial infarction is best determined using algorithms or point schemes which have been developed on the basis of large prospective, epidemiological studies. In Germany, for instance, the PROCAM score developed in Münster is leading in this field. The role of new risk factors lies in the optimum risk prediction in patients with intermediary or high risk for myocardial infarction. It is not necessary to determine additional risk factors in low-risk-patients. At present there is however no conclusive epidemiological evidence so that the decision for investigating newer risk factors lies with the physician in charge. So far the target level for LDL cholesterol in patients with intermediate risk was set at 130 mg/dL, whereas in high risk patients LDL cholesterol should not be more than 100 mg/dL. The results of newer studies suggest that it might be appropriate to define a new category of patients with very high risk in whom the LDL cholesterol value should not exceed 70 mg/dL. This inference must however be substantiated by further studies before it becomes part of the general recommendations for treatment.

The Status of Lipid Management in 1,836 Patients with Coronary Artery Disease: A multicenter survey to evaluate the percentage of Japanese coronary artery disease patients achieving the target low-density lipoprotein cholesterol level specified by the Japan Atherosclerosis Society

To determine the status of lipid management in patients with coronary artery disease (CAD) in Japan, we assessed CAD patients who had been receiving lipid-lowering therapy for six months in a cross-sectional survey conducted between June 2001 and December 2002. We defined the achievement rate as the percentage of patients who achieved the target LDL-C level (< 100 mg/dl) specified by the Japan Atherosclerosis Society (JAS). A total of 1,836 Japanese CAD patients were enrolled. In total, 549 (29.9%) achieved the target level. The achievement rate among those receiving statin therapy was 41.3%, which was significantly higher than that (23.4%) among the patients not receiving statin (P < 0.0001). The rate differed with the type of statin; being 54.7% for atorvastatin, 24.8% for pravastatin, 37.1% for simvastatin, and 27.8% for fluvastatin. A multiple regression analysis revealed that atorvastatin use (P < 0.001), and simvastatin use (P = 0.004) significantly contributed to the achievement of the target LDL-C level. In conclusion, large proportions of CAD patients are not achieving the JAS target and the success rates are not similar among different statin therapies, suggesting that cardiologists should consider a more aggressive lipid-lowering therapy with the appropriate choice of statins in Japanese CAD patients.

Management of diabetic dyslipidemia: need for reappraisal of the goals

Cardiovascular disease is the leading cause of mortality among people with diabetes mellitus, accounting for 70% of all deaths. As the prevalence of diabetes increases significantly worldwide, greater attention must be focused on preventing cardiovascular events in this group. One contributor to this increased event rate is the characteristic pattern of dyslipidemia in diabetic patients, consisting of elevated serum triglyceride levels, decreased high-density lipoprotein levels, and an increased proportion of small, dense, low-density lipoproteins. Several pharmacologic agents have been used to treat this dyslipidemia including HMG-CoA reductase inhibitors, fibric acid derivatives, niacin (nicotinic acid), thiazolidinediones, and fish oils, as well as other non-pharmacologic measures. Currently, the most extensive data for a reduction in cardiovascular events in patients with diabetes exist for HMG-CoA reductase inhibitors. The results of these trials indicate that HMG-CoA reductase inhibitor therapy should be considered for all patients with diabetes at sufficient risk for cardiovascular events, regardless of serum low-density lipoprotein-cholesterol level. Several ongoing trials of various pharmacologic agents should help clarify the role of these agents alone and in combination with HMG-CoA reductase inhibitors in the management of diabetic dyslipidemia.

