Mixed Dyslipidemia Among Patients Using Lipid-Lowering Therapy in French General Practice: An Observational Study

doi:10.1016/j.clinthera.2007.08.003

Clinical Therapeutics

Volume 29, Issue 8, August 2007, Pages 1671-1681

Portions of this research were presented at the 2007 European Atherosclerosis Meeting, June 10–13, 2007, Helsinki, Finland.

https://doi.org/10.1016/j.clinthera.2007.08.003 Get rights and content

Abstract

Background: Low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs) are associated with an increased incidence of coronary heart disease (CHD). However, limited data are available about the prevalence of dyslipidemias related to LDL-C, HDL-C, and TGs among French patients treated with lipid-lowering agents.

Objective: This paper describes the prevalence of various types of dyslipidemias among patients treated with lipid-lowering agents in French general practice.

Methods: This was a cross-sectional, observational study conducted using retrospective data collection at the time of enrollment. Eligible patients were those treated pharmacologically for dyslipidemia in the Cegedim Strategic Data general practice network. Fasting lipid values and cardiovascular (CV) risk factors were gathered by investigators using an ad hoc questionnaire. European guidelines were used to define various types of dyslipidemias. Polytomous logistic regression was used to assess the associations between different dyslipidemias and diabetes mellitus, a history of CHD, and the number of CV risk factors.

Results: A total of 946 patients had a complete lipid profile and valid data for determining CV risk status. The mean (SD) age of these patients was 64.0 (9.9) years, and 55.7% of the patients were men. At least 1 abnormality in LDL-C, HDL-C, or TGs was present in 791 (83.6 %) of the 946 patients. The rates of elevated LDL-C, low HDL-C, and elevated TGs were 73.2%, 16.9%, and 30.3%, respectively (these groups are not mutually exclusive). Among those who did not reach the LDL-C goal, 38.7% had dyslipidemias with low HDL-C, elevated TGs, or both. Compared with having a normal lipid profile, each additional CV risk factor increased the likelihood of the following types of dyslipidemias: low HDL-C and/or elevated TGs, but normal LDL-C (odds ratio [OR], 1.36; 95% CI, 1.03–1.79); elevated LDL-C and TGs, but normal HDL-C (OR, 1.58; 95% CI, 1.24–2.02); and all 3 lipid abnormalities (OR, 1.54; 95% CI, 1.10–2.14). Patients with diabetes had a similarly increased risk of mixed dyslipidemias, whereas patients with a history of CHD did not.

Conclusions: Among these patients treated with lipid-lowering agents, 38.7% had mixed dyslipidemias, including low HDL-C, elevated TGs, both low HDL-C and elevated TGs, or all 3 lipid abnormalities. Patients with a greater number of nonlipid CV risk factors or with diabetes had a significantly increased risk of mixed dyslipidemias involving elevated TGs and/or low HDL-C in addition to elevated LDL-C.

