Prevalence of Low High-Density Lipoprotein Cholesterol in Patients With Documented Coronary Heart Disease or Risk Equivalent and Controlled Low-Density Lipoprotein Cholesterol

doi:10.1016/j.amjcard.2007.06.058

The American Journal of Cardiology

Volume 100, Issue 10, 15 November 2007, Pages 1499-1501

https://doi.org/10.1016/j.amjcard.2007.06.058 Get rights and content

Current guidelines identify low-density lipoprotein (LDL) cholesterol as the primary target for cardiovascular prevention but also recognize low high-density lipoprotein (HDL) cholesterol as an important secondary target. This study was conducted to determine the prevalence of low HDL cholesterol in a contemporary ambulatory high-risk population across various LDL cholesterol levels, including patients taking statins. Screening of 44,052 electronic medical records from a primary care practice identified 1,512 high-risk patients with documented coronary heart disease (CHD) or CHD risk equivalents. Low HDL cholesterol (≤40 mg/dl in men, ≤50 mg/dl in women) was present in 66% of the 1,512 patients. Low HDL cholesterol was prevalent across all LDL cholesterol levels but most prevalent in patients with LDL cholesterol ≤70 mg/dl (79% vs 66% in those with LDL cholesterol 71 to 100 mg/dl and 64% in patients with LDL cholesterol >100 mg/dl, p <0.01). Low HDL cholesterol was equally and highly prevalent in patients taking statins (67%) and those not taking statins (64%) (p = NS). HDL cholesterol and LDL cholesterol levels correlated poorly (R² = 0.01), and this was unaffected by gender or statin treatment. In conclusion, in high-risk patients with CHD or CHD risk equivalents, low HDL cholesterol levels remain prevalent despite statin treatment and the achievement of aggressive LDL cholesterol goals.

Section snippets

Methods and Results

We used electronic medical records from a large primary care practice affiliated with an academic tertiary care hospital, with 27 primary care physicians, 7 nurse practitioners, and >55,000 outpatient visits per year. Through a computerized search, we screened 44,502 medical records to identify high-risk patients, defined as having documented coronary heart disease (CHD) or CHD risk equivalents. Patients were noted as having CHD if they had 1 of the following: CHD by coronary angiography,

Discussion

In the present analysis of a large contemporary high-risk population, we make 3 observations. First, despite statin treatment and with aggressively controlled LDL cholesterol, most of these high-risk patients had low HDL cholesterol levels. Second, there was essentially no relation between HDL cholesterol and LDL cholesterol, highlighting the independent nature of these 2 lipid targets. Third, present-day strategies to increase HDL cholesterol are underused.

The present findings are consistent

References (8)

J. Genest et al.
Lipoprotein cholesterol, apolipoprotein A-I and B and lipoprotein (a) abnormalities in men with premature coronary artery disease
J Am Coll Cardiol
(1992)
A.A. Alsheikh-Ali et al.
High-density lipoprotein cholesterol in the cardiovascular equation: does the “good” still count?
Atherosclerosis
(2005)
S.M. Grundy et al.
Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines
Circulation
(2004)
ClinicalTrials.gov. Niacin Plus Statin to Prevent Vascular Events. Available at:...

There are more references available in the full text version of this article.

Cited by (61)

