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Statin treatment patterns and clinical profile of patients with risk factors for coronary heart disease defined by National Cholesterol Education Program Adult Treatment Panel III.
Kern, DM, Balu, S, Tunceli, O, Anzalone, D
Current medical research and opinion. 2014;(12):2443-51
Abstract
OBJECTIVE To compare clinical characteristics, statin treatment patterns and adherence among patients at different risk for coronary heart disease (CHD) as defined by National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines. METHODS Patients ≥ 18 years old with ≥ 1 claim for dyslipidemia, ≥ 1 statin claim, or ≥ 1 LDL-C value ≥ 100 mg/dL were identified from 1 January 2007 to 31 July 2012. Patients were classified as low risk (LR) (0-1 risk factor: hypertension, age ≥ 45 years [men] or ≥ 55 years [women], or low HDL-C), moderate/moderately high risk (MR) (≥ 2 risk factors), high risk (HR) (CHD or CHD risk equivalent), or very high risk (VHR) (acute coronary syndrome, or established cardiovascular disease plus diabetes or metabolic syndrome). Medication use and lipid levels during the 12 months before and statin use during the 6 months after index were compared across risk groups. RESULTS There were 1,524,351 LR, 242,357 MR, 188,222 HR, and 57,469 VHR patients identified. Statin use was observed in 15% of all patients, but was higher in the VHR group (45%) versus LR (12%), MR (18%), and HR (29%) groups. Simvastatin accounted for 50%-52% of all statin use, and average statin dose was higher among VHR patients compared with all other groups. Adherence was low overall (mean proportion of days covered [PDC]: 0.57), but higher among VHR (0.69) versus others (mean PDC: 0.55, 0.59, and 0.59 in LR, MR, and HR groups, respectively). CONCLUSIONS Statin treatment was low across all risk groups, and VHR patients had higher doses and better adherence compared with other risk groups. However, adherence was not optimal, indicating a potential limited benefit from statin treatment.
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Nutraceuticals and coronary heart disease.
Garcia-Rios, A, Delgado-Lista, J, Alcala-Diaz, JF, Lopez-Miranda, J, Perez-Martinez, P
Current opinion in cardiology. 2013;(4):475-82
Abstract
PURPOSE OF REVIEW Although many reviews have focused on diet as a determinant of coronary heart disease (CHD), little is known about the use of specific nutrients or food products. The aim of this review was to examine the role of several functional foods, or nutraceuticals, in the prevention or treatment of CHD. RECENT FINDINGS CHD continues to be one of the main causes of death in modern societies. Far from diminishing, its prevalence and incidence continue to grow and are probably linked to the increase in metabolic disorders such as obesity, diabetes and metabolic syndrome. Numerous preventive measures and treatments are being considered for these metabolic diseases. In this context, nutraceuticals and functional foods are seen as powerful tools for maintaining health and fighting against cardiometabolic risk factors. For example, the association between saturated fat and the development of CHD has been clearly established. However, the consumption of other sources of fat, such as olive oil enriched in monounsaturated fatty acids, has been associated with beneficial cardiovascular effects. SUMMARY Nutraceuticals have demonstrated physiological effects that have a positive influence on the development of atherosclerosis and therefore of CHD.
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[Is hypertriglyceridaemia a risk factor for coronary heart disease?].
Reiner, Z, Muacević-Katanec, D, Katanec, D, Tedeschi-Reiner, E
Lijecnicki vjesnik. 2012;(3-4):105-11
Abstract
Although it is still not clear whether elevated serum triglycerides are directly atherogenic or not, the results of many studies indicate that they are undoubtedly an important risk factor/biomarker for coronary heart disease (CHD). Therefore, targeting hypertriglyceridaemia should be beneficial for subjects at high risk for CHD. Elevated triglycerides are often accompanied with low HDL cholesterol, particularly in high risk patients with diabetes type 2 and/or metabolic syndrome. Such a disturbance is called atherogenic dyslipidaemia and has an increasing prevalence. The treatment of hypertriglyceridaemia has to be focused primarily on intensive lifestyle changes (weight reduction in obesity, reduction of alcohol consumption as well as reduction of added sugars, fructose and trans-fatty acids, regular aerobic physical activity) by which reduction of up to 50% in triglycerides can be achieved. Subjects with high CHD risk who cannot lower hypertriglyceridaemia by lifestyle measures should be treated with pharmacological therapy. The available medications include fibrates, niacin and prescription omega-3 polyunsaturated fatty acids. If LDL cholesterol is elevated too, combination therapy is needed. Based upon recent studies in such patients a combination of a statin with fenofibrate and/or omega-3 fatty acids can be recommended.
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Gender differences in risk factors for coronary heart disease.