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Citation Excerpt :
Overall, only approximately a quarter (26.8%) of patients attained their target LDL-C level, despite chronic statin therapy. Other studies have also reported poor target achievement for patients receiving statin treatment [12–15]. However, the numbers cannot be directly compared to those of DYSIS owing to differences in the study populations, targets used, and methodology of acquisition.
There is an inconsistency between international guidelines on lipid-lowering treatment regarding whether to pursue LDL-C treatment targets or to focus on the intensity of treatment. While either approach is attractive, there is no recent global data on actual LDL-C values, treatment targets attained, and the intensity of treatment in statin-treated patients. We aimed to determine and compare the extent of treatment target attainment globally using standardized data collection.
Analyses were based on the Dyslipidemia International Study (DYSIS), a cross-sectional study documenting statin-treated outpatients throughout 30 countries worldwide (across Europe, the Middle East, Canada, Africa, and Asia). Patients were classified as being at very high, high, or non-high cardiovascular risk based on the 2011 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines.
Data were available for a total of 57,885 patients with a median LDL-C value of 98.2 mg/dl (IQR: 76.6, 125.7 mg/dl). Overall, only 26.8% of patients were documented to have attained their risk-based target LDL-C level. Of the 76% of patients who were classified as being at very high risk, only 21.7% attained their LDL-C goal. Globally, the median distance to target was 33.0 mg/dl, ranging from 18.8 to 42.1 mg/dl across countries. We calculated that a further LDL-C reduction of just 10 mg/dl would result in an 11% increase in the proportion of very-high-risk and high-risk patients attaining their target level (9% for non-high risk patients).
In spite of statin therapy, LDL-C values were high, with a substantial distance to target that was even more pronounced in (very) high risk patients. These results call for the optimization of existing treatment strategies and a collaborative effort to improve the impact of treatment guidance on clinical practice.
Prevalence of atherogenic dyslipidemia in primary care patients at moderate-very high risk of cardiovascular disease. Cardiovascular risk perception
2014, Clinica e Investigacion en Arteriosclerosis
Citation Excerpt :
Additionally, we found a high prevalence of poor control of LDL-C. Only 8.8% of patients had achieved the recommended targets. Several studies showed similar target achievement rates for this lipoprotein,18,22–24 and a worse control in patients with higher cardiovascular risk.18 Thus, our results corroborated that a high proportion of patients do not meet target levels of LDL-C, particularly in high-risk cases, even though therapy for AD is directed to first lowering serum LDL-C levels.
Atherogenic dyslipidemia is an important risk factor for cardiovascular disease. We aim to determine atherogenic dyslipidemia prevalence in primary care patients at moderate-very high cardiovascular risk and its associated cardiovascular risk perception in Spain.
This cross-sectional study included 1137 primary care patients. Patients had previous cardiovascular disease, diabetes mellitus, SCORE risk ≥3, severe hypertension or dyslipidemia. Atherogenic dyslipidemia was defined as low HDL-C (<40 mg/dL [males], <50 mg/dL [females]) and elevated triglycerides (≥150 mg/dL). A visual analog scale was used to define a perceived cardiovascular disease risk score.
Mean age was 63.9 ± 9.7 years (64.6% males). The mean BMI was 29.1 ± 4.3 kg/m², and mean waist circumference 104.2 ± 12.7 cm (males), and 97.2 ± 14.0 cm (females). 29.4% were smokers, 76.4% had hypertension, 48.0% were diabetics, 24.7% had previous myocardial infarction, and 17.8% peripheral arterial disease. European guidelines classified 83.6% at very high cardiovascular risk. Recommended HDL-C levels were achieved by 50.1% of patients and 37.3% had triglycerides in the reference range. Target LDL-C was achieved by 8.8%. The overall atherogenic dyslipidemia prevalence was 27.1% (34.1% in diabetics). This prevalence in patients achieving target LDL-C was 21.4%. Cardiovascular risk perceived by patients was 4.3/10, while primary care physicians scored 5.7/10.
When LDL-C levels are controlled, atherogenic dyslipidemia is more prevalent in those patients at highest cardiovascular risk and with diabetes. This highlights the importance of intervention strategies to prevent the residual vascular risk in this population. Both patients and physicians underestimated cardiovascular risk.
La dislipidemia aterogénica representa un factor de riesgo importante de enfermedad cardiovascular. Se pretende determinar la prevalencia de dislipidemia aterogénica en pacientes de atención primaria con riesgo cardiovascular de moderado a muy alto y la percepción de riesgo cardiovascular asociado en España.
Estudio transversal que incluyó 1.137 pacientes de atención primaria. Los pacientes presentaban enfermedad cardiovascular previa, diabetes mellitus, SCORE ≥3, hipertensión arterial severa o dislipidemia. La dislipidemia aterogénica se definió como C-HDL bajo (<40 mg/dl [hombres], <50 mg/dl [mujeres]) y triglicéridos elevados (≥150 mg/dl). Para definir la puntuación de percepción de riesgo de enfermedad cardiovascular se utilizó una escala visual analógica.
