Advertisement

Management of Dyslipidemias

Part of the Contemporary Cardiology book series (CONCARD)

Abstract

This chapter covers the following areas:
  • The salient points related to diagnosis of dyslipidemias and advance beyond the National Cholesterol Education Program (NCEP) guidelines (1).

  • The revolutionary statins: the changes in management of dyslipidemia based on the proven effectiveness of statins in achieving goal low-density lipoprotein (LDL-C) levels and improvement in survival. In patients with coronary heart disease (CHD), statins result in an approximately 29% decrease in risk of cardiac death and about 20% decrease in total mortality. The decrease in the risk of mortality provided by statins is equal to that observed with angiotensin-converting enzyme (ACE) inhibitors, whereas the combined effects of estrogens, antioxidants, folic acid, vitamin E, and herbal remedies are insignificant, and their effects are unfairly exploited, to the detriment of patients who are thus deprived of proven mortality- and morbidity-reducing agents. It is not surprising, therefore, that τ;40% of individuals who require aggressive control of dyslipidemia are not receiving adequate treatment. Goal LDL-C must be achieved if we are to stem the plague of CHD.

  • LDL-C-HDL-C goal: Agents that decrease LDL-C to goal and also increase high- density lipoprotein (HDL-C) levels by τ;20% are ideal agents. Although fibrates significantly increase HDL-C, they only modestly decrease LDL-C and rarely achieve goal LDL-C levels. Fortunately, newer statins such as atorvastatin and rosuvastatin have been shown to decrease LDL-C by 40–50% and virtually always achieve goal levels except in patients with genetic familial hyperlipidemia.

