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


Cholesterol Management in Primary Care: The Good, the Bad, and the Non-HDL


GOAL
To provide primary care physicians with up-to-date information on the treatment and management of patients with non–high-density lipoprotein cholesterol levels.

TARGET AUDIENCE
This activity is designed for primary care physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, the participant should be able to:
  • Define non–high-density lipoprotein cholesterol (HDL-C), including its composition and the methods used to measure its levels.
  • Recognize the implications of non–HDL-C on cardiovascular risk.
  • Identify recommended non–HDL-C levels in selected patient populations.
  • Outline practical strategies for medical and nonpharmacologic treatment of patients with elevated levels of non–HDL-C.
ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: February 15, 2007. Expiration date: February 15, 2009.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Reliant Pharmaceuticals, Inc.Full Disclosure Policy Affecting CE Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. Johns Hopkins Office of Continuing Medical Education has identified and resolved all faculty conflicts of interest regarding this educational activity. The Program Director, Nursing Guest Editor, and Participating Faculty reported the following:

PROGRAM DIRECTOR

Roger S. Blumenthal, MD
Associate Professor of Medicine
Director, The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease
Baltimore, Maryland
Dr Blumenthal reports receiving grants/research support from KOS Pharmaceuticals, Inc, Merck & Co, Inc, Novartis, and Pfizer, Inc.
PARTICIPATING FACULTY
Vera Bittner, MD, MSPH
Professor of Medicine
Section Head
Preventive Cardiology
University of Alabama
Birmingham, Alabama
Dr Bittner reports receiving grants/research support from Atherogenics, the National Institutes of Health/KOS Pharmaceuticals, Inc (joint grant), and Pfizer, Inc; and serving as a consultant for CV Therapeutics, Pfizer, Inc, and Reliant Pharmaceuticals, Inc.

Michael H. Davidson, MD, FACC, FACP
Executive Medical Director
Radiant Research
Preventive Cardiology Center
Professor of Medicine
Rush University Medical Center
Chicago, Illinois
Dr Davidson reports receiving grants/research support from Abbott Laboratories, AstraZeneca, Bristol-Myers Squibb, KOS Pharmaceuticals, Inc, Merck & Co, Inc, Merck/Schering-Plough, Novartis, Pfizer, Inc, Reliant Pharmaceuticals, Inc, Roche Pharmaceuticals, Sankyo Pharma, and Takeda Pharmaceuticals North America, Inc; serving as a consultant for Abbott Laboratories, AstraZeneca, KOS Pharmaceut-icals, Inc, Merck & Co, Inc, Merck/Schering-Plough, Novartis, Pfizer, Inc, Reliant Pharmaceuticals, Inc, Roche Pharmaceuticals, Sankyo Pharma, Sumitomo Pharmaceuticals, and Takeda Pharmaceuticals North America, Inc; and serving on the speakers' bureau for Abbott Laboratories, AstraZeneca, KOS Pharmaceuticals, Inc, Merck & Co, Inc, Merck/Schering-Plough, Pfizer, Inc, Reliant Pharmaceuticals, Inc, Sankyo Pharma, and Takeda Pharmaceuticals North America, Inc.

Notice: All faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins 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.Cholesterol Management in Primary Care: The Good, the Bad, and the Non-HDL
Roger S. Blumenthal, MD*

Although many healthcare practitioners continue to focus on "good" and "bad" cholesterol, this classification is increasingly understood as an oversimplification.

The reduction of cardiovascular event risk with reduced low-density lipoprotein cholesterol (LDL-C) levels is well documented,1 and LDL-C remains the main target of lipid-lowering therapy.  However, not all patients with coronary heart disease have elevated LDL-C levels. Data from the Framingham Heart Study show the continuous relationship between dyslipidemia and the risk of developing cardiovascular disease (CVD) over 8 years.2 The relationship between level of total cholesterol and CVD risk is graded and continuous. Risk is not confined to the upper quartile.2