La edad media fue de 63,9 ± 9,7 años (64,6% hombres). El IMC promedio fue de 29,1 ± 4,3 kg/m², y la media del perímetro de la cintura de 104,2 ± 12,7 cm (hombres) y 97,2 ± 14,0 cm (mujeres); el 29,4% eran fumadores, el 76,4% hipertensos, el 48,0% diabéticos, el 24,7% tenían antecedentes de infarto de miocardio y el 17,8% enfermedad arterial periférica. El 83,6% se clasificaron como pacientes de muy alto riesgo cardiovascular según las guías europeas. El 50,1% de los pacientes alcanzaron los niveles recomendados de C-HDL y el 37,3% tenían los triglicéridos dentro del rango. El 8,8% consiguieron niveles objetivo de C-LDL. La prevalencia general de dislipidemia aterogénica fue del 27,1% (34,1% en diabéticos). Esta prevalencia en los pacientes que alcanzaron niveles objetivo de C-LDL fue del 21,4%. El riesgo cardiovascular percibido por los pacientes fue de 4,3/10, mientras que sus médicos de atención primaria puntuaron un 5,7/10.
Cuando se controlan los niveles de C-LDL la dislipidemia aterogénica es más prevalente en aquellos pacientes con mayor riesgo cardiovascular y diabéticos, lo que pone de manifiesto la importancia de las estrategias de intervención para prevenir el riesgo vascular residual en esta población. Tanto pacientes como médicos subestimaron el riesgo cardiovascular.
Attainment of normal lipid levels among high cardiovascular risk patients: Pooled analysis of observational studies from the United Kingdom, Sweden, Spain and Canada
2013, European Journal of Internal Medicine
Citation Excerpt :
On the other hand, more than a third of high-risk patients continued to have low HDL-C, and over 40% of patients still had low HDL-C and/or elevated triglycerides despite lipid modifying treatment. The results of this longitudinal study are largely consistent with those of cross-sectional studies, which analyzed normal lipid level attainment among patients who did and did not receive lipid modifying treatment [19–21]. Although these studies found a high prevalence of multiple lipid abnormalities ranging from 30 to 40%, the cross-sectional design made it difficult to determine the extent to which LMT was associated with changes in lipid profiles among the patients studied.
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Among 12,768 high-risk patients, 75% had elevated LDL-C, 37% low HDL-C, and 30% elevated TG before LMT. Despite therapy (97% statins only), 23% had elevated LDL-C, 36% low HDL-C, 16% elevated TG, and 17% had ≥ 2 abnormal lipid levels. Framingham risk score > 20% (Odds Ratio, 95% confidence interval: 0.37,0.31–0.43), diabetes (0.75,0.64–0.88), hypertension (1.26,1.09–1.46), current smoker (0.82,0.70–0.95) and increased body mass index (0.95,0.94–0.96) were associated with the likelihood of attaining ≥ 2 normal lipid levels (vs. LDL-C goal only).
Current approaches to lipid management improve LDL-C goal attainment; however, control of multiple lipid risk factors remains poor. Patients may benefit from more comprehensive approaches to lipid management, which treat multiple lipid abnormalities, as suggested in clinical guidelines.
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2013, Clinical Therapeutics
Citation Excerpt :
A longitudinal study using data from a US health maintenance organization reported that LMT use significantly improved LDL-C goal attainment; however, nearly 50% of patients did not achieve normal HDL-C, and 24% of patients continued to have multiple lipid abnormalities.10 Studies conducted in Europe have reported that the prevalence of multiple lipid abnormalities in patients primarily treated with statins is 30% to 40%.11,12 In contrast, few studies have investigated the attainment of multiple normal lipid levels in Asian patients treated with LMTs.
Although LDL-C is the primary lipid target for coronary heart disease (CHD) risk reduction, HDL-C and triglycerides (TG) have also emerged as CHD risk factors.
The objective of this study was to evaluate goal/normal lipid level attainment after lipid-modifying therapy (LMT) in an ethnically diverse sample of patients in Malaysia.
Retrospective, longitudinal data were collected from the medical records of patients aged ≥35 years in whom LMT was initiated between January 2004 and December 2006. Eligible patients had records of full lipid panels 12 months before and after the start of therapy. LDL-C goals and normal levels of HDL-C and TG were defined as per the Clinical Practice Guidelines on Management of Dyslipidemia (4th edition), Malaysia. A subgroup of patients at high risk for CHD events (established CHD, diabetes but no CHD, or a 10-year history of Framingham risk score ≥20%) was also studied.
Among 607 eligible patients (mean age, 57.1 years; 40% male), 89% had elevated LDL-C, 37% had low HDL-C, 56% had elevated TG, and 62% had ≥2 abnormal lipid levels before LMT. Despite therapy (87% statins only), 60% had elevated LDL-C, 37% had low HDL-C, 40% had elevated TG, and 44% continued to have ≥2 abnormal lipid levels.
In this longitudinal study of Malaysian patients treated with lipid-modifying therapy, primarily using statins, attainment of LDL-C goal is suboptimal. Furthermore, a large proportion of patients do not achieve normal levels of HDL-C and TG. Therefore, patients may benefit from a more comprehensive approach to lipid management that treats all 3 lipid risk factors, as suggested in clinical guidelines.
Association between dyslipidemia and vascular events in patients treated with statins: Report from the UK General Practice Research Database
2010, Atherosclerosis
Citation Excerpt :
The substantial rates of elevated LDL-C and of abnormal HDL-C and/or TG levels despite statin therapy is consistent with results of smaller previous studies. A 73% rate of elevated LDL-C was reported in a recent cross-sectional observational study involving 946 patients treated with lipid-lowering agents, most often statins [13]. In that study, among individuals with elevated LDL-C, there was a 39% rate of abnormal HDL-C and/or TG levels.
