Most adult patients with CVD are not at recommended levels for all lipids

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1 November 2008

Most adult patients with CVD are not at recommended levels for all lipids – NHANES 2003-2004

In the National Health And Nutrition Examination Survey (NHANES) 2003-2004, less than one fifth of people with cardiovascular disease (CVD) were at recommended levels of the National Cholesterol Education Program (NCEP) for all routine lipids, and less than one half were at goal for HDL-C and triglyceride levels. Lipid values were also suboptimal in cardiovascular disease-free persons.

Ghandehari H, Kamal-Bahl S, Wong ND.

STUDY SUMMARY

Methods

Although epidemiological data collected in the US population have shown improvements in low-density lipoprotein cholesterol (LDL-C) levels, one third of men and one eighth of women have suboptimal high-density lipoprotein cholesterol (HDL-C)¹ and there has actually been an increase in triglyceride levels.²
However, the extent of specific lipid abnormalities had not been reported among individuals with CVD.
The National Health And Nutrition Examination Survey 2003-2004 provided an opportunity to examine among a large representative sample of US adults the distribution of lipid levels and the extent to which recommended levels of all lipids are achieved, notably in people with CVD. For this analysis, recommended levels were adapted from NCEP guidelines:

LDL-C	< 100 mg/dL	≥ 2 risk factors + Framingham risk > 20% or prior CVD, diabetes or chronic kidney disease (CKD)
	< 130 mg/dL	≥ 2 risk factors + Framingham risk ≤ 20%
	< 160 mg/dL	0 to 1 risk factors

Non-HDL-C	< 130 mg/dL	≥ 2 risk factors + Framingham risk > 20% or prior CVD, diabetes or CKD
	< 160 mg/dL	≥2 risk factors + Framingham risk ≤ 20%
	< 190 mg/dL	0 to 1 risk factors

HDL-C	≥ 40 mg/dL	Male
	≥ 50 mg/dL	Female

TG	< 150 mg/dL

Main results

Although 85-89% of persons without CVD were at recommended levels for individual routine lipids (LDL-C, HDL-C, and triglycerides), only 67% were at goal levels for all lipids.
Only 36-37% of patients with CVD were at recommended levels for LDL-C and non–HDL-C, and only 17% were at recommended levels for all lipids. Less than half (45%) achieved recommended levels for both HDL-C and triglycerides.
Data collected in patients with diabetes are also a matter of concern: only a mere 17% had all lipids levels at goal, while 38% had recommended levels of both HDL-C and triglycerides.
Treated persons (vs. untreated) had significantly lower LDL-C (112 vs 157 mg/dL, p < 0.001) and non–HDL-C levels (146 vs 189 mg/dL, p < 0.001), but similar HDL-C (52 vs 50 mg/dL, p=0.09) and triglyceride (160 vs 149 mg/dL, p=0.20) levels.

Figure 1. Percentages of US adults at goal for all lipids and for HDL-C and TG in the overall population, in individuals free of CVD disease, in patients with CVD, in patients with diabetes, and in subjects with metabolic syndrome.
Adapted from Ghandehari H et al., Am Heart J 2008.

COMMENT

Despite treatment availability, two-thirds of people with CVD are still not at recommended levels for LDL-C and non-HDL-C, and the vast majority (83%) are not achieving recommended levels for all lipids.

There remains a significant gap in overall lipid control, particularly for persons with CV comorbidities.

These were the findings of NHANES 2003-2004, which gives a good estimation of lipid levels among the whole US population (Figure 2). The results identified that triglycerides and HDL-C levels are suboptimal in about 40% of all US adults surveyed. Particular alarming are the data collected in patients with known CVD, diabetes and/or metabolic syndrome, even among those on treatment, showing that levels of triglyceride and HDL-C were not well controlled (Figure 1). Indeed, both elevated triglycerides and low HDL-C are important components of atherogenic dyslipidemia and independently confer increased CVD risk.³ Elevated triglycerides are one of the hallmark of insulin resistance states, also associated with an increase in apolipoprotein B100 (apoB) levels, apoB-carrying atherogenic lipoproteins (such as VLDL and LDL) and/or in small dense LDL-C particles.⁴ HDL-C plays an important role in reverse cholesterol transport (RCT), protecting against coronary heart disease (CHD).^5,6 It also has antioxidant and profibrinolytic properties and carries important apolipoproteins such as the atheroprotective apolipoproteins A1.

The inverse relation of HDL-C to CHD risk is well-documented.^5,6
The primary focus of dyslipidemia treatment has been pharmacological modulation of HMG-CoA reductase with HMG-CoA reductase inhibitors (collectively known as “statins”), directed at lowering LDL-C levels. However, there is now an emerging need to identify individuals who require a targeted therapeutic approach to managing all lipid aspects of dyslipoproteinemia, with specific focus on components of atherogenic dyslipidemia.

Figure 2. Proportion and projected number of US adults in 2007 (N = 212 million) with combinations of high LDL-C, triglycerides, and low HDL-C.

References

Carroll MD, Lacher DA, Sorlie PD, et al. JAMA 2005;294:1773-81.
Rosamond W, Flegal K, Furie K, et al.Circulation 2008;117:e25-e146 (Electronic publication 2007 Dec 17).
Bansal S, Buring JE, Rifai N, et al. JAMA 2007;298:309-16.
Volkova NB, Deedwania PC. In: Metabolic syndrome and cardiovascular disease. New York: Informa Healthcare; 2007. p. 191-217.
Kashyap ML. Am J Cardiol 1998;82:42U-8U.
Castelli WP, Garrison RJ, Wilson PW, et al.JAMA 1986;256:2835-8.