Skip to main content
NCBI home page
Canadian Family Physician logoLink to Canadian Family Physician
. 2001 Feb;47:303–309.

Lipid-lowering update 2001. Aggressive new goals.

T K Fenske 1
PMCID: PMC2016239  PMID: 11228031

Abstract

OBJECTIVE: To review the central role of cholesterol in coronary artery disease (CAD), underscore the need for identifying patients at high risk of CAD, and discuss treatment of dyslipidemias. QUALITY OF EVIDENCE: Current literature (1995-2000) was searched via MEDLINE using the MeSH headings "cholesterol," "risk reduction," and "statins." Recommendations in this paper are based mainly on the results of large randomized controlled trials. Preference was given to more recent articles, clinically relevant articles, and landmark clinical trials. MAIN MESSAGE: Lipid lowering, and specifically low-density lipoprotein lowering, has been repeatedly shown in large clinical trials to improve survival dramatically and reduce cardiac events in both primary and secondary prevention. Identifying those at highest risk for future cardiac events is critical because these patients will benefit most from aggressive modification of risk factors. The definition of high risk has been expanded to include patients with diabetes mellitus and peripheral vascular disease, as well as those with established CAD. A full lipid profile is required for these patients to assess risk and develop a lipid-lowering strategy with proven effectiveness. CONCLUSION: With the advent of powerful, efficacious, and well tolerated cholesterol-modifying therapies, lipid normalization should be a mandate for all physicians caring for patients with established CAD and patients at risk of developing CAD.