A retrospective cohort study was conducted to evaluate the association between low high-density lipoprotein cholesterol (HDL-C) and/or elevated triglycerides (TG) and cardiovascular (CV) and/or cerebrovascular (CB) events among patients with elevated low-density lipoprotein cholesterol (LDL-C) despite statin treatment.
Patient demographics, clinical characteristics, laboratory data, and CV/CB events, were collected from the UK General Practice Research Database. Abnormal lipid levels were defined using US and European clinical guidelines. The association between the frequency of CV/CB events among patients with HDL-C/TG abnormalities versus patients with isolated low LDL-C was estimated using multivariate Cox proportional hazards regression.
Of 19,843 statin-treated patients, 6823 had elevated LDL-C despite therapy for a mean follow-up of 1.99 ± 1.06 years. Among these patients, 3115 (45.7%) also had HDL-C/TG abnormalities. A total of 715 patients (10.5%) experienced CV/CB events. In statin-treated patients not at LDL-C goal, the relative risk of a vascular event was 24% higher in patients with HDL-C/TG abnormalities (HR = 1.24, 95% CI: 1.06–1.46, p = 0.006) than in patients without HDL-C/TG abnormalities. Additional variables that were associated with a significantly increased risk of CV/CB events included age (p < 0.0001), gender (p = 0.027), and medication possession ratio (p < 0.0001), while diabetes mellitus (p < 0.0001), hypertension (p < 0.0001), 10-year Framingham risk score > 30% (p = 0.005), statin dose (p < 0.0001), and LDL-C level at baseline (p < 0.0001) were associated with a significantly decreased risk of CV/CB events.
Among statin-treated patients with elevated LDL-C from UK clinical practices, reduced HDL-C and/or elevated TGs were associated with a significantly increased relative risk of CV/CB events.
Prevalence of low high-density lipoprotein cholesterol and hypertriglyceridaemia in patients treated with hypolipidaemic drugs
2009, Archives of Cardiovascular Diseases
To estimate the prevalence of triglyceride and/or high density lipoprotein cholesterol (HDL-C) disorders and their relationships with other cardiovascular risk factors among patients with dyslipidaemia on lipid-lowering therapy.
In this cross-sectional study in dyslipidaemic patients receiving lipid-lowering therapy, lipid disorders were defined as triglyceride greater than 1.5 g/L, HDL-C lesser than 0.4 g/L and low-density lipoprotein cholesterol (LDL-C) above the recommended concentration according to French guidelines. Based on these disorders, patients were classified into four groups: group 1, no lipid disorders; group 2, low HDL-C and/or high triglyceride concentration with normal LDL-C; group 3, isolated elevated LDL-C; and group 4, elevated LDL-C and low HDL-C and/or high triglyceride. Patients’ cardiovascular risk levels were compared across groups.
Among the 2727 patients (mean age 64.7 years, 46.7% women), 28% did not reach the target LDL-C concentration as defined by French guidelines. Prevalence rates of high triglyceride and low HDL-C were 27.2 and 10.3%, respectively. Over half (51.2%) of the patients were in group 1, 20.5% were in group 2, 16.2% in group 3 and 12.1% in group 4. Among patients meeting the target LDL-C, those with high triglyceride and/or low HDL-C exhibited a significantly higher number of risk factors (1.83 vs 1.68, p < 0.001). Smoking, diabetes and hypertension were associated separately with low HDL-C and/or high triglyceride (p = 0.01, p < 0.0001, p = 0.03, respectively). Conversely, these associations were not observed in patients who did not achieve the target LDL-C, with the exception of smoking (p < 0.0001).
HDL-C and triglyceride disorders are relatively frequent among treated patients, particularly when cardiovascular risk level increased.
L’objectif était d’estimer chez des patients dyslipidémiques traités la fréquence de l’hypertriglycéridémie et des taux bas en HDL-C, et leur association avec les autres facteurs de risque cardiovasculaire.
Une étude transversale (REALITY II) a été réalisée en médecine générale auprès de patients sous hypolipémiant. À partir des anomalies étudiées en triglycérides (> 1,5 g/L), HDL-C (< 0,4 g/L) et LDL-C (non-atteinte de l’objectif thérapeutique selon les critères de l’Afssaps–2005), quatre groupes de patients ont été identifiés : 1 – absence d’anomalie lipidique résiduelle, 2 – triglycérides élevés et/ou HDL-C bas avec LDL-C normal, 3 – anomalie isolée du LDL-C, 4 – anomalie du LDL-C avec triglycérides élevés et/ou HDL-C bas. Le niveau de risque cardiovasculaire des patients a été comparé entre ces quatre groupes.
Sur 2727 patients (âge moyen = 64,7, 47 % de femmes), 28 % avaient un LDL-C élevé, 27,2 % des triglycérides élevés et 10,3 % un taux bas de HDL-C. Les fréquences respectives des quatre groupes étaient 51,2, 20,5, 16,2 et 12,1 %. Parmi les patients avec LDL-C à l’objectif, ceux du groupe 2 présentaient davantage de facteurs de risque cardiovasculaire non lipidiques que les patients du groupe 1 (1,83 vs 1,63, p = 0,0004), comme le tabagisme (p = 0,01), le diabète (p < 0,0001) ou l’hypertension artérielle (p = 0,03). Les différences étaient non significatives entre les patients des groupes 3 et 4, sauf pour le tabagisme (p < 0,0001).
L’hypertriglycéridémie et les taux bas en HDL-C sont fréquents chez les patients traités par hypolipémiant, notamment en présence de facteurs de risque cardiovasculaires.