Epidemiologic studies also have established specific lipid parameters as important risk factors for coronary artery disease (CAD). In the Münster Heart Study (PROCAM), which included 17 437 men and 8065 women who were followed for more than 8 years, the incidence of CAD was positively correlated with increasing serum levels of LDL-C and triglycerides (TG), and negatively correlated with increasing high-density lipoprotein cholesterol (HDL-C) concentrations. The correlation between levels of LDL-C and incidence of CAD was particularly strong. Incidence of CAD increased from 2% in individuals with LDL-C less than 133 mg/dL to 10% in individuals with LDL-C greater than 163 mg/dL.3 Additionally, a prospective study of subjects in the Physicians Health Study conclusively showed a correlation between elevated TG levels and the risk of myocardial infarction.4 The recognition that non–HDL-C plays an important role in determining cardiovascular risk has led the National Cholesterol Education Program's Expert Panel to establish non–HDL-C guidelines for individuals with TG levels above 200 mg/dL.1

In this issue of Johns Hopkins Advanced Studies in Medicine, based on a Webcast series presented from November 2006 through January 2007, Vera Bittner, MD, MSPH, Professor of Medicine at the University of Alabama at Birmingham, points out that the equation used to estimate LDL-C becomes increasingly inaccurate in patients with elevated TGs.5  In contrast, determination of non–HDL-C requires only the measurement of total cholesterol and HDL-C, both of which can be easily obtained from non-fasting samples (as opposed to the fasting samples required for accurate LDL-C measurement).6 Therefore, the non–HDL-C value is readily calculated, and assessment of non–HDL-C may in fact be more practical, accurate, and easier to achieve than assessment of LDL-C.

Michael H. Davidson, MD, FACC, FACP, Executive Medical Director for Radiant Research and Professor of Medicine at Rush University Medical Center, reports that non–HDL-C may be especially important in certain populations, such as patients with diabetes, in whom dyslipidemia is characterized by low HDL-C levels and elevated TGs.7 His review of the medical literature shows that even in patients without diabetes, careful attention to non–HDL-C is warranted, as this value has been shown to have important correlates with the severity of atherosclerosis and with cardiovascular morbidity and mortality.8 Dr Davidson also discusses several medications  now available that can be used in place of or in combination with statin therapies to help primary care physicians (PCP) make determinations about appropriate therapies for patients with differing lipid profiles.

We conclude with highlights of the interactive question and answer sessions from the Webcast series, in which the faculty responded to questions about practical issues surrounding the clinical implications of the research.

This issue of Johns Hopkins Advanced Studies in Medicine provides PCPs with important insights into the significance of non–HDL-C levels in their patient population in addition to practical strategies for the assessment, interpretation, and implications of this value. We hope this information will bring new insights to your own medical practice.

REFERENCES

1.    Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.
2.    Kannel WB, Dawber TR, Friedman GD, et al. Risk factors in coronary heart disease. An evaluation of several serum lipids as predictors of coronary heart disease; The Framingham Study. Ann Intern Med. 1964;61:888-899.
3.    Assmann G, Cullen P, Schulte H. The Munster Heart Study (PROCAM). Results of follow-up at 8 years. Eur Heart J. 1998;19:A2-A11.
4.    Stampfer MJ, Krauss RM, Ma J, et al. A prospective study of triglyceride level, low-density lipoprotein particle diameter, and risk of myocardial infarction. JAMA. 1996;276:882-888.
5.    Freidewald W, Levy R, Fredrickson D. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without the use of the preparative ultracentrifuge. Clin Chem. 1972;18:499-552.
6.    Hirsch GA, Vaid N, Blumenthal RS. Perspectives: The significance of measuring non–HDL-cholesterol. Prev Cardiol. 2002;5:156-159.
7.    Garg A, Grundy SM. Management of dyslipidemia in NIDDM. Diabetes Care. 1990;13:153-169.
8.    Frost PH, Havel RJ. Rationale for use of non-high-density lipoprotein cholesterol rather than low-density lipoprotein cholesterol as a tool for lipoprotein cholesterol screening and assessment of risk and therapy. Am J Cardiol. 1998;81:26B-31B.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.

*Associate Professor of Medicine, Director, The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
Address correspondence to: Roger S. Blumenthal, MD, Associate Professor of Medicine, Director, The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, 600 North Wolfe Street, Blalock 524C, Baltimore, MD 21287. E-mail: rblument@jhmi.edu.



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