Current Treatment Options for the Metabolic Syndrome

The metabolic syndrome is defined as a condition characterized by a set of clinical criteria: insulin resistance, visceral obesity, atherogenic dyslipidemia, and hypertension. The major risk factors leading to the epidemic of this syndrome in the United States are visceral obesity, physical inactivity, and an atherogenic diet. The available current evidence suggests that the first step in management of patients with metabolic syndrome should be focused on lifestyle modifications (eg, weight loss and physical activity). The treatment should be based on two major components: behavioral change to reduce caloric intake and an increase in physical activity. A realistic goal for weight reduction should be 7% to 10% over 6 to 12 months. The general dietary recommendations include low intake of saturated fats, trans fats and cholesterol, and diets with low glycemic index. Soy protein could be more beneficial than animal protein in weight reduction and correction of dyslipidemia. Physical activity is associated with successful weight reduction and these therapeutic lifestyle changes can reduce by half the progression to new-onset diabetes in patients with metabolic syndrome. Physical activity recommendations should include practical, regular, and moderated regimens of exercise, with a daily minimum of 30 to 60 minutes. An equal balance between aerobic exercise and strength training is advised. Medication therapy is a critical step in the management of patients with metabolic syndrome when lifestyle modifications fail to achieve the therapeutic goals. There is no single best therapy and the treatment should consist of treatment of individual component(s). Atherogenic dyslipidemia should be controlled with statins if there is concomitant increase in low-density lipoprotein cholesterol and if indicated with combination therapy, including fibrates, nicotinic acid, bile acid-binding resins, or ezetimibe. Drugs such as thiazolidinediones and renin-angiotensin system blockers are a few of the available agents in this category. Some evidence suggests that angiotensin-converting enzyme inhibitors and b blockers are more beneficial for treatment of hypertension in patients with metabolic syndrome. Patients with metabolic syndrome also have elevations in fibrinogen and other coagulation factors leading to prothrombotic state and aspirin may be beneficial for primary prevention in these patients. The new developments in the treatment of metabolic syndrome with drugs, such as peroxisome proliferator-activated receptor agonists, will broaden the horizons of the current treatment options in metabolic syndrome.

Statin use in the metabolic syndrome

The metabolic syndrome is a condition associated with obesity, insulin resistance, hypertension, dyslipidemia, hypercoagulability, and chronic inflammation, all of which increase the risk of cardiovascular disease (CVD). The Third National Cholesterol Education Program Adult Treatment Panel extensively discussed the metabolic syndrome because it is a major health issue in the United States due to the national epidemic of obesity. Statins cause significant CVD risk reduction in patients with the metabolic syndrome by alterations in lipid levels and possibly by decreasing inflammation. Because of the increased CVD risk associated with the metabolic syndrome and extensive clinical trial evidence documenting reduction of CVD risk with statin treatment, all patients with the metabolic syndrome should be evaluated as candidates for statin treatment as part of a multidisciplinary approach to reduce CVD risk.

A constellation of complications:The metabolic syndrome

The metabolic syndrome is a common cluster of risk factors for coronary heart disease and type 2 diabetes mellitus that includes obesity, elevated blood pressure, insulin resistance, and dyslipidemia. The diagnosis of metabolic syndrome itself appears to be an important risk factor for atherogenic cardiovascular disease and diabetes, and there is recent evidence that its components cluster, rather than occurring together by coincidence. A recent statement from the American Heart Association and the National Heart, Lung, and Blood Institute slightly modifies and clarifies the diagnostic criteria for the metabolic syndrome that are most widely used in the United States, along with giving practical guidance about management. Prompt therapeutic attention to the underlying risk factors--abdominal obesity, physical inactivity, and atherogenic/diabetogenic diet--is warranted for all patients with the metabolic syndrome, and drug therapy for specific metabolic risk factors should be considered for those at high or moderately high 10-year absolute risk of atherosclerotic cardiovascular disease. A new class of investigational drugs that block cannabinoid type 1 receptors have shown promise. This review also discusses issues that require additional research and new drugs that are considered promising for treatment of the metabolic syndrome itself.

Should We Screen Asymptomatic Individuals for Coronary Artery Disease or Implement Universal Lipid-Lowering Therapy?