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Mixed Dyslipidemia Among Patients Using Lipid-Lowering Therapy in French General Practice: An Observational Study

Abstract

J Am Coil Cardiol

Am J Cardiol

Diabetes Metab

Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (45)

Lancet

Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia

N EnglJ Med

MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: A randomized placebo-controlled trial

Lancet

Efficacy and safety of cholesterol-lowering treatment: Prospective meta-analysis of data From 90,056 participants in 14 randomised trials ofstatins [published correction appears in Lancet. 2005;366:1358]

Lancet

Recent National Cholesterol Education Program Adult Treatment Panel III update: Adjustments and options

Am J Cardiol

High-density lipoprotein cholesterol and cardiovascular disease. Four prospective American studies

Circulation

Circulation

Targeting low high-density lipoprotein cholesterol for therapy: Lessons from the Veterans Affairs High-density Lipoprotein Intervention Trial

Am J Cardiol

Risk factors for a major coronary event after myocardial infarction in the Scandinavian Simvastatin Survival Study (4S). Impact of predicted risk on the benefit of cholesterol-lowering treatment

Eur Heart J

Therapeutic management of dyslipidemic patients: Guidelines [in French].

European guide-lines on cardiovascular disease prevention in clinical practice: Third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts)

Eur J Cardiovasc Prey Rehabil

Plasma triglyceride level and mortality from coronary heart disease

N Engl J Med

Do triglycerides provide meaningful information about heart disease risk?

Arch Intern Med

Triglyceride concentration and ischemic heart disease: An eight-year follow-up in the Copenhagen Male Study [published correction appears in Circulation. 1998; 97:1995]

Circulation

Plasma triglyceride level is a risk factor for cardiovascular disease independent of high-density lipoprotein cholesterol level: A meta-analysis of population-based prospective studies

J Cardiovasc Risk

Plasma triglyceride and high density lipoprotein cholesterol as predictors of ischaemic heart disease in British men. The Caerphilly and Speed-well Collaborative Heart Disease Studies

Br Heart J

A prospective study of triglyceride level, low-density lipoprotein particle diameter, and risk of myocardial infarction

JAMA