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Advances in Lipid Management

Advances in Lipid Management. The National Cholesterol Education Program (NCEP). Launched by National Heart, Lung, and Blood Institute (NHLBI), a part of the NIH, in November, 1985 Impetus: Definitive evidence linking coronary heart disease (CHD) to elevated total cholesterol levels

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Advances in Lipid Management

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  1. Advances inLipid Management

  2. The National Cholesterol Education Program (NCEP) • Launched by National Heart, Lung, and Blood Institute (NHLBI), a part of the NIH, in November, 1985 • Impetus: Definitive evidence linking coronary heart disease (CHD) to elevated total cholesterol levels • Goal: Educating, monitoring, and developing guidelines for lowering blood cholesterol levels NCEP web site.

  3. Coronary Heart Disease: Despite Advances, Still the #1 Killer • Percentage Breakdown of Deaths From Cardiovascular Diseases • United States: 1995 Mortality, Final Data 22% Other 1% Rheumatic Fever/Rheumatic Heart Disease 1% Congenital Heart Defects 50% Coronary Heart Disease 2% Atherosclerosis 4% Congestive Heart Failure 4% High Blood Pressure 16% Stroke American Heart Association. 1998 Heart and Stroke Facts: Statistical Update.

  4. Major Risk Factors for CHD • The NCEP Adult Treatment Panel Identifies Positive Risk Factors (RF) for CHD • Risk Factors • Family history of early CHD • parent or sibling <55 years of age if male, <65 years of age if female • Age • male ³45 years • female ³55 years, or premature menopause without estrogen replacement therapy (ERT) • Hypertensive (BP ³140/90 mm/Hg or taking antihypertensive medication) • Current smoker • Diabetes mellitus • Low HDL-cholesterol (<35 mg/dL) • Negative Risk Factor • If HDL-C is ³60 mg/dL, subtract one risk factor Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, NHLBI; September 1993.

  5. Risk Stratification for Adults Without CHD • Classification Based on LDL-C LDL-C Level Classification <130 mg/dL 130-159 mg/dL 160 mg/dL Desirable Borderline-high risk High risk Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, NHLBI; September 1993.

  6. NCEP Primary CHD Risk Categories and Goals for Lowering LDL-C Risk Category LDL-C Goal No CHD <2 RF <160 mg/dL No CHD 2 RF <130 mg/dL 100 mg/dL CHD The NCEP recommends lowering LDL-C even further than these goals, if possible. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, NHLBI; September 1993.

  7. High-Risk Adults Not Reaching LDL-C Goals in NHANES-III • (National Health and Nutrition Examination Survey) 55% 83% • 55% of patients with 2 risk factors and no CHD did not reach NCEP goal • 83% of CHD patients did not reach NCEP goal Unpublished data from the Third National Health and Nutrition Examination Survey (NHANES-III), CDC 1994; data from 1988–1991.

  8. Lipid Treatment Assessment Project (L-TAP) • Hypothesis • majority of dyslipidemic patients do not achieve NCEP target LDL-C levels • Primary Objective • to determine percentage of primary care patients on diet and/or drug therapy who are achieving NCEP LDL-C goals Pearson TA, Laurora IM. Scientific Sessions of the American Heart Association; 1997; Abstract 361.

  9. L-TAP: % of Patients at LDL-C Goal LDL-C goal Risk group— Lipid-lowering therapy % Success % Failure P-Value Diet therapy2RF (n=282)2RF (n=361)CHD (n=108)Total (n=751) Drug therapy2RF (n= 861)2RF (n=1924)CHD (n=1352)Total (n=4137) 0.001 0.001 59 22 7 34 70 40 18 39 41 78 93 66 30 60 82 61  Does not include patients who were nonevaluable. Person’s chi-square=682.91; d=2; P=0.001. Data on file. Parke-Davis; Morris Plains, NJ. Pearson TA, Laurora IM. Scientific Sessions of the American Heart Association; 1997; Abstract 361.

  10. L-TAP: Identifying the Patient at Risk • Patient Profile With 2 Risk Factors • 92% Male 45 years Female 55 years • 70% Hypertensive (140/90 mm Hg) • 41% Family history of early CHD • 22% Low HDL-C level • 21% Diabetes mellitus • 19% Current smokers CHD Patients No CHD 2 RF 30% 47% No CHD <2 RF 23% Data on file. Parke-Davis; Morris Plains, NJ.

  11. L-TAP: Many High-Risk Adults Are Not Reaching LDL-C Goals • 63% of patients with 2 risk factors and no CHD did not reach NCEP goal 63% 82% • 82% of CHD patients did not reach NCEP goal Data on file. Parke-Davis; Morris Plains, NJ.

  12. L-TAP: Distance From LDL-C Goal in Patients With 2 Risk Factors 63% Not at goal At goal n=849 n=816 No. of patients n=494 n=126 <130 130-160 161-200 >200 LDL-C (mg/dL) Data on file. Parke-Davis; Morris Plains, NJ.

  13. L-TAP: Distance From LDL-C Goal in Patients With CHD 82% Not at goal n=545 n=416 No. of patients At goal n=256 n=243 £100 101-130 131-160 >160 LDL-C (mg/dL) Data on file. Parke-Davis; Morris Plains, NJ.

  14. Relationship Between Cholesterol and CHD Risk: Epidemiologic Trials • Multiple Risk Factor Intervention Trial (MRFIT) (n=361,662) • Framingham Study (n=5209) 50 40 30 20 10 10-year CHD death rate (Deaths/1000) CHD indications per 1000 300 250 200 150 0 204 205-234 235-264 265-294 295 Serum cholesterol (mg/dL) Serum cholesterol (mg/100 mL) 1% reduction in total cholesterol resulted in a 2% decrease in CHD risk Each 1% increase in total cholesterol level is associated with a 2% increase in CHD risk Gotto AM Jr, et al. Circulation. 1990;81:1721-1733. Castelli WP. Am J Med. 1984;76:4-12.

  15. Relationship Between Cholesterol and CHD Risk: Epidemiologic Trials (cont’d) • Okinawa, Japan • Seven Countries Study† Northern Europe Southern Europe, Mediterranean United States Serbia Southern Europe, Inland Japan Cumulative incidence of AMI per 100,000 screened subjects in 2 years CHD mortality rates (%) 125 175 225 275 325 Range167 168-191 192-217 218 Mean 149.3 179.8 203.7 245.3 Serum cholesterol (mg/dL) Serum cholesterol (mg/dL) Using linear approximation, a 20-mg/dL increase in total cholesterol corresponded to a 17% increase in mortality risk Cumulative incidence of acute myocardial infarction (AMI) increased with the level of serum cholesterol  Cumulative incidence of AMI in each quartile of basal serum cholesterol, expressed per 100,000 screened subjects in 3 years.Serum cholesterol was measured between April 1, 1983 and March 31, 1984. † 25-year CHD mortality rates per baseline cholesterol quartile adjusted for age, cigarette smoking, and systolic blood pressure. Wakugami K, Iscki R, Kimura Y, et al. Japanese Circulation Journal. 1998;62:7-14. Verschuren WMM, Jacobs DR, Bloemberg BPM, et al. JAMA. 1995;274:131-136.

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