Related cardiometabolic factors and prevalence of low HDL-cholesterol levels and atherogenic dyslipidemia. SIMETAP-AD study
2021, Clinica e Investigacion en Arteriosclerosis
Determinar las prevalencias ajustadas por edad y sexo de concentraciones bajas de colesterol HDL (cHDL-bajo) y de dislipidemia aterogénica (DA), y valorar sus asociaciones con factores de riesgo cardiovascular, enfermedad renal crónica, enfermedades cardiovasculares y cardiometabólicas.
Estudio observacional transversal de base poblacional realizado en atención primaria, con sujetos adultos seleccionados aleatoriamente. Se consideró DA si los pacientes tenían hipertrigliceridemia (triglicéridos ≥ 150 mg/dL) y cHDL-bajo (< 40 mg/dL [hombres], < 50 mg/dL [mujeres]). Se determinaron las tasas de prevalencia crudas y ajustadas por edad y sexo, y se realizó análisis univariado y multivariante para evaluar los factores cardiometabólicos relacionados.
Población de estudio con 6.588 adultos (55,9% mujeres) con edad media de 55,1 (± 17,5) años. Las medias de cHDL fueron 49,2 (± 12,6) mg/dL en hombres y 59,2 (± 14,7) mg/dL en mujeres. Las prevalencias crudas de cHDL-bajo y de DA fueron 30,8% (IC95%: 29,7-31,9), y 14,3% (IC95%: 13,5-15,2), respectivamente. Las prevalencias ajustadas de cHDL-bajo fueron 28% en hombres y 31% en mujeres, y de DA fueron 16,4% en hombres y 10,6% en mujeres. El 73% de la población con DA tenía riesgo cardiovascular alto o muy alto. Los factores independientes asociados con cHDL-bajo o con DA fueron diabetes, tabaquismo, obesidad abdominal y obesidad. Los principales factores asociados con cHDL-bajo y con DA fueron hipertrigliceridemia y diabetes, respectivamente.
Casi un tercio de la población adulta presentaba cHDL-bajo y la mitad de ellos cumplía criterios de DA. Los factores cardiometabólicos se asociaban con cHDL-bajo y DA, destacando la hipertrigliceridemia con el cHDL-bajo, y la DM con la DA.
To determine the crude and sex- and age-adjusted prevalence rates of atherogenic dyslipidemia (AD) and low HDL-cholesterol levels (low-HDLc), and to assess their associations with cardiovascular risk factors, chronic kidney disease, cardiovascular and cardiometabolic diseases.
Population-based cross-sectional study conducted in Primary Care, with randomly selected adult subjects. The AD was considered if the patients had hypertriglyceridemia (triglycerides ≥ 150 mg/dL) and low-HDLc (< 40 mg/dL [men]; < 50 mg/dL [women]). Crude and sex- and age-adjusted prevalence rates were determined, and univariate and multivariate analysis were performed to assess related cardiometabolic factors.
Study population with 6,588 adults (55.9% women) with mean age 55.1 (± 17.5) years. The mean HDLc levels were 49.2 (± 12.6) mg/dL in men and 59.2 (± 14.7) mg/dL in women. The crude prevalence rates of low-HDLc and AD were 30.8% (95%CI: 29.7-31.9), and 14.3% (95%CI: 13.5-15.2), respectively. The adjusted prevalence rates of low-HDLc were 28.0% in men and 31.0% in women, and AD were 16.4% in men and 10.6% in women. Seventy-three percent of the population with AD had high or very high cardiovascular risk. The independent factors associated with low HDLc or with AD were diabetes, smoking, abdominal obesity, and obesity. The major factors associated with low HDLc and AD were hypertriglyceridemia and diabetes, respectively.
Almost a third of the adult population had low HDL-C and half of them met AD criteria. Cardiometabolic factors were associated with low HDL-C and AD, highlighting hypertriglyceridemia with low HDLc, and DM with AD.
Effect of 1-y oral supplementation with vitaminized olive oil on platelets from healthy postmenopausal women
2017, Nutrition
Olive oil is the main fat source in the Mediterranean diet and shows a protective role against aging and related diseases. Osteoporosis represents a serious health problem worldwide and is associated with an increased risk for fractures and mortality. Nutrition should be part of bone disease prevention strategies, especially in light of the aging population and the effect of diet on bone health. The aim of this study was to investigate whether oral supplementation with extra virgin olive oil (VOO) enriched with vitamins D₃, K₁, and B₆ (VitVOO) is able to modify some physicochemical and functional plasma membrane properties and nitrosative stress markers status.
