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| ORIGINAL ARTICLE |
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| Year : 2006 | Volume
: 7
| Issue : 2 | Page : 69-73 |
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How good are we at controlling lipids? A cohort study
Douraid K Shakir, Omar Al-Tamimi
Hamad Medical Corporation, Cardiology and Cardiovascular Surgery Department, Doha, Qatar
| Date of Web Publication | 17-Jun-2010 |
Correspondence Address:
Douraid K Shakir
P.O.Box: 39046 Doha
Qatar
 Source of Support: None, Conflict of Interest: None  | Check |
 Abstract | | |
Background : Elevated low-density lipoprotein cholesterol (LDL-C) is a major cause of coronary heart disease (CHD). The relationship between LDL-C and CHD risk is continuous over a broad range of LDL-C levels: the higher the LDL-C level, the greater the risk of CHD1. Although national guidelines for cholesterol management have existed since 19882, many patients with elevated cholesterol do not achieve their target cholesterol with treatment. Our aim was to identify the rate of lipid control in the cardiology outpatient clinics of Hamad General Hospita, and this may lead to improved patient care. This is the first out-patient data study performed in our department.
Methods : Cohort study of one -hundred and one (101) consecutive documented CHD patients investigated for lipid profile. Blood samples were taken after a strict 12 hours of fasting, the presence of diabetes was also recorded.
Results: LDL-C level was less than 2.6 mmol/l in 55 patients (54%), with a mean of 2.66 mmol/l; while HDL-C level was more than 1.15 mmol/l in 76 patients (75%), with a mean level of 1.08 mmol/l. Triglyceride level was less than 1.7 mmol/l in 51 patients (50%), with mean level of 2.22 mmol/l.
Conclusions : Acceptable lipid control was achieved in the cardiology outpatient clinics in Hamad General Hospital and the majority of CHD patients were on lipid lowering therapy.
How to cite this article:
Shakir DK, Al-Tamimi O. How good are we at controlling lipids? A cohort study. Heart Views 2006;7:69-73 |
| Introduction | |  |
Elevated low-density lipoprotein cholesterol (LDL-C) is a major cause of coronary heart disease (CHD). The relationship between LDL-C and CHD risk is continuous over a broad range of LDL-C levels: the higher the LDL-C level, the greater the risk of CHD [1] . Although national guidelines for cholesterol management have existed since 1988 [2] many patients with elevated cholesterol do not achieve their targeted cholesterol level with treatment. Studies [3],[4] have shown that between 17% to 73% of treated patients actually meet their target levels, but the people at greatest risk (patients with known CHD) rarely achieve their target levels. Our aim was to identify the rate of lipid control in the cardiology outpatient clinics of Hamad General Hospita, and this may lead to improved patient care. This is the first out-patient data study performed in our department.
| Patients and Methods | | |
Cohort study of one-hundred and one (101) consecutive documented CHD patients investigated for lipid profile. Blood samples were taken after a strict 12 hours of fasting, the presence of diabetes was also recorded
Inclusion criteria:
- Documented CHD on statin therapy for a minimum of three months.
- Documented CHD and with no statin therapy.
Documented CHD includes a history of any of the following:
- Coronary artery bypass surgery
- Positive coronary angiogram or percutaneous coronary angioplasty
- Myocardial infarction
- Positive results of cardiac imaging
- Positive results of cardiac stress testing
Epi-info 6 software was used for creating the database and its analysis.
| Results | | |
Elevated blood lipids are considered a major risk factor for the development of atherosclerosis; and it is one of the major modifiable risk factors that the cardiologist can target.
This survey was used to evaluate how good we are at achieving the targets for lipid control.
We considered the LDL goal for non-diabetic patients as less than 2.6 mmol/l, while for diabetics it was less than 1.8 mmol/l; the HDL goal was more than 0.9 mmol/l for non-diabetics and more than 1.15 mmol/l for diabetics. While triglyceride levels for non-diabetic should be less than 1.8 mmol/l, and less than 1.7 mmol/l for diabetics.
LDL-C level was less than 2.6 mmol/l in 55 patients ( 54% of the total cases), with a mean of 2.66 mmol/l; while HDL-C level was more than 1.15 mmol/l in 76 patients (75% of patients), with a mean level of 1.08 mmol/l. Triglyceride level was less than 1.7 mmol/l in 51 patients (50%), with mean level of 2.22 mmol/l [Table 1] [Figure 1].
In sub-analysis for diabetics (41 patients), if we apply the ordinary goal for non-diabetics then 25 patients (60% of diabetics) have controlled LDL, 32 patients (78% of diabetics) have controlled HDL and 16 patients (39% of diabetics) have controlled triglyceride [Figure 2].