Full Text

The Full Text of this article is available as a PDF (55.7 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bradford R. H., Shear C. L., Chremos A. N., Dujovne C., Downton M., Franklin F. A., Gould A. L., Hesney M., Higgins J., Hurley D. P. Expanded Clinical Evaluation of Lovastatin (EXCEL) study results. I. Efficacy in modifying plasma lipoproteins and adverse event profile in 8245 patients with moderate hypercholesterolemia. Arch Intern Med. 1991 Jan;151(1):43–49. doi: 10.1001/archinte.151.1.43. [DOI] [PubMed] [Google Scholar]
  2. Buchwald H., Bourdages H. R., Campos C. T., Nguyen P., Williams S. E., Boen J. R. Impact of cholesterol reduction on peripheral arterial disease in the Program on the Surgical Control of the Hyperlipidemias (POSCH). Surgery. 1996 Oct;120(4):672–679. doi: 10.1016/s0039-6060(96)80016-x. [DOI] [PubMed] [Google Scholar]
  3. Criqui M. H., Langer R. D., Fronek A., Feigelson H. S., Klauber M. R., McCann T. J., Browner D. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992 Feb 6;326(6):381–386. doi: 10.1056/NEJM199202063260605. [DOI] [PubMed] [Google Scholar]
  4. Downs J. R., Clearfield M., Weis S., Whitney E., Shapiro D. R., Beere P. A., Langendorfer A., Stein E. A., Kruyer W., Gotto A. M., Jr Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA. 1998 May 27;279(20):1615–1622. doi: 10.1001/jama.279.20.1615. [DOI] [PubMed] [Google Scholar]
  5. Dupuis J., Tardif J. C., Cernacek P., Théroux P. Cholesterol reduction rapidly improves endothelial function after acute coronary syndromes. The RECIFE (reduction of cholesterol in ischemia and function of the endothelium) trial. Circulation. 1999 Jun 29;99(25):3227–3233. doi: 10.1161/01.cir.99.25.3227. [DOI] [PubMed] [Google Scholar]
  6. Feher M. D., Foxton J., Banks D., Lant A. F., Wray R. Long-term safety of statin-fibrate combination treatment in the management of hypercholesterolaemia in patients with coronary artery disease. Br Heart J. 1995 Jul;74(1):14–17. doi: 10.1136/hrt.74.1.14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Fodor J. G., Frohlich J. J., Genest J. J., Jr, McPherson P. R. Recommendations for the management and treatment of dyslipidemia. Report of the Working Group on Hypercholesterolemia and Other Dyslipidemias. CMAJ. 2000 May 16;162(10):1441–1447. [PMC free article] [PubMed] [Google Scholar]
  8. Goldbourt U., Yaari S., Medalie J. H. Isolated low HDL cholesterol as a risk factor for coronary heart disease mortality. A 21-year follow-up of 8000 men. Arterioscler Thromb Vasc Biol. 1997 Jan;17(1):107–113. doi: 10.1161/01.atv.17.1.107. [DOI] [PubMed] [Google Scholar]
  9. Gould A. L., Rossouw J. E., Santanello N. C., Heyse J. F., Furberg C. D. Cholesterol reduction yields clinical benefit: impact of statin trials. Circulation. 1998 Mar 17;97(10):946–952. doi: 10.1161/01.cir.97.10.946. [DOI] [PubMed] [Google Scholar]
  10. Grundy S. M., Pasternak R., Greenland P., Smith S., Jr, Fuster V. Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 1999 Sep 28;100(13):1481–1492. doi: 10.1161/01.cir.100.13.1481. [DOI] [PubMed] [Google Scholar]
  11. Grundy S. M. Statin trials and goals of cholesterol-lowering therapy. Circulation. 1998 Apr 21;97(15):1436–1439. doi: 10.1161/01.cir.97.15.1436. [DOI] [PubMed] [Google Scholar]
  12. Haffner S. M., Lehto S., Rönnemaa T., Pyörälä K., Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998 Jul 23;339(4):229–234. doi: 10.1056/NEJM199807233390404. [DOI] [PubMed] [Google Scholar]
  13. Hulley S., Grady D., Bush T., Furberg C., Herrington D., Riggs B., Vittinghoff E. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA. 1998 Aug 19;280(7):605–613. doi: 10.1001/jama.280.7.605. [DOI] [PubMed] [Google Scholar]
  14. Kannel W. B., McGee D. L. Diabetes and cardiovascular disease. The Framingham study. JAMA. 1979 May 11;241(19):2035–2038. doi: 10.1001/jama.241.19.2035. [DOI] [PubMed] [Google Scholar]
  15. Knopp R. H. Drug treatment of lipid disorders. N Engl J Med. 1999 Aug 12;341(7):498–511. doi: 10.1056/NEJM199908123410707. [DOI] [PubMed] [Google Scholar]
  16. Knopp R. H. Drug treatment of lipid disorders. N Engl J Med. 1999 Aug 12;341(7):498–511. doi: 10.1056/NEJM199908123410707. [DOI] [PubMed] [Google Scholar]
