The prevention of cardiovascular disease: Emphasis on Secondary Prevention

Little is known about the lipid profiles and associated treatment patterns of patients in whom atherosclerosis is diagnosed. This investigation assessed and described the low-density lipoprotein (LDL) cholesterol levels and treatment patterns for hypercholesterolemia in patients with atherosclerosis who were treated in routine clinical practice. This retrospective database study used a random sample (1 million patients) from a national outpatient electronic medical record database (GE Medical Systems, Milwaukee, WI) and included patients with a diagnostic code for atherosclerosis (International Classification of Diseases [ICD]-9 code of 440.xx or 414.x or 437.x) between January 2004 and March 2006. Use of hypercholesterolemia medications at the time ICD codes for atherosclerosis were recorded and thereafter was documented. Patient demographics, comorbid conditions, baseline LDL cholesterol (closest value within 6 months of the diagnosis date), and follow-up LDL cholesterol (after diagnosis) were also documented. A total of 10,637 eligible patients had an ICD diagnostic code for atherosclerosis. Most patients (61.3%) were not taking any dyslipidemia medication at the time of and after atherosclerosis diagnosis. A total of 3% were prescribed therapy with a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) before the time of atherosclerosis diagnosis, and 25% were prescribed a statin after diagnosis. Approximately 62% of patients with atherosclerosis did not have a baseline LDL cholesterol estimate. Of patients with LDL cholesterol recorded at diagnosis (n = 4,067), 24% had LDL cholesterol ≥130 mg/dL (1 mg/dL = 0.02586 mmol/L), 53% had LDL cholesterol ≥100 mg/dL, and 87% had LDL cholesterol ≥70 mg/dL. Among patients with LDL cholesterol ≥100 mg/dL at diagnosis, 57% were not prescribed statin treatment after diagnosis. Of those with baseline and postdiagnosis LDL cholesterol values (n = 1,395), 49% had baseline LDL cholesterol ≥100 mg/dL. Among patients on statin or any other hypercholesterolemia therapy after diagnosis who had baseline and follow-up LDL cholesterol values (n = 682), 87% had baseline LDL cholesterol ≥70 mg/dL and 51% had baseline LDL cholesterol ≥100 mg/dL, whereas 82% had postdiagnosis LDL cholesterol ≥70 mg/dL and 43% had postdiagnosis LDL cholesterol ≥100 mg/dL. The results from this study, which was conducted in a routine clinical practice setting, indicate the opportunities and the need for better monitoring and management of lipid levels in patients with atherosclerosis.

The most rapidly growing segment of the United States population is the geriatric group, especially those above 75 years of age. Hypertension, diabetes mellitus, and dyslipidemia increase with advancing years in Westernized, industrialized societies such as the United States. These disorders contribute significantly to strokes and myocardial infarctions and associated morbidity and mortality in our elderly population. The increase in these chronic disease processes with aging is related, in part, to increasing obesity, reductions in physical activity, and medications that predispose to these conditions (ie, nonsteroidal inflammatory agents and hypertension). Hypertension in the elderly is characterized by high peripheral vascular resistance/reduced cardiac output, impaired baroflex sensitivity, relatively greater systolic pressures, increased blood pressure variability, and a propensity to salt sensitivity. Type 2 diabetes in the elderly is related to alterations in body composition (ie, increased central adiposity and decreased lean body mass) and to reduced physical activity. There is an increasing body of evidence that aggressive treatment of hypertension and dyslipidemia in the elderly results in comparable, if not greater, reductions in cardiovascular morbidity and mortality in the elderly as in younger counterparts. (J Lab Clin Med 2000;135:379-86)

Objectives. The aim of this study was to examine physician specialty differences in cardiovascular disease prevention practices.

Background. Despite the importance of cardiovascular disease prevention, little is known about current national practices, particularly physician specialty differences.

Methods. Using a national survey of office visits, we evaluated differences in the propensity of physicians of different specialties to provide prevention services. We analyzed 30,929 adult visits to 1,521 physicians selected by stratified random sampling in the 1995 National Ambulatory Medical Care Survey. Standard and ordinal multiple logistic regression models were employed to estimate the independent effects of physician and patient characteristics.

Results. A variety of cardiovascular disease prevention services were provided during an estimated 547 million adult office visits to US physicians in 1995, including blood pressure measurement (50% of visits), cholesterol testing (5%) and counseling for exercise (12%), weight (6%), cholesterol (4%) and smoking (3%). In addition, medication management was reflected by the report of antihypertensives in 12% of visits and lipid-lowering medications in 2%. Across these eight services, propensity to provide services varied consistently with specialty. Controlling for patient and visit characteristics and compared to general internists, the likelihood of providing services was higher for cardiologists (adjusted odds ratio 1.65, 95% confidence interval 1.44 to 1.89) but lower for obstetrician/gynecologists (0.75, 0.68 to 0.82), family physicians (0.69, 0.64 to 0.74), general practitioners (0.58, 0.53 to 0.63), other medical specialists (0.65, 0.59 to 0.72) and surgeons (0.06, 0.05 to 0.06).

Conclusions. Cardiologists have the greatest propensity to provide cardiovascular disease prevention services, while primary care physicians vary substantially in their practices. These findings suggest a need to address variations in cardiovascular disease prevention.

The organic extract of the fermentation broth of a fungus was found to contain a depsipeptide SCH 58149 (1), containing three amino acids and a β-hydroxy acid, by spectroscopic studies. The amino acids were phenyl alanine, alanine and leucine and the β-hydroxy acid is 3-hydroxy-4-methyl octanoic acid. SCH 58149 exhibited weak activity against cholesterol ester transfer protein (CETP) with an IC₅₀ of 50 μM.

Wiedendiol-A and -B, novel sesquiterpene-hydroquinones which inhibit cholesteryl ester transfer protein (CETP), have been isolated from the marine sponge Xestospongia wiedenmayeri. Additional related marine natural products were also evaluated for CETP inhibition. Compounds that inhibit the activity of CETP may find utility as antiatherosclerosis therapy.