If the strict guidelines for diabetics are applied5, LDL-C was controlled in 10 (25%) patients with mean of 2.79 mmol/l, while HDL-C was controlled in 11 (25%) patients with mean of 1.022 mmol/l and triglyceride was controlled in 14 (34%) patients with mean of 2.23 mmol/l, [Figure 3].
Sixty patients were non-diabetic; their sub-analysis showed that LDL-C was controlled in 30 patients (50% of non-diabetics). While HDL-C was controlled in 44 patients (73%) and triglyceride was controlled in 35 patients (58% of total non-diabetic patients), [Figure 4].
One of the major findings was that 14 patients (14%) with documented CHD were not on any lipid lowering agents; some of these patients had had percutaneous coronary intervention with stents or coronary bypass surgery.
The majority of patients were on a dose of 20 mg of statin (72 patients, 71%), while only 9 patients were on 40 mg and none on 80 mg. Only one patient was taking Fibrate [Figure 5].
| Discussion | | |
In spite of guidelines recommending the target LDL being < 2.6 mmol/l in cardiovascular disease, the percentage of patients who achieve this goal is disappointing. According to the 2004 Adult Treatment Panel III (ATP III) statement the goal for the very high risk group should be < 1.8 mmol/l. The recent "REALITY-PHARMO" survey revealed only 60% of the patients achieved the goal, and the last EURO HEART SURVEY showed that coronary heart disease patients on statins had a LDL-C of 3.6 mmol/l. An analysis of 138001 patients from 1470 US hospitals in the National Registry of Myocardial Infarction 3, revealed that only 31.7% of patients hospitalized with acute myocardial infarction (MI) were discharged on lipid-lowering medication [6] . Similarly, among the 8515 patients hospitalized with an acute coronary syndrome and enrolled in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, only 25.1% were discharged on lipid-lowering therapy [7] . We must acknowledge that a considerable gap exists between current practice and the given goals.
Considering diabetes mellitus as a major risk factor for CHD with its effects on lipids especially LDL-C and triglyceride, many guidelines and studies recommend more aggressive lipid control to less than 1.8mmol/l in diabetics with overt CHD [5].
Lipid control starts from life style modification and ends with LDL-C aphoresis [8] , gene therapy [9] or even liver transplantation [10] ; but the majority of cases respond well to pharmacological therapy. In the out-patient setting, this treatment gap persists. The Quality Assurance Project analyzed treatment rates in 48586 outpatients with CHD from 140 medical practices (80% cardiology) [11] . Only 39% of patients were treated with lipid-lowering medication and only 11% were documented to have LDL-C levels < 100 mg/dl. In the third National Health and Nutrition Examination Survey (NHANES III), lipid-lowering medication was used in an estimated 11% of participants with CHD [3] . In the Lipid Treatment Assessment in Practice (L-TAP) study, only 18% of outpatients with CHD treated for hyperlipidemia had LDL-C levels < 100 mg/dl [4] .
In this survey we found only 14% of cases with documented CHD were not on statin therapy, this is an excellent figure if we compare it to the studies above, yet more effort should be made [11] . LDL control was achieved in 54% of patients and this is roughly the same as or even better than the studies mentioned [4],[11] . In Euro heart survey of stable angina, patients on statin therapy achieved a cholesterol level of 5.7 mmol/l while LDL level was 3.6 mmol/l [12] . In our survey the mean LDL was 2.66 mmol/l which is near to the guideline recommendation. Both triglyceride and HDL were controlled in our survey giving 75% and 50% respectively, but these figures were for whole sample. In the sub-analysis for diabetics, we found that our data is far from the recommended guidelines for strict lipid control in this high risk group, and thus action should be taken [5] . In the non-diabetic group the achieved levels were in the acceptable range for LDL and triglyceride and excellent for HDL.
Regarding statin doses, we are still using low doses in the majority of cases. Less than 9% were on 40 mg of statin and none on 80 mg. No case was on combination therapy. The rational for hyperlipidemia therapy now is the use of a combination of statins, fibrate and Ezetimibe to achieve a better control.
Limitations of the study include small sample size, unequal sex distribution and other contributory risk factors related to lipid profile such as body weight not being studied.
| Conclusion | | |
Acceptable lipid control was achieved in the cardiology out-patients clinics in Hamad General Hospital, and the majority of CHD patients were on lipid lowering therapy. Diabetic patients, who form a high-risk group, need more attention to improve their lipid control by encouraging the use of high doses of statins possibly with combination therapy. Lastly, this survey shows the importance of initiating registries to evaluate and develop our practice to maximise patient care.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1]
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