  17. Knopp R. H., Ginsberg J., Albers J. J., Hoff C., Ogilvie J. T., Warnick G. R., Burrows E., Retzlaff B., Poole M. Contrasting effects of unmodified and time-release forms of niacin on lipoproteins in hyperlipidemic subjects: clues to mechanism of action of niacin. Metabolism. 1985 Jul;34(7):642–650. doi: 10.1016/0026-0495(85)90092-7. [DOI] [PubMed] [Google Scholar]
  18. Muldoon M. F., Manuck S. B., Matthews K. A. Lowering cholesterol concentrations and mortality: a quantitative review of primary prevention trials. BMJ. 1990 Aug 11;301(6747):309–314. doi: 10.1136/bmj.301.6747.309. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Murray C. J., Lopez A. D. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet. 1997 May 24;349(9064):1498–1504. doi: 10.1016/S0140-6736(96)07492-2. [DOI] [PubMed] [Google Scholar]
  20. Pitt B., Waters D., Brown W. V., van Boven A. J., Schwartz L., Title L. M., Eisenberg D., Shurzinske L., McCormick L. S. Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators. N Engl J Med. 1999 Jul 8;341(2):70–76. doi: 10.1056/NEJM199907083410202. [DOI] [PubMed] [Google Scholar]
  21. Rubins H. B., Robins S. J., Collins D., Fye C. L., Anderson J. W., Elam M. B., Faas F. H., Linares E., Schaefer E. J., Schectman G. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med. 1999 Aug 5;341(6):410–418. doi: 10.1056/NEJM199908053410604. [DOI] [PubMed] [Google Scholar]
  22. Sacks F. M., Pfeffer M. A., Moye L. A., Rouleau J. L., Rutherford J. D., Cole T. G., Brown L., Warnica J. W., Arnold J. M., Wun C. C. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med. 1996 Oct 3;335(14):1001–1009. doi: 10.1056/NEJM199610033351401. [DOI] [PubMed] [Google Scholar]
  23. Santanello N. C., Barber B. L., Applegate W. B., Elam J., Curtis C., Hunninghake D. B., Gordon D. J. Effect of pharmacologic lipid lowering on health-related quality of life in older persons: results from the Cholesterol Reduction in Seniors Program (CRISP) Pilot Study. J Am Geriatr Soc. 1997 Jan;45(1):8–14. doi: 10.1111/j.1532-5415.1997.tb00971.x. [DOI] [PubMed] [Google Scholar]
  24. Schwartz G. G., Oliver M. F., Ezekowitz M. D., Ganz P., Waters D., Kane J. P., Texter M., Pressler M. L., Black D., Chaitman B. R. Rationale and design of the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study that evaluates atorvastatin in unstable angina pectoris and in non-Q-wave acute myocardial infarction. Am J Cardiol. 1998 Mar 1;81(5):578–581. doi: 10.1016/s0002-9149(97)00963-6. [DOI] [PubMed] [Google Scholar]
  25. Shepherd J., Cobbe S. M., Ford I., Isles C. G., Lorimer A. R., MacFarlane P. W., McKillop J. H., Packard C. J. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med. 1995 Nov 16;333(20):1301–1307. doi: 10.1056/NEJM199511163332001. [DOI] [PubMed] [Google Scholar]
  26. Stampfer M. J., Krauss R. M., Ma J., Blanche P. J., Holl L. G., Sacks F. M., Hennekens C. H. A prospective study of triglyceride level, low-density lipoprotein particle diameter, and risk of myocardial infarction. JAMA. 1996 Sep 18;276(11):882–888. [PubMed] [Google Scholar]
  27. Teo K. K. Coronary artery disease prevention: better management of dyslipidemias required. Can J Cardiol. 1997 Feb;13(2):127–128. [PubMed] [Google Scholar]
  28. Turner R. C., Millns H., Neil H. A., Stratton I. M., Manley S. E., Matthews D. R., Holman R. R. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23) BMJ. 1998 Mar 14;316(7134):823–828. doi: 10.1136/bmj.316.7134.823. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Vaughan C. J., Murphy M. B., Buckley B. M. Statins do more than just lower cholesterol. Lancet. 1996 Oct 19;348(9034):1079–1082. doi: 10.1016/S0140-6736(96)05190-2. [DOI] [PubMed] [Google Scholar]
  30. Vogt M. T., Cauley J. A., Newman A. B., Kuller L. H., Hulley S. B. Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA. 1993 Jul 28;270(4):465–469. [PubMed] [Google Scholar]
  31. Walden C. E., Retzlaff B. M., Buck B. L., McCann B. S., Knopp R. H. Lipoprotein lipid response to the National Cholesterol Education Program step II diet by hypercholesterolemic and combined hyperlipidemic women and men. Arterioscler Thromb Vasc Biol. 1997 Feb;17(2):375–382. doi: 10.1161/01.atv.17.2.375. [DOI] [PubMed] [Google Scholar]
  32. de Lorgeril M., Salen P., Martin J. L., Monjaud I., Delaye J., Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999 Feb 16;99(6):779–785. doi: 10.1161/01.cir.99.6.779. [DOI] [PubMed] [Google Scholar]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

RESOURCES