In this single-center, randomized placebo-controlled trial, 60 postmenopausal women were administered either VitVOO or placebo (PlaVOO). After 1 y of oral supplementation, platelet membrane fluidity changes, Na⁺/K⁺-ATPase activity, serum nitric oxide, and peroxynitrite levels were determined in participants.
After 1 y (time 1), women taking VitVOO showed lower nitric oxide levels than those taking PlaVOO; the same trend was found for peroxynitrite levels. As far as membrane fluidity was concerned, a significant decrease in anisotropy of diphenylhexatriene and trimethylammonium-diphenylhexatriene at time 1 in VitVOO participants compared with PlaVOO was found. Finally, Na⁺/K⁺-ATPase activity showed a significant increase after VitVOO supplementation.
The supplementation of VitVOO into the diet of postmenopausal women could represent a proper tool for platelet function and a useful strategy against nitrosative stress and related diseases, thus confirming the antioxidant role played by the added vitamins.
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
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.
Prevalence of atherogenic dyslipidemia: Association with risk factors and cardiovascular risk in Spanish working population. "ICARIA" study
2014, Atherosclerosis
Citation Excerpt :
The prevalence of AD in the general population is not well known [11]. AD is common in patients with type 2 diabetes, metabolic syndrome and/or cardiovascular disease (CVD) [5,12,13]. In the United States, about two-thirds of coronary heart disease (CHD), or CHD equivalent patients, treated with statins with controlled LDL cholesterol levels, have low levels of HDL cholesterol (<40 mg/dl in men and <50 mg/dl in women), and this remains despite reaching common LDL-c goals aggressively (≤70 mg/dl) [13].
The aim of this study was to assess the prevalence of atherogenic dyslipidemia (AD) and the lipid triad (LT) in the working population in Spain, their associated variables and how far they are linked to cardiovascular risk (CVR).
Observational cross-sectional study of 70,609 workers (71.5% male (M), 28.5% female (F), mean age 39.2 ± 10), who attended medical checkups and agreed to participate. Plasma samples were analysed in a central laboratory. AD definition used was: triglycerides ≥150 mg/dl and HDL cholesterol <40 mg/dl (M)/<50 mg/dl (F) and LT when LDL cholesterol > 160 mg/dl is further added. Univariate comparisons in the absence and presence of AD and LT and the probability of AD according to different parameters and their possible association with CVR were assessed. CVR was stratified following the European SCORE model for low risk-population.
5.7% (95% CI 4.7–6.9) of the working population have AD and 1.1% (95% CI 1.0–1.2) LT. In univariate analysis, workers with AD and LT had a higher prevalence of obesity, hypertension, smoking and diabetes than those who had not (p < 0.001). In multivariate analysis, BMI, sex, age 40–49, diabetes, tobacco, uric acid, LDL or blood pressure significantly influenced the risk of AD. AD was significantly associated with CVR after adjusting for alcohol and obesity. However, most of the AD subjects (91.8%) were classified as low risk.
About 6% of the working population in Spain meets AD criteria. Assuming that these subjects have increased CVR, AD allows to identify additional 5% of subjects with increased CVR to that one the SCORE model detects, helping to improve cardiovascular risk stratification.
Should low high-density lipoprotein cholesterol (HDL-C) be treated?
2014, Best Practice and Research: Clinical Endocrinology and Metabolism
Citation Excerpt :
Diabetic retinopathy also has an independent association with low HDL-C [36]. Patients with CAD have a high prevalence of low HDL-C, and among those with LDL-C levels of 70–100 mg/dL or <70 mg/dL the prevalence is 66% and 79%, respectively [37]. Currently, 13% of US adults have diabetes mellitus and 34% meet the Third National Cholesterol Education Program Adult Treatment Panel (NCEP ATP III) criteria for metabolic syndrome [38,39].