The lifetime risk of developing coronary heart disease after age 40 has been estimated to be 49% and 32% in men and women, respectively. Including other diseases secondary to atherosclerosis makes the likelihood of developing cardiovascular disease even greater. Lacking an adequate screening test for subclinical cardiovascular disease, or for those in whom it will develop, our current national prevention and treatment strategy is to screen for risk factors of coronary artery disease (CAD), treating only those at greatest risk. Although pharmacologic lipid-lowering therapy has proven to be effective at reducing the development and manifestations of CAD, as well as remarkably safe, our current strategy withholds treatment of many in whom cardiovascular disease will ultimately develop. An alternate strategy is to implement universal lipid-lowering therapy, initiated in men at age 30 and at the time of menopause in women. Such a policy would not limit effective treatment to only those at greatest risk. While the cost of such a program would be substantial, although decreasing with the increasing availability of generic agents, this must be weighed against the direct and indirect costs of cardiovascular disease, estimated to be $368 billion in 2004. If such a strategy were implemented, the goal of screening would shift from CAD detection to detection of a disease burden such that therapies shown to decrease events among those with manifest CAD would be expected to benefit. Such treatments currently include aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and revascularization.

Clinical Update on the Use of Niacin for the Treatment of Dyslipidemia

PURPOSE

To provide nurse practitioners (NPs) with clinical and practical information about the use of niacin in the treatment of dyslipidemia.

DATA SOURCES

Research-based and review articles in the medical literature and National Cholesterol Education Program guidelines.

CONCLUSIONS

Niacin provides beneficial effects on all major lipid fractions, particularly high-density lipoprotein cholesterol and triglycerides. Niacin also reduces low-density lipoprotein (LDL) cholesterol; lipoprotein (a); and the number of highly atherogenic small, dense LDL particles. Niacin promotes angiographic regression when used in combination with other drugs that lower LDL cholesterol and can reduce cardiovascular risk in patients with coronary heart disease. Several niacin formulations are available, but the safety (i.e., from hepatotoxicity) and tolerability (i.e., severity of flushing) of these niacin formulations may differ.

IMPLICATIONS FOR PRACTICE

Niacin therapy is appropriate for many types of lipid abnormalities, including complex dyslipidemias. NPs can take several steps to minimize potential side effects of niacin therapy and to ensure that patients adhere to this important intervention.

Impaired glucose metabolism in patients with heart failure: pathophysiology and possible treatment strategies

The firm association of diabetes mellitus with congestive heart failure (CHF) has been undoubtedly established. Recent reports support the presence of the reciprocal interrelationships between CHF and glucose abnormalities. The present review provides an overview of some aspects of the multifactorial interrelationships between heart failure and diabetes mellitus. Patients with heart failure are generally at higher risk of developing type 2 diabetes mellitus. Several factors may be involved, such as a lack of physical activity, hypermetabolic state, intracellular metabolic defects, poor muscle perfusion, and poor nutrition. Serum levels of inflammatory cytokines and leptin are elevated in patients with heart failure. Activation of the sympathetic system in CHF not only increases insulin resistance but also decreases the release of insulin from the pancreatic beta cells, increases hepatic glucose production by stimulating both gluconeogenesis and glycogenolysis, and increases glucagon production and lipolysis. People who develop type 2 diabetes mellitus usually pass through the phases of nuclear peroxisome proliferator-activated receptor modulation, insulin resistance, hyperinsulinemia, pancreatic beta-cell stress and damage leading to progressively decreasing insulin secretion, and impaired fasting and postprandial blood glucose levels. Once hyperglycemia ensues, the risk of metabolic and cardiovascular complications also increases. It is possible that the cornerstone of diabetes mellitus prevention in patients with CHF could be controlled by increased physical activity in a cardiac rehabilitation framework. Pharmacologic interventions by some medications (metformin, orlistat, ramipril and acarbose) can also effectively delay progression to type 2 diabetes mellitus in general high risk populations, but the magnitude of the benefit in patients with CHF is unknown. In patients with CHF and overt diabetes mellitus, ACE inhibitors may provide a special advantage and should be the first-line agent. Recent reports have suggested that angiotensin receptor antagonists (angiotensin receptor blockers), similar to ACE inhibitors, provide beneficial effects in patients with diabetes mellitus and should be the second-line agent if ACE inhibitors are contraindicated. Treatment with HMG-CoA reductase inhibitors should probably now be considered routinely for all diabetic patients with CHF, irrespective of their initial serum cholesterol levels, unless there is a contraindication.

[Oral diabetes treatment. Which substance is indicated at which time?]

