Lipid disorders: justification of methods and goals of treatment.

Dyslipidemia is a major risk factor for coronary heart disease (CHD). While some uncertainty exists about the clinical significance of improving high-density lipoprotein cholesterol and triglyceride levels, large primary- and secondary-prevention studies aimed at lowering low-density lipoprotein cholesterol levels with statins have convincingly reduced CHD events and total mortality. Despite the strong clinical evidence and widely publicized treatment guidelines, many hyperlipidemic patients receive inadequate lipid-lowering treatment. This failure to achieve clinical treatment goals may be due to poor physician adherence to treatment guidelines, patient noncompliance, and the presence of concomitant medical conditions that modify typical hyperlipidemia management. This review considers the challenges and available strategies to optimize lipid management in patients at risk for CHD.

Secondary prevention of coronary artery disease in patients undergoing elective surgery for peripheral arterial disease.

The purpose of the study was to assess the implementation of secondary prevention guidelines of coronary artery disease (CAD) in patients undergoing peripheral revascularization surgery. The design was a descriptive study of the prevalence of cardiac risk factors and preventive pharmacological therapy in vascular surgical patients set in an academic medical center between July 1996 and February 1999. A total of 237 patients were recruited, 82 (35%) having carotid surgery and 155 (65%) having lower extremity bypass. Data were collected from an existing database of a study examining perioperative cardiac events in vascular surgery patients. The majority of patients were hypertensive and 58% of patients had a blood pressure >140/90 mmHg. Most patients (81%) reported a history of tobacco use and 23% were active smokers. Of the 41% of patients who were diabetic, 46% had a random glucose >140 mg/dl. Half of the patients took aspirin, 35% a lipid-lowering medication, 30% a beta-blocker. Patients with lower extremity disease were less likely than patients with carotid disease to be on aspirin (45% vs. 62%), a lipid-lowering agent (30% vs. 45%), or a beta-blocker (26% vs. 39%) (all p<0.05). Of patients with heart disease, more men than women were on aspirin (62% vs. 45%) (p<0.05). In conclusion, our findings suggest that patients presenting for vascular surgery have a high prevalence of modifiable CAD risk factors that are not being adequately managed. Preoperative examination of vascular patients is an important opportunity to assess and implement neglected secondary prevention measures.

ABCs of cardiovascular disease risk management.

The past 20 years have witnessed a marked decline in morbidity and mortality from cardiovascular disease. This decline has been due in large part to advances in coronary risk factor modification and a better understanding of the atherosclerotic process. Compelling scientific and clinical trial evidence proves that comprehensive risk factor modification extends patient survival and reduces cardiovascular and cerebrovascular events. This article reviews the ABCs of optimal medical and lifestyle management in patients with documented atherosclerotic vascular disease as well as in those adults who are at increased risk for the development of cardiovascular disease, based on contemporary clinical trial evidence.

Effectiveness of remifentanil versus traditional fentanyl-based anesthetic in high-risk outpatient surgery.

STUDY OBJECTIVE: To determine if remifentanil would offer a superior hemodynamic and recovery profile compared to the current standard of care, which implements a fentanyl-based technique. DESIGN: Randomized, single-blind study. SETTING: Outpatient center associated with tertiary care center. PATIENTS: 75 outpatients undergoing microsuspension laryngoscopy. INTERVENTIONS: Patients were randomized to either a remifentanil induction (0.5 microg/kg/min) and maintenance (0.25 microg/kg/min) versus fentanyl (maximum of 250 microg) as the only opioid. All patients received propofol as part of the induction and maintenance with or without the use of nitrous oxide. MEASUREMENTS: Assessment of hemodynamics [heart rate (HR) and blood pressure(BP)], presence of perioperative myocardial ischemia on ambulatory electrocardiographic monitoring, and time to discharge. MAIN RESULTS: Significantly fewer patients in the remifentanil group demonstrated episodes of tachycardia (HR > 100 beats per min) compared to the fentanyl group (14% vs. 40%, p<0.05), with significantly fewer episodes of tachycardia and hypertension per patient. Recovery profiles between the two groups did not show clinically significant differences. CONCLUSIONS: Remifentanil, a new short-acting opioid, offers excellent hemodynamic control for brief, intense outpatient procedures performed in high-risk patients; however, its use was not associated with any improvement in recovery profiles.

Global risk assessment for lipid therapy to prevent coronary heart disease.

Randomized clinical trials have established that lipid- lowering pharmacologic therapy can substantially reduce morbidity and mortality in patients with known coronary artery disease (CAD). Researchers are now working to define the role of lipid-lowering agents in the primary prevention of CAD to extend their benefit to patients at increased risk for future coronary events. The risk assessment models presently used for secondary prevention are not sufficient to identify high-risk, asymptomatic patients. Building on the accumulated data about the physiologic mechanisms and metabolic factors that contribute to CAD, novel serum markers and diagnostic tests are being critically studied to gauge their utility for the assessment of high-risk patients and occult vascular disease. New risk prediction models that combine traditional risk factors for CAD with the prudent use of new screening methods will allow clinicians to target proven risk reduction therapies at high-risk patients before they experience a cardiac event.

Glitazones and the potential improvement of lipid profiles in diabetes patients at high risk for cardiovascular disease.

Most deaths and hospitalizations in patients with diabetes are related to atherosclerotic vascular disease. An asymptomatic patient with type 2 diabetes has a cardiovascular risk comparable to that of a patient without diabetes who has a history of a myocardial infarction. The American Heart Association classifies diabetes as a coronary heart disease risk equivalent. Thus, it is important in patients with diabetes to aim for systolic blood pressures less than 130 mm Hg, using an angiotensin-converting enzyme inhibitor-based regimen. The target hemoglobin A1C (HbA1C) for those patients is < 7%. New oral insulin-sensitizing medications, known as thiazolidinediones or glitazones, are useful to improve glycemic control. Most patients with diabetes require 2 or more oral agents to achieve optimal glucose control. Glitazones generally lower HbA1C by 1% to 2%. They also raise high-density lipoprotein cholesterol levels and lower triglycerides. Thus, they may potentially improve low-density lipoprotein (LDL) particle sizes by converting small, dense LDL particles into larger, less atherogenic ones. Current data concerning the lipid effects of pioglitazone and rosiglitazone are reviewed in this article.