Keywords

National Cholesterol Education Program Scandinavian Simvastatin Survival Study Coronary Atheroma Scandinavian Simvastatin Survival Study Group Early Recurrent Ischemic Event 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Expert Panel, Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004; 110:227–239. [Erratum, Circulation 2004;l 10:763.]CrossRefGoogle Scholar
  2. 2.
    ASTEROID: Nissen SE, Nicholls SJ, Sipahi I, et al. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: The ASTEROID trial. JAMA 2006;295:1556–1565.PubMedCrossRefGoogle Scholar
  3. 3.
    Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004;350:1495–1504.PubMedCrossRefGoogle Scholar
  4. 4.
    Schwartz GG, Olsson AG, Ezekowitz MD, et al. for the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) Study Investigators. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes. The MIRACL STUDY: A randomized controlled trial. JAMA 2001;285:1711–1718.PubMedCrossRefGoogle Scholar
  5. 5.
    Ridker PM, Cannon CP, Morrow D, et al. for the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI 22) Investigators. C-reactive protein levels and outcomes after statin therapy. N Engl J Med 2005;352:20–28.PubMedCrossRefGoogle Scholar
  6. 6.
    Brown MS, Goldstein JL. A receptor-mediated pathway for cholesterol homeostasis. Science 1979;323: 361.Google Scholar
  7. 7.
    Gundersen T, Kjekshus J, Stokke O, et al. Timolol maleate and HDL cholesterol after myocardial infarction. Eur Heart J 1985;6:840.PubMedGoogle Scholar
  8. 8.
    Valimaki M, Maass L, Harno K, et al. Lipoprotein lipids and apoproteins during beta-blocker administration: Comparison of penbutolol and atenolol. Eur J Clin Pharmacol 1986;30:17.PubMedCrossRefGoogle Scholar
  9. 9.
    Khan M Gabriel. Angina. Dyslipidemias. In: Heart Disease, Diagnosis and Therapy. Totowa, NJ, Humana Press, 2005.Google Scholar
  10. 10.
    Trustwell AS. End of a static decade for coronary disease? BMJ 1984;289:509.CrossRefGoogle Scholar
  11. 11.
    Pietinen P, Huttunen JK. Dietary determinants of plasma high-density lipoprotein cholesterol. Am Heart J 1987;113:620.PubMedCrossRefGoogle Scholar
  12. 12.
    Sanders TAB, Roshanai F. The influence of different types of n-3-polyunsaturated fatty acids on blood lipids and platelet function in healthy volunteers. Clin Sci 1983;64:91.PubMedGoogle Scholar
  13. 13.
    Nestel PH, Connor WE, Reardon MF, et al. Suppression by diets rich in fish oil on very low density lipoprotein production in man. J Clin Invest 1984;74:82.PubMedCrossRefGoogle Scholar
  14. 14.
    Illingworth DR, Harris WS, Connor WE. Inhibition of low density lipoprotein synthesis by dietary omega-3 fatty acids in humans. Arteriosclerosis 1984;4:270.PubMedGoogle Scholar
  15. 15.
    Singer P, Wirth M, Voigt S, et al. Blood pressure and lipid-lowering effect of mackerel and herring diet in patients with mild essential hypertension. Atherosclerosis 1985;56:223.PubMedCrossRefGoogle Scholar
  16. 16.
    Van Lossonczy TO, Ruiter A, Bronsgeest-Schoute HC, et al. The effect of a fish diet on serum lipids in healthy human subjects. Am J Clin Nutr 1985;31:1340.Google Scholar
  17. 17.
    Fehily AM, Burr ML, Phillips KM, Deadman NM. The effect of fatty fish on plasma lipid and lipoprotein concentrations. Am J Clin Nutr 1983;38:349.PubMedGoogle Scholar
  18. 18.
    Hepburn FN, Exler J, Weihrauch JL. Provisional tables on the content of omega-3 fatty acids and other fat components of selected foods. J Am Diet Assoc 1986;86:788.PubMedGoogle Scholar
  19. 19.
    Exler J, Wehlrauch JL. Provisional table on the content of omega-3 fatty acids and other fat components in selected seafoods (Publication HNIS/PT-103). Washington, DC, US Department of Agriculture, 1986.Google Scholar
  20. 20.
    de Lorgeril M, Renaud S, Mamelle N, et al. Mediterranean alpha-linolenic acid rich diet in secondary prevention of coronary heart disease. Lancet 1994;343:1454.PubMedCrossRefGoogle Scholar
  21. 21.
    de Lorgeril M, Salen P, Maril JL, et al. Mediterranean diet: Traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: Final report of the Lyon Diet Heart Study. Circulation 1999;99:779.PubMedGoogle Scholar
  22. 22.
    Maxwell AJ, Zapien MP, Pearce GL, et al. Randomized trial of a medical food for the dietary management of chronic, stable angina. J Am Coll Cardiol 2002;39:37.PubMedCrossRefGoogle Scholar
  23. 23.
    CARE: For the Cholesterol and Recurrent Events Trial Investigators. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996; 335:1001.CrossRefGoogle Scholar
  24. 24.
    Willett WC, Stamper MJ, Manson JE, et al. Intake of trans fatty acids and risk of coronary heart disease among women. Lancet 1994;341:581.CrossRefGoogle Scholar
  25. 25.
    American Heart Association: Heart and Stroke Statistical Update. Dallas, AHA, 1997.Google Scholar
  26. 26.
    Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995;333:1301.PubMedCrossRefGoogle Scholar
  27. 27.
    Wierbicki AS, Lumb PJ, Semra YK, et al. Effect of atorvastatin on plasma fibrinogen. Lancet 1998;351: 569.CrossRefGoogle Scholar
  28. 28.
    Oliver MF, for the MAAS Investigators. Effect of simvastatin on coronary atheroma: The Multi-Centre Anti-Atheroma Study (MAAS). Lancet 1994;344:633.CrossRefGoogle Scholar
  29. 29.
    Hunninghake DB, Stein EA, Dujovne CA. The efficacy of intensive dietary therapy alone or combined with lovastatin in outpatients with hypercholesterolemia. N Engl J Med 1993;328:1213.PubMedCrossRefGoogle Scholar
  30. 30.
    Tobert JA, Sheer CL, Chremos AN, etal. Clinical experience with lovastatin. Am J Cardiol 1990;65:23F.PubMedCrossRefGoogle Scholar
  31. 31.
    O’Connor P, Freely J, Shepherd J. Lipid lowering drugs. BMJ 1990;300:667.PubMedGoogle Scholar
  32. 32.
    Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344:1383.CrossRefGoogle Scholar
  33. 33.
    Pitt B, Mancini GBJ, Ellis SG, et al. Pravastatin limitation of atherosclerosis in the coronary arteries. J Am Coll Cardiol 1995;26:1133.PubMedCrossRefGoogle Scholar
  34. 34.
    Hoeg JM, Maher MB, Bailey KR, et al. Comparison of six pharmacological regimens for hypercholesterolemia. Am J Cardiol 1987;59:812.PubMedCrossRefGoogle Scholar
  35. 35.
    Vega GL, Grundy SM. Treatment of primary moderate hypercholesterolemia with lovastatin (mevinolin) and colestipol. JAMA 1987;2571:33.CrossRefGoogle Scholar
  36. 36.
    Sommariva D, Bonfiglioli D, Tirrito M, et al. Probucol and cholestyramine combination in the treatment of severe hypercholesterolemia. Int J Clin Pharmacol Ther Toxicol 1986;24:505.PubMedGoogle Scholar
  37. 37.
    Jacobson TA, Chin MM, Fromell GJ, et al. Fluvastatin with or without niacin for hypercholeserolemia. Am J Cardiol 1994;74:149.PubMedCrossRefGoogle Scholar
  38. 38.
    Murati EN, Peters TK, Leitersdorf E. Fluvastatin in familial hypercholesterolemia: A cohort analysis of the response to combination treatment. Am J Cardiol 1994;73:30D.CrossRefGoogle Scholar
  39. 39.
    Rosenson RS, Frauenheim WA. Safety of combined pravastatin-gemfibrozil therapy. Am J Cardiol 1994; 74:499.PubMedCrossRefGoogle Scholar
  40. 40.
    Lipid Research Clinics Coronary Primary Prevention Trial Results. I. Reduction in incidence of coronary heart disease. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. JAMA 1984;251:351.CrossRefGoogle Scholar
  41. 41.
    Mullin GE, Greenson JK, Mitchell MC. Fulminant hepatic failure alter ingestion of sustained-release nicotinic acid. Ann Intern Med 1989;111:253.PubMedGoogle Scholar
  42. 42.
    Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study: Primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. N Engl J Med 1987;317:1237.PubMedCrossRefGoogle Scholar
  43. 43.
    Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): Randomised controlled trial. The FIELD study investigators. Lancet 2005; 366:1849–1861.Google Scholar
  44. 44.
    PROVE IT-TIMI 22: Ray KK, Cannon CP, Cairns R, et al. for the PROVE IT-TIMI 22 Investigators. Relationship between uncontrolled risk factors and C-reactive protein levels in patients receiving standard or intensive statin therapy for acute coronary syndromes in the PROVE IT-TIMI 22 TRIAL. J Am Coll Cardiol 2005;46:1417–1424.PubMedCrossRefGoogle Scholar
  45. 45.
    CARE: For the Cholesterol and Recurrent Events Trial Investigators. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335: 1001.CrossRefGoogle Scholar
  46. 46.
    TNT: Larosa JC, Grundy SM, Waters DD, et al. for the Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005; 352:1425–1435.PubMedCrossRefGoogle Scholar
  47. 47.
    IDEAL: Pedersen TR, Faergeman O, Kastelein JJP, et al. High-dose atorvastatin versus usual-dose simvastatin for secondary prevention after myocardial infarction: The IDEAL study: A randomized controlled trial. JAMA 2005;294:2437–2445.PubMedCrossRefGoogle Scholar
  48. 48.
    LIPID Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998;339:1349–1357.CrossRefGoogle Scholar