The prevalence of type 2 diabetes continues to show a clear upward trend in Germany. In earlier days it was considered the "harmless diabetes of old age," but has become increasingly recognized as a disease carrying a high risk of vascular sequelae as well as shortening the diabetic's remaining life expectancy if adequate therapy is not initiated. In addition to correcting hyperglycemia, treatment consists in effective management of concomitant risk factors such as hypertension, dyslipidemia, and adiposity resulting from faulty nutrition and lack of exercise. In the large majority of overweight type 2 diabetics, metformin is the oral antidiabetic agent of first choice provided the patient does not exhibit renal insufficiency, which represents the most important contraindication. This recommendation for monotherapy of overweight type 2 diabetics is supported by an endpoint study. In contrast, no equivalent evidence is available on any of the possible options for oral combination therapy.

Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER) 2: a double-blind, placebo-controlled study of extended-release niacin on atherosclerosis progression in secondary prevention patients treated with statins

BACKGROUND

Niacin reduces coronary heart disease morbidity and mortality when taken either alone or in combination with statins; however, the incremental impact of adding niacin to background statin therapy is unknown.

METHODS AND RESULTS

This was a double-blind randomized placebo-controlled study of once-daily extended-release niacin (1000 mg) added to background statin therapy in 167 patients (mean age 67 years) with known coronary heart disease and low levels of high-density lipoprotein cholesterol (HDL-C; <45 mg/dL). The primary end point was the change in common carotid intima-media thickness (CIMT) after 1 year. Baseline CIMT (0.884+/-0.234 mm), low-density lipoprotein cholesterol (89+/-20 mg/dL), and HDL-C (40+/-7 mg/dL) were comparable in the placebo and niacin groups. Adherence to niacin exceeded 90%, and 149 patients (89.2%) completed the study. HDL-C increased 21% (39 to 47 mg/dL) in the niacin group. After 12 months, mean CIMT increased significantly in the placebo group (0.044+/-0.100 mm; P<0.001) and was unchanged in the niacin group (0.014+/-0.104 mm; P=0.23). Although the overall difference in IMT progression between the niacin and placebo groups was not statistically significant (P=0.08), niacin significantly reduced the rate of IMT progression in subjects without insulin resistance (P=0.026). Clinical cardiovascular events occurred in 3 patients treated with niacin (3.8%) and 7 patients treated with placebo (9.6%; P=0.20).

CONCLUSIONS

The addition of extended-release niacin to statin therapy slowed the progression of atherosclerosis among individuals with known coronary heart disease and moderately low HDL-C.

Fluvastatin and fluvastatin extended release: a clinical and safety profile

Cardiovascular diseases due to atherosclerosis are the leading causes of mortality in the Western world. Cholesterol-lowering therapy with 3-hydroxy-3-methylglutaryl coenzyme Areductase inhibitors (statins) has demonstrated a reduction in cardiovascular morbidity and mortality in diverse populations. Fluvastatin (Lescol, Novartis Pharmaceuticals) was the first totally synthetic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor on the market and has recently become available in an extended-release formulation (Lescol XL, Novartis Pharmaceuticals). Data from several clinical outcome trials have shown substantial benefits from fluvastatin treatment in diverse populations. Fluvastatin exists primarily in its acid form and as inactive metabolites in vivo, while active metabolites as well as the lactone form are only present in small amounts. The demonstration of the safe use of fluvastatin in a wide range of patients may be associated with the predominant acid form of the drug in vivo, as well as its predominant metabolism via the cytochrome P450 2C9 pathway.

Treatment of lipids and type 2 diabetes

The development of type 2 diabetes is increasing in epidemic proportions. There is a significant risk for cardiovascular disease, which is the most prevalent and detrimental complication for the diabetic population. Serum lipid abnormalities are common in patients with diabetes, and due to this increased vascular risk, it is recommended to aggressively treat the hyperlipidemia. Therefore, intensive lipid-lowering therapy should be used for primary and secondary prevention against macrovascular complications for patients with type 2 diabetes. In this article some of the key studies justifying the need for lipid reduction in patients with type 2 diabetes are reviewed and practical guidelines for management of the dyslipidemia are suggested.