Tan, YY, Gast, GC, van der Schouw, YT
Maturitas. 2010;(2):149-60
Abstract
Coronary heart disease (CHD), traditionally considered a male disease, is also a major threat to women. This review article addresses independent risk factors for CHD that are specific for women as well as non-gender-specific risk factors and how their effects differ between men and women. Although polycystic ovary syndrome (PCOS) in women is associated with an adverse metabolic risk profile, current evidence regarding future risk of CHD is conflicting. Preeclampsia is consistently associated with higher risk of CHD later in life. Menopause is associated with an increased risk of CHD, and the earlier the onset of menopause, the larger the risk. Existing data on postmenopausal hormone therapy (HT) was inconclusive with regard to possible protection when HT is initiated close to menopause in young peri- or postmenopausal women. Evidence on use of low-dose oral contraceptives strongly suggests no increased risk of CHD. Although levels of physical inactivity are similar for men and women, the higher prevalences of hypertension, diabetes, and obesity in older women portends a greater risk in women than in men. Additionally, risk factors like smoking, hypertriglyceridemia and low high-density lipoprotein cholesterol levels have greater impact in women than in men. This review indicates that acknowledgement of non-gender-specific risk factors in addition to those that are unique to women would help optimize diagnosis, treatment and earlier prevention of CHD in women. Further research is needed to ascertain if incorporating these gender-specific risks into a clinically used risk stratification model would change outcome in women.
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Is vitamin K consumption associated with cardio-metabolic disorders? A systematic review.
Rees, K, Guraewal, S, Wong, YL, Majanbu, DL, Mavrodaris, A, Stranges, S, Kandala, NB, Clarke, A, Franco, OH
Maturitas. 2010;(2):121-8
Abstract
Associations have been found between various micronutrients and cardio-metabolic outcomes. Vitamin K deficiency has been associated with increased calcification of the main arteries and with insulin resistance. The present study aimed to examine the association between vitamin K intake and cardio-metabolic outcomes including cardiovascular disease, type 2 diabetes and the metabolic syndrome. A systematic review of the literature was performed in January 2010. Nine electronic databases, and trial registers, reference lists of retrieved articles and citations were searched. Intervention, cohort, case-control or cross-sectional studies in adults were included if they examined the association between vitamin K levels (dietary intake, biomarkers, supplements) on clinical outcomes relevant to cardio-metabolic disease. Five studies met the inclusion criteria (1 trial, 4 cohort studies). Heterogeneity of designs, exposures/interventions and outcomes meant that meta-analysis was not possible. No associations were found between vitamin K1 intake and coronary heart disease (CHD) (4 cohorts) or stroke (2 cohorts) in multivariate analyses. No differences were seen in the prevalence of diabetes in a trial of vitamin K1 supplementation. Two cohorts examined the effects of vitamin K2 intake on the incidence of CHD; both found significant associations where higher vitamin K2 intake was associated with fewer CHD events. Few studies have examined the effects of vitamin K intake on clinical outcomes relevant to cardio-metabolic disorders. None of the studies used biomarkers. Currently there is no evidence for an effect of vitamin K1, but results for vitamin K2 look promising. Further prospective studies are required to confirm these findings.
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Managing diabetic dyslipidemia: aggressive approach.
Spratt, KA
The Journal of the American Osteopathic Association. 2009;(5 Suppl):S2-7
Abstract
The United States is experiencing a marked increase in rates of diabetes mellitus and metabolic syndrome, almost certainly in part due to the increase in obesity rates. This phenomenon is likely to also result in an increased risk of coronary artery disease as risk factors increase exponentially. This article defines diabetic dyslipidemia, the rationale for aggressive treatment, and options for ongoing management, including nonpharmacologic therapy and medications, alone or in combination, for management of all aspects of the lipid profile.
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Intensive lowering of low-density lipoprotein cholesterol levels for primary prevention of coronary artery disease.
Karalis, DG
Mayo Clinic proceedings. 2009;(4):345-52
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Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the United States, and a high concentration of low-density lipoprotein cholesterol (LDL-C) is a major risk factor for CAD. Current guidelines recommend the use of statins to lower LDL-C levels for the primary prevention of CAD based on an individual's risk factor profile and baseline LDL-C level. For moderaterisk individuals, those with 2 or more major risk factors for CAD and a Framingham risk score of 10% to 20%, the recommendation is to use a statin to lower LDL-C levels to less than 130 mg/dL. However, up to 40% of individuals who develop CAD have LDL-C levels lower than this cutoff. In 2004, the National Cholesterol Education Program Adult Treatment Panel III guidelines were updated to include an LDL-C goal of less than 100 mg/dL for individuals at moderately high risk of developing CAD. The guidelines identified several risk factors that when present would favor the use of pharmacological therapy to achieve this more aggressive LDL-C goal. This review evaluates the evidence supporting an LDL-C target of less than 100 mg/dL for moderately high-risk individuals and reviews those risk factors that when present help identify patients who would benefit from achieving this lower LDL-C goal. English-language publications in MEDLINE and references from relevant articles published between January 1, 1980, and November 30, 2008, were reviewed. Main keywords searched were coronary artery disease, hyperlipidemia, statins, cardiac risk factors, inflammatory markers, metabolic syndrome, and coronary artery calcium.
