Rationale for effective treatment of hypercholesterolemia

Cholesterol risk management: a systematic examination of the gap from evidence to practice

Hypercholesterolemia is a major risk factor for coronary heart disease, and data indicate that aggressive cholesterol reduction decreases mortality and morbidity associated with this disease. Many patients with hypercholesterolemia, however, are not screened, prescribed appropriate lipid-lowering therapy, or treated to target cholesterol levels. Practice patterns are particularly inadequate for those patients at highest risk for having a cardiac event. We performed a literature search to identify studies of practice patterns in the management of patients with hypercholesterolemia with regard to screening, implementing lipid-lowering therapy, and treating to lipid goals. The findings highlight the potential for substantial opportunities to improve patient outcomes. Future studies should evaluate reasons for suboptimal cholesterol management as well as provide steps to improve management.

Population-based screening with the Coronary Heart Disease Risk Factor Calculator

Data from the Framingham Heart Study and risk-appraisal models were used to develop a Coronary Heart Disease (CHD) Risk Factor Calculator for early identification of high-risk individuals. The Calculator was tested at an employee health fair for a large northeastern US corporation. Of the 590 employees who registered for cholesterol screening, 514 had their CHD risk calculated, and 134 (26.1%) of this group had a relative risk greater than 2. Elevated risk increased with age, ranging from 26.2% of those younger than 35 years to 75% of the over-64 group. Of special concern was the percentage of individuals below 45 years of age whose relative risk of CHD in the next 10 years was more than twice that of coevals with standard risk. The program also estimates and visually demonstrates possible benefits of interventions, allows monitoring of progress, and serves as an educational aid to motivate behavior modification. In this test, the software functioned as designed, and graphic demonstration of individual risk estimations appeared to motivate several participants to seek medical follow-up.

Safety of drugs commonly used to treat hypertension, dyslipidemia, and type 2 diabetes (the metabolic syndrome): part 1

The benefits of blood pressure lowering, lipid lowering, and glycemic control on morbidity and mortality have been established in major long-term clinical trials. The most extensive information is available for diuretics or beta-blockers in hypertension, hepatic hydroxymethyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) in dyslipidemia, and insulin or sulfonylureas in diabetes. Other drug classes provide similar improvements in blood pressure, lipid profile, and glycemic control, and thereby might be expected to provide comparable long-term benefits. As a result, national guidelines advocate treating patients aggressively in order to achieve control of blood pressure low-density lipoprotein (LDL) cholesterol, and blood glucose. The risks associated with drug treatment are generally class-specific. Among antidiabetic agents, sulfonylureas and insulin are associated with risk for severe hypoglycemia, metformin with risk for lactic acidosis, and troglitazone with risk for idiosyncratic hepatocellular injury. Similarly, widely used antihypertensive and lipid-lowering agents are associated with risk for serious complications, such as angioedema with angiotensin-converting enzyme inhibitors, possible increased risk for myocardial infarction and cancer with calcium antagonists, and myositis and liver dysfunction with statins. Physicians must take an aggressive approach to patient management in order to achieve a level of disease control that optimally reduces risk for morbidity and mortality. Serious adverse events may occur rarely with most drug classes; these events can be minimized by appropriately monitoring or selecting patients for treatment.