A multicenter, randomized, double-blind, placebo-controlled, factorial design study to evaluate the lipid-altering efficacy and safety profile of the ezetimibe/simvastatin tablet compared with ezetimibe and simvastatin monotherapy in patients with primary hypercholesterolemia

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety profile of ezetimibe/simvastatin(EZE/SIMVA) combination tablet, relative to ezetimibe (EZE) and simvastatin (SIMVA) monotherapy, in patients with primary hypercholesterolemia.

METHODS

This was a randomized, multicenter, double-blind, placebo-controlled, factorial design study After a 6- to 8-week washout period and 4-week, single-blind, placebo run in, hypercholesterolemic patients (low-density lipoprotein cholesterol [LDL-C], 145-250 mg/dL; triglycerides [TG], < or =350 mg/dL) were randomized equally to 1 of 10 daily treatments for 12 weeks: EZE/SIMVA 10/10, 10/20, 10/40, or 10/80 mg; SIMVA 10, 20, 40, or 80 mg; EZE 10 mg; or placebo. The primary efficacy analysis was mean percent change from baseline in LDL-C to study end point Secondary end points included percent changes in other lipid variables and C-reactive protein [CRP].

RESULTS

There were 1528 patients randomized to treatment (792 women, 736 men); mean (SD) age ranged from 54.9 (112) years to 56.4 (10.6) years across pooled treatment groups. The treatment groups were well balanced for baseline demographics. Pooled EZE/SIMVA was associated with greater reductions in LDL-C than pooled SIMVA or EZE alone (P < 0.001). Depending on dose, EZE/SIMVA was associated with reductions in LDL-C of -44.8% to -602%, non-high-density lipoprotein cholesterol of -40.5% to -55.7%, and TG of -22.5% to -30.7%; high-density lipoprotein cholesterol increased by 5.5% to 9.8%. EZE/SIMVA was associated with greater reductions in CRP and remnant-like particle-cholesterol than SIMVA alone (P < 0.001). More patients receiving EZE/SIMVA versus SIMVA achieved LDL-C concentrations <100 mg/dL (78.6% vs 45.9%; P < 0.001). EZE/SIMVA was generally well tolerated, with a safety profile similar to SIMVA monotherapy There were no significant differences between EZE/SIMVA and SIMVA in the incidence of consecutive liver transaminase levels > or =3 times the upper limit of normal (ULN) (1 .5% for EZE/SIMVA and 1.1% for SIMVA; P = NS) or creature kinase levels > or =10 times ULN (0.0% for EZE/SIMVA and 02% for SIMVA; P = NS).

CONCLUSION

The EZE/SIMVA tablet was a highly effective and well-tolerated LDL-C-lowering therapy in this study of patients with primary hypercholesterolemia.

Markers of Myocardial Injury and Dysfunction

Acute coronary syndrome (ACS) is defined as the spectrum of diagnoses from angina to sudden cardiac death caused by ischemic coronary artery disease. Although cardiovascular disease is the leading cause of death of adults in the United States, the ability to diagnose ACS is not always definitive. Cardiac markers are laboratory tests that are used to assist in the diagnosis. Research continues to develop new and refine "old" cardiac markers to improve diagnostic testing that then leads to appropriate and timely interventions for patients with ACS. The purpose of this article is to review the cardiac markers and their role in the diagnosing, as well as predicting the risk of ACS.

Secondary prevention strategies in ischemic stroke: identification and optimal management of modifiable risk factors

The identification and treatment of modifiable Ischemic stroke risk factors, in addition to appropriate antithrombotic therapy, can reduce the likelihood of first or recurrent stroke, prevent long-term morbidity and mortality after first stroke or transient Ischemic attack, and lower health care costs. Long-term morbidity and mortality in patients with ischemic stroke includes patients with coronary artery disease. Therefore, in patients with ischemic stroke (especially those with carotid artery disease and lacunar disease), the goal is to prevent not only recurrent stroke but also coronary artery disease. Neurologists and general practitioners must be aware of the specific risk factors and recommendations for patients with ischemic stroke and apply the information systematically. We review known risk factors for ischemic stroke and current recommendations for treatment, focusing primarily on atherosclerotic risk factors as they apply to patients with stroke. In particular, recent data on hypertension and hyperlipidemia are described. In addition, we discuss the challenges in managing these risk factors and the potential strategies for overcoming them.

