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


Treatment of Dyslipidemia: Lessons Learned and Future Directions


GOAL
To provide primary care physicians with the most recent developments regarding the treatment of dyslipidemia.

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, participants should be able to:

  • Discuss the NCEP ATP III guidelines, especially the importance of lowering low-density lipoprotein cholesterol and raising high-density lipoprotein cholesterol.
  • Identify approaches that can be taken by patients to achieve better therapeutic results.
  • Evaluate the results of the most recent clinical trials for current and future statins and other drug therapies.
  • Discuss the concerns and limitations of available therapies.

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 category 1 credits toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

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

Release date: January 15, 2004. Expiration date: January 15, 2006.

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 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 unrestricted educational grant from AstraZeneca LP.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of 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 sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

    Peter O. Kwiterovich, MD
    Professor
    Department of Pediatrics Department of Medicine
    Chief, Lipid Research Atherosclerosis Division
    Johns Hopkins University
    School of Medicine
    Baltimore, Maryland
    Dr Kwiterovich reports receiving grants/research support from AstraZeneca LP, and Merck & Co, Inc; serving as a consultant to Abbott Laboratories, AstraZeneca LP, Merck & Co, Inc, Sankyo Pharma, and Schering-Plough; and receiving honoraria from Abbott Laboratories, AstraZeneca LP, Kos Pharmaceuticals, Inc, Merck & Co, Inc, Pfizer, Inc, Sankyo Pharma, and Schering-Plough.

PARTICIPATING FACULTY

    Benjamin J. Ansell, MD, FACP
    Director
    UCLA Comprehensive Health Program
    University of California, Los Angeles
    Los Angeles, California
    Dr Ansell reports receiving grants/research support from Merck & Co, Inc, and Pfizer, Inc; and receiving honoraria from AstraZeneca LP and Pfizer, Inc.

    Michael B. Clearfield, DO, FACOI
    Professor of Medicine
    Associate Dean for Clinical Research Department of Internal Medicine
    University of North Texas Health Science Center
    Fort Worth, Texas
    Dr Clearfield reports receiving grants/research support from AstraZeneca LP; and serving as a consultant to AstraZeneca LP, Merck & Co, Inc, Pfizer, Inc, and Sankyo Pharma.

    Robert M. Guthrie, MD
    Professor
    Department of Emergency Medicine
    Ohio State University
    Columbus, Ohios Health Science Center
    Fort Worth, Texas
    Dr Guthrie reports receiving grants/research support from AstraZeneca LP, Boehringer Ingelheim, GlaxoSmithKline, and Pfizer, Inc; serving as a consultant to AstraZeneca LP, Bristol-Myers Squibb Company, GeneSoft, Inc, and Sanofi-Synthelabo; and receiving honoraria from AstraZeneca LP, Bristol-Myers Squibb Company, and Sanofi-Synthelabo.

    Notice:
    In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty member has disclosed that his article has referenced the following unlabeled/unapproved uses of drugs or products:

    Dr Guthrie—Pitavastatin.

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

    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.

Importance of Identifying Patients at Risk for CHD
Peter O. Kwiterovich, MD*

It has been nearly 3 years since the National Cholesterol Education Program (NCEP) Third Adult Treatment Panel (ATP III) guidelines for the management of dyslipidemia in adults have been updated. The NCEP ATP III guidelines marked an important change in the way dyslipidemia is managed in adults by naming coronary heart disease (CHD) equivalents (most notably, diabetes) and by nearly tripling the number of Americans who are now eligible for lipid-modifying pharmacotherapy—from 13 million to 36 million. The guidelines, based on the major statin trials that were available at the time, focus on reducing low-density lipoprotein (LDL) cholesterol to levels below 100 mg/dL in those at highest risk.

Since 2001, several other large, randomized, controlled trials of statins have provided additional insight into the best approaches to managing dyslipidemia to ultimately reduce CHD risk. Dr Benjamin J. Ansell reviews these studies and the lessons learned from the results. The results from these studies show that reducing LDL cholesterol levels to below 100 mg/dL appears to provide additional clinical benefit, prompting clinical researchers to ask, “Is there an LDL cholesterol level that is too low?”

Another important outcome of the NCEP ATP III guidelines was the definition of the metabolic syndrome, the implications of which are only now being  realized. As Dr Michael B. Clearfield discusses in his article on future directions of lipid-lowering therapies, the metabolic syndrome is not necessarily synonymous with obesity or overweight. The metabolic syndrome also has important implications in determining CHD risk because of its defining components and because it appears to correlate with increasing C-reactive protein levels, another important marker of inflammation and, perhaps, CHD risk. In addition, the Step II diet appears to be beneficial only in obese persons with metabolic syndrome. As obesity and overweight continue to dominate the lay press headlines as an epidemic in this country, clinicians must recognize that the metabolic syndrome is also reaching dangerously high levels of prevalence (22% by recent estimates). The risk factors are largely modifiable by lifestyle changes, and degree of risk varies by specific factors. The metabolic syndrome is more common in older patients, post-menopausal women, Mexican Americans, those with greater body mass index (although waist circumference is the most important indicator), current smokers, and those with low household income, high carbohydrate intake, no alcohol consumption, and low levels of physical activity.1

One of the goals of this issue of Advanced Studies in Medicine is to emphasize the importance of early identification of patients who are at risk for CHD and aggressive implemention of treatment strategies. As Dr Guthrie notes in his article on aggressive and safe approaches to lipid therapy, the incidence of CHD is frighteningly high, and too often, a myocardial infarction or CHD death is the first sign of atherosclerotic disease. We can no longer rely on angiographic imaging methods to provide information on the risk of CHD based on lumenal occlusion alone. As we learn more about the nature of atherosclerotic plaques, it is clear that plaque formation is insidious and even more dangerous than previously realized.

Primary care physicians are the conduit to early identification of patients at high risk for CHD and implementation of aggressive therapies. Primary care physicians have access to patients on a more frequent basis than cardiologists and are familiar with the patient’s family history and risk factors for CHD. The NCEP ATP III guidelines, as well as the new data reviewed here, provide important tools for early identification and aggressive, safe treatment:abdominal obesity, hypertension, lipid profile (ie, both LDL cholesterol and high-density lipoprotein cholesterol), smoking status, and age—the components of the Framingham risk calculation for CHD risk.

Calculating this risk takes only 1 to 2 minutes, but the result provides a wealth of information on not only CHD risk but also targets for therapeutic intervention. Taking the time to calculate this risk for all primary care patients is well worth the time investment, as it can identify those eligible for treatment and thus avoid the often fatal consequences of atherosclerosis.

REFERENCE
1. Park YW, Zhu S, Palaniappan L, Heshka S, Carnethon MR, Heymsfield SB. The metabolic syndrome: prevalence associated risk factor findings in the US population from the Third National Health and Nutrition Examination Survey, 1988-1994. Arch Intern Med. 2003;163(4):427-436.

*Professor of Medicine and Pediatrics, and Chief, Lipid Research Atherosclerosis Division, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Peter O. Kwiterovich, MD, Johns Hopkins University School of Medicine, Lipid Clinic, 550 Bldg - Rm 308, 600 North Wolfe St, Baltimore, MD 21287. E-mail: pkwitero@jhmi.edu.





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.