Suggested Reading

  1. Baigent C, Keech A, Kearney PM, et al. Efficacy and safety of cholesterol-lowering treatment: Prospective meta-analysis of data from 90,05 6 participants in 14 randomised trials of statins. Lancet 2005;366:1267–1278.PubMedCrossRefGoogle Scholar
  2. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004;350:1495–1504.PubMedCrossRefGoogle Scholar
  3. Cannon CP, Steinberg B A, Murphy S A, et al. Meta-analysis of cardiovascular outcomes trials comparing intensive versus moderate statin therapy. J Am Coll Cardiol 2006;48:438–445.PubMedCrossRefGoogle Scholar
  4. Deedwania P, Barter P, Carmena R, et al. for the Treating to New Targets Investigators. Reduction of low-density lipoprotein cholesterol in patients with coronary heart disease and metabolic syndrome: Analysis of the Treating to New Targets study. Lancet 2006;368:919–928.PubMedCrossRefGoogle Scholar
  5. Gotto AM Jr. Statin therapy and the elderly. SAGE advise? Circulation 2007;l15:681–683.CrossRefGoogle Scholar
  6. Griffin BP. Statins in aortic stenosis: new data from a prospective clinical trial. J Am Coll Cardiol 2007;49: 562–564.PubMedCrossRefGoogle Scholar
  7. Khush KK, Waters DD, Bittner V, et al. Effect of high-dose atrovastatin on hospitalization for heart failure: subgroup analysis of the treating to new targets (TNT) study. Circulation 2007;115:576–583.PubMedCrossRefGoogle Scholar
  8. Klein BE, Klein R, Lee KE, et al. Statin use and incident nuclear cataract. JAMA 2006;295:2752–2758.PubMedCrossRefGoogle Scholar
  9. Larosa JC, Grundy SM, Waters DD, et al. for the Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005;352:1425–1435.PubMedCrossRefGoogle Scholar
  10. LIPID Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998;339:1349–1357.CrossRefGoogle Scholar
  11. Nakamura H, Arakawa K, Itakura H, et al. for the MEGA Study Group. Primary prevention of cardiovascular disease with pravastatin in Japan (MEGA Study): A prospective randomized controlled trial. Lancet 2006; 368:1155–1163.PubMedCrossRefGoogle Scholar
  12. Nissen SE, Nicholls S J, Sipahi I, et al. Effect of very high-intensity statin therapy on regression of coronary atherosclerosis: The ASTEROID trial. JAMA 2006;295:1556–1565.PubMedCrossRefGoogle Scholar
  13. Ramasubbu K, Mann DL. The emerging role of statins in the treatment of heart failure. J Am Coll Cardiol 2006; 47:342–344.PubMedCrossRefGoogle Scholar
  14. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383.CrossRefGoogle Scholar
  15. Scirica BM, Morrow DA, Cannon CP. Intensive statin therapy and the risk of hospitalization for heart failure after an acute coronary syndrome in the PROVE IT-TIMI 22 study. J Am Coll Cardiol 2006;47:2326.PubMedCrossRefGoogle Scholar
  16. Setoguchi S, Glynn RJ, Avorn J, et al. Statins and the risk of lung, breast, and colorectal cancer in the elderly. Circulation 2007;115:27–33.PubMedCrossRefGoogle Scholar
  17. Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995;333:1301.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc., Totowa, NJ 2007

Personalised recommendations