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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Treating Hypercholesterolemia in Women


GOAL
To provide practicing clinicians with cutting-edge clinical information on the prevention and treatment of cardiovascular disease in women.

TARGET AUDIENCE
Cardiologists, internists, primary care physicians, nurses, and pharmacists.

LEARNING OBJECTIVES
After reading this issue, the participant should be able to:

  • Identify the unmet need in cholesterol-lowering therapy as pertains to women.
  • Construct a practical approach to integrate the prevention of hypercholesterolemia into daily practice.
  • Analyze the findings of the ATP III guidelines relating to the treatment of women and define their impact on current practice.

ACCREDITATION STATEMENT
This activity has been planned and produced in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education. The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this continuing medical education activity for a maximum of 2 hours in Category 1 credit toward the American Medical Association Physicians' Recognition Award. Each physician should claim only those hours of credit that are actually spent on the educational activity. Credits are available until the expiration date of July 31, 2004.

This continuing education activity was produced under the supervision of Roger S. Blumenthal, MD, Director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease

This program is approved for 2 hours of credit (0.2 CEUs) and is co-sponsored by The University of Tennessee College of Pharmacy who is approved by the American Council on Pharmaceutical Education as a provider of continuing pharmaceutical education. ACPE Program #064-999-02-219-H01.

This continuing pharmacy education activity was produced under the supervision of Glen E. Farr, PharmD, Associate Dean of Continuing Education, University of Tennessee College of Pharmacy.

CONTINUING NURSING EDUCATION ACCREDITATION
This educational activity has been approved for 2 contact hours by the Institute for Johns Hopkins Nursing, which is accredited as a provider of continuing education in nursing by the American Nurses' Credentialing Center's Commission on Accreditation. Credit will be awarded until July 31, 2004.

This nursing education activity was produced under the supervision of Shirley Van Zandt, MS, MPH, CRNP, The Institute for Johns Hopkins Nursing.

This program is supported by an unrestricted educational grant from Sankyo Pharma.

Publisher's Note and Disclaimer: The opinions expressed in this issue are those of the authors, presenters, and/or panelists and are not attributable to the publisher, editor, advisory board of Advanced Studies in Medicine, or The Johns Hopkins University School of Medicine or its Office of Continuing Medical Education. Clinical judgment must guide each professional in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use for products referred to in this issue are not necessarily the same as indicated in the package insert for the product and may reflect the clinical experience of the authors, presenters, and/or panelists or may be derived from the professional literature or other clinical sources. Consult complete prescribing information before administering.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

CHAIR

    Roger S. Blumenthal, MD
    Director of Preventive Cardiology
    The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Blumenthal reports receiving grants and research support from Merck, Pfizer, Wyeth-Ayerst, Bristol-Myers Squibb, and Novartis; receiving honoraria from Merck, Pfizer, Medcom, and Physicians World.

PARTICIPATING FACULTY

    Sandra Lewis, MD
    Director of Research
    Portland Cardiovascular Institute
    Associate Clinical Professor
    Oregon Health Sciences University
    Portland, Oregon
    • Dr Lewis reports receiving grants and research support from Pfizer, Bristol-Myers Squibb, and AstraZeneca; receiving honoraria from Merck, AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline.

    Lori Mosca, MD, PhD, MPH
    Director, Preventive Cardiology
    New York Presbyterian Hospital
    New York, New York
    • Dr Mosca reports serving as a consultant for/ on the advisory board of/and on the speakers bureau for Abbott Laboratories, Bayer Corporation, Cholestech Corporation, Kos/Snell, Eli Lilly Research Laboratories, Merck, Novartis, Organon, Pharmacia, Wyeth-Ayerst, Pfizer, and Sankyo Pharma; having research contracts with Eli Lilly Research Laboratories, Organon, and Vasocor.
    • Dr Mosca is funded by a Research Career Award from the National Institutes of Health (KO8 HL 03681).

    Carla A. Sueta, MD, PhD
    Associate Professor of Medicine
    Director of Cardiology Clinics
    University of North Carolina at Chapel Hill
    Chapel Hill, North Carolina
    • Dr Sueta reports serving as a consultant for Merck; receiving honoraria from Merck and Sankyo Pharma.

    Karol Watson, MD, PhD
    Co-Director
    UCLA Program in Preventive Cardiology
    University of California at Los Angeles
    Redondo Beach, California
    • Dr Watson reports serving as a consultant for AstraZeneca, Merck, and Pfizer.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Heart disease is the number one killer of women in the United States and accounted for over half a million deaths in women in 1998. When comparing this staggering statistic to deaths due to all forms of cancer, which killed half as many women that same year, cardiovascular disease (CVD) should be a primary health concern for women today. This issue of Advanced Studies in Medicine covers the proceedings of the National Summit for Cardiovascular Care in Women, which was held in Santa Barbara, California, August 3 - 5, 2001. The primary objectives of this summit were: (1) improving cardiovascular care in women, in particular preventive cardiology, (2) understanding the unmet need in cholesterol-lowering therapy, (3) identifying risk factors in women and improving the management of these factors, and (4) developing optimum lipid management strategies.

