Majority of Patients Hospitalized With CAD at Guideline-Recommended LDL Targets

Michael O'Riordan

January 21, 2009

January 21, 2009 (Los Angeles, California) — A majority of patients hospitalized with coronary artery disease (CAD) have LDL-cholesterol levels considered normal by current guidelines, a new study has shown [1]. The findings suggest that current lipid targets are not low enough to prevent risk in patients who would benefit, say researchers.

"There have been modest improvements in LDL-cholesterol levels over time," lead investigator Dr Gregg Fonarow (University of California Los Angeles Medical Center) told heartwire . "One of the major findings of this study that should serve as a wake-up call for anyone interested in reducing death and disability due to cardiovascular disease is that nearly 75% of patients having first ACS events had LDL levels below 130 mg/dL, and nearly 50% had LDL levels below 100 mg/dL."

The study is published in the January 2009 issue of the American Heart Journal with lead investigator Dr Amit Sachdeva (University of California, Los Angeles Medical Center).

GWTG Database

The new data, obtained from a national database sponsored by the American Heart Association Get With the Guidelines program, includes admission lipid levels on 137 000 individuals from more than 500 hospitals who were admitted with CAD. Admission diagnoses were most commonly related to acute coronary syndromes.

Before admission to the hospital, 21% of patients were taking lipid-lowering medications. Among patients with a medical history of CAD, other atherosclerotic vascular disease, or diabetes, just 29.4% were taking lipid-lowering therapy prior to hospital admission, compared with 14% of patients without a history of CAD.

The mean LDL-cholesterol level among hospitalized patients was 104.9 mg/dL. Of these, almost 50% of patients had LDL-cholesterol levels <100 mg/dL, with 17% of patients having LDL levels lower than the more stringent target of <70 mg/dL. In the total cohort, roughly 75% of patients had levels <130 mg/dL.

Regarding HDL-cholesterol levels, 54.6% of patients hospitalized had levels <40 mg/dL and only 7.8% of patients had levels that exceeded 60 mg/dL. Just 1.4% of patients hospitalized with CAD had ideal levels of LDL and HDL cholesterol.

Total Cohort (N=103 632)

HDL cholesterol levels, mg/dL LDL <70 mg/dL (%) LDL 70–99 mg/dL (%) LDL 100–129 mg/dL (%) LDL 130–159 mg/dL (%) LDL >160 mg/dL (%) Total
<40 10.8 17.8 14.7 7.6 3.8 54.6
40–59 5.3 11.7 10.6 6.2 3.7 37.5
>60 1.4 2.5 2.1 1.1 0.7 7.8
Total 17.6 32.0 27.4 14.9 8.2 100

Patients Without CAD, Other Atherosclerotic Vascular Disease, or Diabetes (N=48 093)

HDL cholesterol levels, mg/dL LDL <70 mg/dL (%) LDL 70-99 mg/dL (%) LDL 100-129 mg/dL (%) LDL 130-159 mg/dL (%) LDL >160 mg/dL (%) Total
<40 7.1 15.3 16.0 9.0 4.4 52.0
40–59 4.0 11.0 12.0 7.7 4.4 39.1
>60 1.3 2.7 2.6 1.4 0.9 8.9
Total 12.5 29.0 30.6 18.2 9.7 100

"The conventional cholesterol guidelines are missing the majority of patients having cardiovascular events," said Fonarow. "While certainly there are other risk factors beyond LDL, there are hundreds of thousands of potentially preventable cardiovascular events occurring because the LDL levels for primary prevention are missing too many individuals."

Among patients without established vascular disease or diabetes, 42% of patients had LDL-cholesterol levels <100 mg/dL and 72% had levels <130 mg/dL. On the other hand, 52% of patients without established disease had HDL cholesterol levels <40 mg/dL.

Low HDL was observed in a majority of patients presenting with first and recurrent cardiovascular events, noted Fonarow. "Finding safe, well-tolerated, and effective therapies to raise cardioprotective HDL appears to be very important," he added. "However, it is essential that large-scale trials be conducted to demonstrate reduction in clinical events incremental to LDL lowering with statin therapy and that the benefits of treating HDL outweigh potential risks."

The group also points out that a large proportion of patients included in the present study could reach the standard or optional National Cholesterol Education Program (NCEP) LDL goals without statin therapy or with a statin dose lower than used in clinical trials.

  1. Sachdeva A, Cannon CP, Deedwania PC, et al. Lipid levels in patients hospitalized with coronary artery disease: an analysis of 136,905 hospitalizations in Get With the Guidelines. Am Heart J 2009; 157:111-117. Abstract

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