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Clinical insights from the Treating to New Targets trial.
Waters, DD
Progress in cardiovascular diseases. 2009;(6):487-502
Abstract
The Treating to New Targets (TNT) trial enrolled 10,001 patients with coronary disease to treatment with atorvastatin, 80 or 10 mg/d, and observed them for a median of 4.9 years. Mean low-density lipoprotein cholesterol (LDL-C) levels were 77 mg/dL in the 80-mg group and 101 mg/dL in the 10-mg group. The primary end point, a composite of cardiovascular death, myocardial infraction, resuscitated cardiac arrest, and stroke, occurred in 10.9% of patients in the 10-mg and 8.7% of patients in the 80-mg group (P = .0002). In large subgroups of patients in TNT, specifically those with diabetes, the metabolic syndrome, chronic kidney disease, or previous coronary bypass (CABG) surgery, the risk of an event was significantly higher than in patients without these features. The absolute risk reduction in the 80-mg group was greater in each of these subgroups than in other TNT patients. The rates of stroke and hospitalization for heart failure were significantly lower in the more aggressively treated patients. A total of 18,696 patients have taken 80 mg of atorvastatin in clinical trials, usually for 4 to 5 years, with an excellent safety record. Pharmacoeconomic studies indicate that treatment with the 80-mg dose instead of the 10-mg dose almost costs neutral in US TNT-like patients (additional cost $181 for 5 years). In summary, wider use of the 80-mg dose of atorvastatin in patients with stable coronary disease is safe, cost-effective, and provides an incremental reduction in coronary events.
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Improvement in lipid profiles over 6 years of follow-up in adults with AIDS and immune reconstitution.
Williams, P, Wu, J, Cohn, S, Koletar, S, McCutchan, J, Murphy, R, Currier, J, ,
HIV medicine. 2009;(5):290-301
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Abstract
OBJECTIVES The aim of the study was to evaluate long-term changes in lipids and to assess other coronary heart disease (CHD) risk factors in highly experienced AIDS patients with immune reconstitution, and to examine their association with antiretroviral therapy (ART). METHODS We evaluated 433 AIDS patients with prior severe immunosuppression and ART-based immune reconstitution, followed in a multicentre prospective observational study between 2000 and 2006. We estimated the prevalence at entry of hypercholesterolaemia and metabolic syndrome, and 10-year CHD risks. Trends in total cholesterol (TC), triglycerides (TG) and high-density lipoprotein (HDL) cholesterol were evaluated over time, and use of specific ART drugs at each study visit was assessed using mixed effect models, adjusting for CHD risk factors and use of lipid-lowering agents. RESULTS At entry to observational follow-up, 28% of the 433 subjects had hypercholesterolaemia and 15% had a predicted 10-year CHD risk above 20%. Average TC and fasting TG levels declined over the follow-up period (median=5.8 years), and these declines were associated with increased use of physician-prescribed lipid-lowering agents and changes in ART regimens. After adjustment for CHD risk factors, TC and TG levels were significantly higher for those on ritonavir-boosted protease inhibitors and those on nonnucleoside reverse transcriptase inhibitors (NNRTIs), particularly efavirenz, than for other patients. CONCLUSIONS Abnormalities in serum lipids were common at baseline but became less so over time, and this improvement was associated with increased use of lipid-lowering agents and selection of ART agents with less deleterious effects on lipids.
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Metabolic efficiency with ranolazine for less ischemia in non-ST elevation acute coronary syndromes (MERLIN TIMI-36) study.
Melloni, C, Newby, LK
Expert review of cardiovascular therapy. 2008;(1):9-16
Abstract
Ranolazine is a piperazine derivative believed to reduce anginal symptoms by preventing ischemia-mediated sodium and calcium overload in myocardial cells through inhibition of the late sodium current (late INa). Three small studies demonstrated the antianginal efficacy of ranolazine alone and in combination with betablockers or calcium channel blockers on conventional end points such as total exercise duration and time to ischemia/angina on a treadmill; however, questions of safety related to QT prolongation, efficacy in women and potential utility in higher risk populations remained. Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST Elevation Acute Coronary Syndromes-Thrombolysis in Myocardial Infarction (MERLIN-TIMI) 36 was a large randomized, double-blind, placebo-controlled trial, which evaluated the efficacy and safety of ranolazine initiated acutely and continued as chronic therapy following a non-ST-segment elevation acute coronary syndrome event. A total of 6560 patients were randomized 1:1 to ranolazine or placebo; the primary efficacy end point of the trial was a composite of cardiovascular death, myocardial infarction or recurrent ischemia. The key safety end points were death from any cause and symptomatic documented arrhythmia. Although statistically significant differences between the ranolazine and placebo groups were not reached in the primary efficacy analysis or in the major secondary outcome end point analyses (cardiovascular death, myocardial infarction or severe recurrent ischemia), the individual component of recurrent ischemia was significantly reduced by ranolazine, and ranolazine was demonstrated to be safe.