Biosynthesis of isoprenoids via the non-mevalonate pathway

The mevalonate pathway for the biosynthesis of the universal terpenoid precursors, isopentenyl diphosphate (IPP) and dimethylallyl diphosphate (DMAPP), is known in considerable detail. Only recently, the existence of a second mevalonate-independent pathway for the biosynthesis of IPP and DMAPP was detected in plants and certain eubacteria. Experiments with 13C and/or 2H-labelled precursors were crucial in the elucidation of this novel route. The pathway is essential in plants, many eubacteria and apicomplexan parasites, but not in archaea and animals. The genes, enzymes and intermediates of this pathway were rapidly unravelled over the past few years. Detailed knowledge about the mechanisms of this novel route may benefit the development of novel antibiotics, antimalarials and herbicides.

Cost-effectiveness of ezetimibe coadministration in statin-treated patients not at cholesterol goal: application to Germany, Spain and Norway

BACKGROUND

Despite the growing use of statins, many hypercholesterolaemic patients fail to reach their lipid goal and remain at elevated risk of coronary heart disease (CHD). Alternative treatment strategies, such as ezetimibe coadministration and statin titration, can help patients achieve greater lipid control, and thereby lower their CHD risk. But is it cost effective to more aggressively lower cholesterol levels across a broad range of current statin users?

METHODS

Using a decision-analytic model based on epidemiological and clinical trials data, we project the lifetime benefit and cost of alternative lipid-lowering treatment strategies for CHD and non-CHD diabetic patients in Germany, Spain and Norway.

RESULTS

It is projected that from 40% to 76% of these patients who have failed to reach their lipid goal with their current statin treatment will be able to reach their goal with ezetimibe coadministration; this represents a gain of up to an additional absolute 14% who will be able to reach their goal compared with a 'titrate to goal' strategy where patients are titrated in order to reach their lipid goal (up to the maximum approved dose). For CHD patients, the estimated incremental cost-effectiveness ratio for ezetimibe coadministration is under Euro 18 000 per life-year gained (Euro/LYG) and 26 000 Euro/LYG compared with strategies based on the observed titration rates and the aggressive 'titrate to goal' strategy, respectively; for non-CHD diabetic patients, these ratios are under 26 000 Euro/LYG and 48 000 Euro/LYG for ezetimibe coadministration compared with the two titration strategies.

CONCLUSION

Compared with statin titration, ezetimibe coadministration is projected to be cost effective in the populations and countries studied.

The metabolic syndrome: Diagnosis and treatment

The metabolic syndrome is a clustering of risk factors that, in the aggregate, sharply increase the risk of cardiovascular disease (CVD). The syndrome is characterized by abdominal obesity, a characteristic atherogenic dyslipidemia, hypertension, insulin resistance with or without hyperglycemia, a prothrombotic state, and a proinflammatory state. CVD is the most important clinical sequela of the metabolic syndrome. The syndrome also carries a greatly increased risk for development of type 2 diabetes mellitus, which in turn increases cardiovascular risk even further. Conventional risk formulas may underestimate actual CVD risk in metabolic syndrome patients because of their concentration of nontraditional risk factors. Management of the metabolic syndrome should focus on weight loss, increased physical activity, and improvement of atherogenic diet. Pharmacologic therapy for lipids and blood pressure will be needed in most cases. The atherogenic dyslipidemia includes high triglyceride, low high-density lipoprotein cholesterol levels and small, dense low-density lipoprotein cholesterol particles. Management should allow for statin in virtually all cases, accompanied by a triglyceride-lowering agent in many cases. Hypertension should be managed aggressively, with a blood pressure target of 130/80 mm Hg. Multiple agents are usually required to treat hypertension. Simultaneous management of multiple risk factors has the potential to greatly reduce the incidence of CVD in individuals with the metabolic syndrome.