Clinical practice: Low HDL cholesterol levels

Johns Hopkins Hospital, Baltimore, MD 21287, USA.
New England Journal of Medicine (Impact Factor: 54.42). 10/2005; 353(12):1252-60. DOI: 10.1056/NEJMcp044370
Source: PubMed
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    ABSTRACT: Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) can significantly decrease cardiovascular mortality and morbidity, irrespective of the patients' cholesterol status. This paper reviews the effects of perioperative statin therapy in patients undergoing noncardiac surgery. A systematic literature review was undertaken of all published literature on this subject using Medline and cross-referenced. All published relevant papers on the perioperative use of statins were used. Perioperative statin therapy is associated with a lower perioperative morbidity and mortality in patients undergoing elective or emergency surgery. The effects are due to a combination of lipid-lowering and pleiotropic properties of statins. Ideally a large scale multi-centre randomized controlled trial of perioperative statin therapy should be performed but this may be difficult to conduct since there is already overwhelming evidence in the literature to suggest perioperative cardiovascular protective properties. Statins may still be under-prescribed in surgical patients.
    Vascular Health and Risk Management 02/2008; 4(1):75-81.
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    ABSTRACT: A genome-wide linkage scan was conducted to identify regions potentially having quantitative trait loci (QTLs) influencing high-density lipoprotein (HDL) cholesterol. We found suggestive evidence of a QTL (lod score (LOD)=1.75, p=0.00224, and q=0.07649) influencing the variation of plasma levels of age- and sex-adjusted HDL-cholesterol on chromosome 15q21 at marker D15S659 in the NHLBI FHS data. Owing to the perturbations to lipid profiles associated with diabetes, the analysis was repeated excluding diabetic subjects from the sample. The lod score increased from 1.75 to 2.71 (p=0.00021, q=0.05392) at the same chromosome 15 location, despite the reduction in sample size. This finding indicates that the inclusion of diabetic subjects in the analysis may confound the presence of a QTL for HDL-cholesterol on 15q21. Because of the known effects of important covariates such as metabolic variables and lifestyle habits that may interact with a putative QTL, we also analyzed HDL-cholesterol with a progressive adjustment. When body mass index, smoking, and habitual alcohol intake were added to age- and sex-adjustment, we found strong evidence for linkage in the complete sample (LOD=4.77, p=0.0000013, and q=0.00016) as well as in the non-diabetic sub-sample (LOD=4.52, p=0.0000025, and q=0.00026) on chromosome 15q21 (between D15S659 and D15S195 markers). These results suggest that there are multiple pathways and factors involving genetic and environmental effects influencing HDL-cholesterol levels, and by taking some of these known factors into account, we obtained strong evidence of a QTL influencing HDL-cholesterol levels. While this putative QTL may also have an effect in diabetes, our data suggest a more pronounced role in non-diabetics. A prominent candidate gene residing within the linkage region on 15q21 is hepatic lipase (HL), which has a major role in lipoprotein metabolism.
    Atherosclerosis 02/2007; 190(1):232-7. DOI:10.1016/j.atherosclerosis.2006.02.006 · 3.97 Impact Factor
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    ABSTRACT: Plasma lipid disorders can occur either as a primary event or secondary to an underlying disease or use of medications. Familial dyslipidaemias are traditionally classified according to the electrophoretic profile of lipoproteins. In more recent texts, this phenotypic classification has been replaced with an aetiological classification. Familial dyslipidaemias are generally grouped into disorders leading to hypercholesterolaemia, hypertriglyceridaemia, a combination of hypercholesterolaemia and hypertriglyceridaemia, or abnormal high-density lipoprotein-cholesterol (HDL-C) levels. The management of these disorders requires an understanding of plasma lipid and lipoprotein metabolism. Lipid transport and metabolism involves three general pathways: (i) the exogenous pathway, whereby chylomicrons are synthesised by the small intestine, and dietary triglycerides (TGs) and cholesterol are transported to various cells of the body; (ii) the endogenous pathway, whereby very low-density lipoprotein-cholesterol (VLDL-C) and TGs are synthesised by the liver for transport to various tissues; and (iii) the reverse cholesterol transport, whereby HDL cholesteryl ester is exchanged for TGs in low-density lipoptrotein (LDL) and VLDL particles through cholesteryl ester transfer protein in a series of steps to remove cholesterol from the peripheral tissues for delivery to the liver and steroidogenic organs. The plasma lipid profile can provide a framework to guide the selection of appropriate diet and drug treatment. Many patients with hyperlipoproteinaemia can be treated effectively with diet. However, dietary regimens are often insufficient to bring lipoprotein levels to within acceptable limits. In this article, we review lipid transport and metabolism, discuss the more common lipid disorders and suggest some management guidelines. The choice of a particular agent depends on the baseline lipid profile achieved after 6–12 weeks of intense lifestyle changes and possible use of dietry supplements such as stanols and plant sterols. If the predominant lipid abnormality is hypertriglyceridaemia, omega-3 fatty acids, a fibric acid derivative (fibrate) or nicotinic acid would be considered as the first choice of therapy. In subsequent follow-up, when LDL-C is >130 mg/dL (3.36 mmol/L) then an HMG-CoA reductase inhibitor (statin) should be added as a combination therapy. If the serum TG levels are <500 mg/dL (2.26 mmol/L) and the LDL-C values are over 130 mg/dL (3.36 mmol/L) then a statin would be the first drug of choice. The statin dose can be titrated up to achieve the therapeutic goal or, alternatively, ezetimibe can be added. A bile acid binding agent is an option if the serum TG levels do not exceed 200 mg/dL (5.65 mmol/L), otherwise a fibrate or nicotinic acid should be considered. The decision to treat a particular person has to be individualised.
    Drugs 01/2006; 66(15). DOI:10.2165/00003495-200666150-00005 · 4.13 Impact Factor