The first observations linking a low serum level of HDL-C to increased risk for cardiovascular disease were made over 50 years ago. High serum levels of HDL-C appear to protect against the development of atherosclerotic disease, while low serum levels of this lipoprotein are among the most important predictors of atherosclerotic disease in both men and women and people of all racial and ethnic groups throughout the world. It has long been assumed that therapeutic interventions targeted at raising HDL-C levels would lower risk for such cardiovascular events as myocardial infarction, ischemic stroke, and death. Even after five decades of intensive investigation, evidence to support this assumption has been fleeting. A number of post hoc analyses of randomized controlled trials and meta-analyses suggest that HDL-C raising, particularly when coupled with aggressive LDL-C reduction, impacts risk for cardiovascular events and rates of progression of atherosclerotic disease. Unfortunately, four recent prospective trials performed with the intent of testing the “HDL hypothesis” (ILLUMINATE, dal-OUTCOMES, AIM-HIGH, and HPS2-THRIVE) failed to meet their primary composite endpoints. These results have lead many clinicians and investigators to question the validity of the assumption that HDL-C raising reduces risk for cardiovascular events. Additional trials with other drugs are underway. In the meantime, HDL-C cannot be considered a target of therapy. Given the complexity of the HDL proteome and lipidome, there is biological plausibility for how HDL particles might exert atheroprotection. We explore the evidence supporting the inverse relationship between HDL-C and cardiovascular disease risk, documented mechanisms by which HDL particles may exert atheroprotection, and the findings either supporting or negating specific therapeutic interventions in patients afflicted with low HDL-C.
Residual dyslipidemia among united states adults treated with lipid modifying therapy (data from national health and nutrition examination survey 2009-2010)
2013, American Journal of Cardiology
Despite available medications for dyslipidemia, many treated patients still have suboptimal lipid levels. The aim of this study was to examine the extent of residual dyslipidemia in United States adults. Of 2509 United States adults aged ≥18 years from the National Health and Nutrition Examination Survey (NHANES) 2009-2010, 1,129 (41.8% weighted) had hyperlipidemia on the basis of modified treatment guidelines for low-density lipoprotein (LDL) cholesterol according to risk category or pharmacologic treatment. Of these, 484 (42.4%) were treated with lipid-modifying therapy, and the proportions of subjects who still had LDL cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, or non-HDL cholesterol not at recommended levels were examined. In this cohort treated for hyperlipidemia, the mean age was 60.1 ± 14.9 years, and 52% were men. Only 36.5% of subjects receiving treatment for hyperlipidemia were at goal or normal levels for all 3 lipids (LDL cholesterol, HDL cholesterol, and triglycerides). LDL cholesterol remained higher than goal for 37.5% of subjects, 28.9% had low HDL cholesterol, and 36.3% had elevated triglycerides. One, 2, and 3 lipid parameters were at abnormal levels in 32.4%, 23.0%, and 8.2% of subjects, respectively; 36.5% had no lipid disorder. In addition, 38.6% of treated subjects were above non-HDL cholesterol goal, and even in those at LDL cholesterol goal, 12.9% were not at non-HDL cholesterol goal. Those with cardiovascular disease conditions had poorer goal attainment of LDL cholesterol, HDL cholesterol, and composite all lipids than those without cardiovascular disease. In conclusion, despite widely available treatments for dyslipidemia, many patients remain at suboptimal lipid levels, indicating need for greater adherence to lifestyle and medical therapies to address these gaps in the management of dyslipidemia.

View all citing articles on Scopus

View full text

Coronary artery diseasePrevalence of Low High-Density Lipoprotein Cholesterol in Patients With Documented Coronary Heart Disease or Risk Equivalent and Controlled Low-Density Lipoprotein Cholesterol

Section snippets

Methods and Results

Discussion

J Am Coll Cardiol

Atherosclerosis

Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines

Circulation

Coronary artery disease
Prevalence of Low High-Density Lipoprotein Cholesterol in Patients With Documented Coronary Heart Disease or Risk Equivalent and Controlled Low-Density Lipoprotein Cholesterol