J. David Schnatz, M.D.
Director, Lipid Education Service
Saint Francis Hospital and Medical Center
114 Woodland Street, Hartford, CT 06105
Telephone: (860) 714-5555

October 1997

In the HERS study analysis, an LDL level at or above 130 mg/dl was positively associated with a higher body mass index and diagnosis of CHD before 1990. It was inversely associated with a number of factors, including lipid lowering treatment, a regular exercise or walking program, never having been married and post-graduate education. Non-use of drug therapy was associated with African-American race, higher BMI, amount of alcohol consumption, current smoking and CHD before 1985.

In light of the 4S study, the authors estimated that 80% of the HERS participants could achieve an LDL less than 100 mg/dl. Yet, about one-third had an LDL between 130 and 160 mg/dl and almost one-third had LDL levels greater than 160 mg/dl. Why? They raise a number of possibilities, including slowness to disseminate treatment recommendations, reluctance of the medical community to accept them, reduced access to medical care, high cost of medication, and the effect of being an elderly woman. More than one-half of the patients were on no lipid lowering therapy. They concluded that "Better implementation of these guidelines among women with coronary disease would be highly desirable," and "We can achieve more reduction in LDL-C level than has been observed in the HERS cohort."

In an editorial accompanying the HERS report, Pearson and Myerson question if this finding reflects a bias against women or a more general finding (2). To demonstrate the generality of the phenomenon of non-treatment, they cite the so-called ASPIRE study done in the United Kingdom (3). Six months after a revascularization procedure for CHD or hospital admission for an acute myocardial infarction, 72% of the men and 83% of the women had a total cholesterol greater than 200 mg/dl. Pearson and colleagues have presented an abstract on a study which sampled patients from 16 primary care practices and found that few cholesterol lowering drugs were used, even if the patient had a cholesterol greater than 240 mg/dl or between 200 and 240 mg/dl along with two risk factors (4).

In a study on 90 San Francisco VA patients, only 33% of the patients met the NCEP LDL goal, and only 2 out of the 90 were on a maximal drug regimen (5). One group cardiology practice, using allied health professionals and a computerized software program, used modified guidelines to achieve a "significant" number of patients with desirable LDL and HDL (6). The use of a multidisciplinary approach, using a team comprised of a nurse practitioner, clinical pharmacist, dietitian and clinical psychologist have been shown to be beneficial. At the Cincinnati VA, patients who attended the lipid clinic with the aforementioned team approach were four times more likely to reach NCEP goals than comparable patients attending general medical clinic (7). At the San Francisco VA mentioned above, 29% of patients followed by attending physicians, and 31% followed by residents or fellows met NCEP LDL goals while 45% followed by non-physicians met goals.

The Milwaukee VA Lipid Clinic provides comprehensive evaluation and management of lipid disorders for referred patients. A study of patients with cardiovascular disease from this clinic demonstrated that even with the effort they made, approximately 25% of patients did not achieve lipid goals when the baseline LDL was less than or equal to 160 mg/dl and more than one-half did not make goals when baseline LDL was more than 160 mg/dl (8). Factors which predicted achievement of lipid goals were lower baseline LDL, combination drug therapy and patient adherence to treatment. The highest percentage of achieving goals was with niacin and a statin, yet the largest obstacle to combined drug therapy was inability to tolerate niacin and/or colestipol. Similarly, a stepped care approach, beginning with niacin, was more likely to produce bothersome side effects than lovastatin, but was considerably less expensive and more effective in raising HDL (9).

The need for combination therapy to achieve NCEP goals has been highlighted by Pasternak et al in CHD patients with "normal" cholesterol levels (10). During 2.5 years of study, 70% of patients needed combination therapy to reach NCEP goals. Adding nicotinic acid to pravastatin, where the goal was not met, gave 94% achievement of NCEP goals. They found combinations of pravastatin with nicotinic acid and/or gemfibrozil to be well tolerated in these normolipidemic patients and to be important in achieving a high percentage of patients at goal.

The 4S (11) and CARE (12) studies document the importance of lowering lipids in CHD patients and the CARE study helps confirm the NCEP guidelines. A variety of issues converge in making it difficult to achieve these goals in many patients. Yet, the effort is important and worthwhile.

REFERENCES

(1) JAMA 277:1281-1286, 1997.
(2) JAMA 277:1320-1321, 1997.
(3) Heart 75:334-342, 1996
(4) Circulation 94 (Suppl):1030, 1996
(5) Am J Med 100:605-610, 1996.
(6) Southern Med J 86:289-292, 1993
(7) Arch Int Med 155:2330-2335, 1995.
(8) Am J Med 100:197-204, 1996
(9) Arch Int Med 156:731-739, 1996
(10) Ann Int Med 125:529-540, 1996
(11) Lancet 344:1383, 1984
(12) NE J Med 335:1001-1009, 1996
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