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.

"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.


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