Morbidity and mortality benefits of lipid-lowering therapy have been well documented in primary and secondary prevention studies. However, as Carla Sueta, MD, PhD, University of North Carolina, points out in her article, the results of these trials have not been fully implemented in clinical practice. In patients with coronary artery disease the prescription rate for lipid-lowering agents is as low as 39%. Equally important is the statistic that only about half of these patients are achieving goal low-density lipoprotein (LDL) levels. In addition, studies have shown that diabetic patients are 20% less likely to receive lipid-lowering therapy than those without diabetes, despite the fact that diabetes is a well-known risk factor for CVD. An improvement in lipid management currently observed in clinical practice needs to be made in order to reduce cardiovascular mortality.

Appropriate lipid management in all patients, including women, involves many aspects including the education of physicians treating such patients. Part of this educational effort includes the establishment of clinical practice guidelines. The National Cholesterol Education Program Adult Treatment Panel (ATP) recently released their third report updating clinical guidelines for cholesterol testing and management (ATP III). Several important changes were made from previous ATP II guidelines in the development of ATP III including the introduction of coronary heart disease (CHD) risk equivalents, discussion of the metabolic syndrome, establishment of non-high-density lipoprotein goals, and Framingham risk projections to identify higher risk primary prevention patients. In this issue, Karol Watson, MD, PhD, Co-Director, Lipid Clinic, University of California at Los Angeles, discusses the ATP III guidelines. New target LDL goals are defined as <100 mg/dL for patients with established CVD as well as those determined to be a CHD risk equivalent. As Dr Watson mentions in her article, changes in ATP III may classify more patients as qualifying for more aggressive therapy and such therapy may be initiated earlier than under ATP II.

As stressed in ATP III, the primary prevention of CHD is grounded in lifestyle changes such as:
(1) reduced intake of saturated fact and cholesterol, (2) increased physical activity, and (3) weight control. The adoption of ATP III warrants aggressive treatment of hyperlipidemia. Therefore, the addition of drug treatment should be considered when these lifestyle changes prove insufficient in meeting LDL goals. Lipid levels should be followed every 6-12 weeks so that alterations to the pharmacologic regimen may be performed as necessary. Currently, 4 different classes of lipid-lowering agents are available: statins, nicotinic acid, fibric acid derivatives, and bile acid sequestrants. In addition, cholesterol absorption inhibitors represent a new class of agents currently under investigation. Perhaps due to the relatively flat dose-response curve of statins, several landmark secondary prevention trials evaluating statin monotherapy did not meet the ATP III LDL goal of <100 mg/dL. Combination therapy with statins and niacin or bile acid sequestrants has demonstrated greater reduction in LDL levels than with statin monotherapy. As Sandra Lewis, MD, Director of Research, Portland Cardiovascular Institute, points out in her article, specific patient characteristics must be considered in selecting the most appropriate lipid-lowering agent. For example, concurrent medical history, concomitant medications, and childbearing potential must be evaluated in women prior to initiating therapy.

In any effort to reduce cardiovascular events, it is critical that barriers to optimal lipid management be identified and eliminated. Lori Mosca, MD, PhD, MPH, Director, Preventive Cardiology, New York Presbyterian Hospital, outlines patient, physician, health system, and societal barriers to achieving lipid goals. Patients need to recognize the need for reducing CVD risk including lifestyle changes and lipid management. While both men and women are impacted with a variety of barriers, some are specific to women. A general lack of awareness of the importance of CVD as a primary cause of morbidity and mortality in women is an important barrier in preventive cardiology. In general, risk reduction efforts for women need to target self-esteem, stress management, time, knowledge, and skills; however, treating physicians need to individualize intervention strategies in order to achieve maximal benefit.

In addition to the 4 articles presented in this issue, some of the latest literature has focused on CVD in women. Recent study has demonstrated that physical activity and physical fitness provide cardiovascular benefits in men as well as women including positive effects on blood pressure, lipid metabolism, insulin resistance, and obesity. In addition, men have been found to be more likely than women to be compliant to a healthy lifestyle before and after coronary artery bypass graft surgery. The selected abstracts that conclude this issue of Advanced Studies in Medicine address those and other topics focusing on the subject of cardiovascular health in women.

The fact that CVD is an important public health issue for both men and women is undeniable. In order to reduce morbidity and mortality associated with CVD more aggressive lipid management strategies should be initiated. In addition, barriers to achieving lipid goals in all patients need to be addressed.

*Director of Preventive Cardiology, The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.