A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. Coaching patients with coronary heart disease to achieve the target cholesterol: a method to bridge the gap between evidence-based medicine and the "real world"--randomized controlled trial. Computerized community cholesterol control (4C): meeting the challenge of secondary prevention. Surveillance and treatment of dyslipidemia in the post-infarct patient: can a nurse-led management approach make a difference? A long-term nutrition intervention experience: lipid responses and dietary adherence patterns in the Multiple Risk Factor Intervention Trial. Rationale and design of the Department of Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial (HIT) for secondary prevention of coronary artery disease in men with low high-density lipoprotein cholesterol and desirable low-density lipoprotein cholesterol. Clinical and economic impact of ambulatory care clinical pharmacists in management of dyslipidemia in older adults: the IMPROVE study. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers. Lipid-lowering medication for secondary prevention of coronary heart disease in a German outpatient population: the gap between treatment guidelines and real life treatment patterns. Bridging the quality gap in diabetic hyperlipidemia: a practice-based intervention. A prospective study in primary care in patients without vascular disease comparing levels of coronary risk factors in those recommended for lipid-lowering drugs based on either absolute risk or absolute risk reduction. Nurse case management of hypercholesterolemia in patients with coronary heart disease: results of a randomized clinical trial. Nurse-mediated cholesterol management compared with enhanced primary care in siblings of individuals with premature coronary disease. The ACC/AHA 2013 guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: the good the bad and the uncertain: a comparison with ESC/EAS guidelines for the management of dyslipidaemias 2011. A Case-Management System for Coronary Risk Factor Modification after Acute Myocardial Infarction Cost‐effectiveness of nurse practitioner management of hypercholesterolemia following coronary revascularization Clinical and humanistic outcomes of a lipid management program in the community pharmacy setting. Intervention to improve adherence to lipid-lowering medication and lipid-levels in patients with an increased cardiovascular risk. Prevalence of Dyslipidemia and Lipid Goal Attainment in Statin-Treated Subjects From 3 Data Sources: A Retrospective Analysis Assessment of clinical pharmacist management of lipid-lowering therapy in a primary care setting. Case management for blood pressure and lipid level control after minor stroke: PREVENTION randomized controlled trial An assessment of cholesterol goal attainment in patients with chronic kidney disease. Effects of a global risk educational tool on primary coronary prevention: the Atherosclerosis Assessment Via Total Risk (AVIATOR) study Canadian Cardiovascular Society position statement--recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease. SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: a randomized controlled trial protocol The effect of pharmacist intervention and patient education on lipid-lowering medication compliance and plasma cholesterol levels. Comprehensive cardiac rehabilitation improves the control of dyslipidemia in secondary prevention. Clinical utility of different lipid measures for prediction of coronary heart disease in men and women. A Randomized Trial of a Strategy for Increasing High-Density Lipoprotein Cholesterol Levels: Effects on Progression of Coronary Heart Disease and Clinical Events IMProving Adherence using Combination Therapy (IMPACT): design and protocol of a randomised controlled trial in primary care. Team-based care approach to cholesterol management in diabetes mellitus: two-year cluster randomized controlled trial. The Effect of a Disease Management Algorithm and Dedicated Postacute Coronary Syndrome Clinic on Achievement of Guideline Compliance The Effect of Primary Care Management on Lipids Testing and LDL‐C Control of Elderly Patients With Comorbidities The Lipid Research Clinics Coronary Primary Prevention Trial results. II. The relationship of reduction in incidence of coronary heart disease to cholesterol lowering.
AIM The aim of this study was to examine the effect of a cardiac rehabilitation programme on health behaviours and physiological risk parameters in patients with coronary heart disease in Chengdu , China . BACKGROUND Epidemiological studies indicate a dose- , level- and duration -dependent relationship exists between cardiac behavioural and physiological risks and coronary heart disease incidence as well as subsequent cardiac morbidity and mortality . Cardiac risk factor modification has become the very primary goal of modern cardiac rehabilitation programmes . DESIGN METHODS A r and omized controlled trial was conducted . Coronary heart disease patients ( n = 167 ) who met the sampling criteria in two tertiary medical centres in Chengdu , south-west China , were r and omly assigned to either an intervention group ( the cardiac rehabilitation programme ) or control group ( the routine care ) . The change of health behaviours ( walking performance , step II diet adherence , medication adherence , smoking cessation ) and physiological risk parameters ( serum lipids , blood pressure , body weight ) were assessed to evaluate the programme effect . RESULTS Patients in the intervention group demonstrated a significantly better performance in walking , step II diet adherence , medication adherence ; a significantly greater reduction in serum lipids including triglyceride , total cholesterol , low-density lipoprotein ; and significantly better control of systolic and diastolic blood pressure at three months . The majority of these positive impacts were maintained at six months . The effect of the programme on smoking cessation , body weight , serum high-density lipoprotein , was not confirmed . CONCLUSIONS A cardiac rehabilitation programme led by a nurse can significantly improve the health behaviours and cardiac physiological risk parameters in coronary heart disease patients . Nurses can fill significant treatment gaps in the risk factor management of patients with coronary heart disease . RELEVANCE TO CLINICAL PRACTICE This study raises attention regarding the important roles nurses can play in cardiac rehabilitation and the unique way for nurses to meet the rehabilitative care needs of coronary heart disease patients . Furthermore , the hospital-home bridging nature of the programme also created a model for interfacing the acute care and community rehabilitative care Community studies have demonstrated suboptimal achievement of lipid targets in the management of patients with coronary heart disease ( CHD ) . An effective strategy is required for the application of evidence -based prevention therapy for CHD . The objective of this study was to test coaching as a technique to assist patients in achieving the target cholesterol level of < 4.5 mmol/L. Patients with established CHD ( n = 245 ) underwent a stratified r and omization by cardiac procedure ( coronary artery bypass graft surgery or percutaneous coronary intervention ) to receive either the coaching intervention ( n = 121 ) or usual medical care ( n = 124 ) . The primary outcome measure was fasting serum total cholesterol ( TC ) , serum triglyceride ( TG ) , high-density lipoprotein cholesterol ( HDL-C ) , and calculated low-density lipoprotein cholesterol ( LDL-C ) level , measured at 6 months post-r and omization . At 6 months , the serum TC and LDL-C levels were significantly lower in the coaching intervention group ( n = 107 ) than the usual care group ( n = 112 ) : mean TC ( 95%CI ) 5.00 ( 4.82 - 5.17 ) mmol/L versus 5.54 ( 5.36 - 5.72 ) mmol/L ( P < .0001 ) ; mean LDL-C ( 95%CI ) 3.11 ( 2.94 - 3.29 ) mmol/L versus 3.57 ( 3.39 - 3.75 ) mmol/L ( P < .0004 ) , respectively . Coaching had no impact on TG or on HDL-C levels . Multivariate analysis showed that being coached ( P < .001 ) had an effect of equal magnitude to being prescribed lipid-lowering drug therapy ( P < .001 ) . The effectiveness of the coaching intervention is best explained by both adherence to drug therapy and to dietary advice given . Coaching may be an appropriate method to reduce the treatment gap in applying evidence -based medicine to the " real world . BACKGROUND Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease . The Computer-based Clinical Decision Support System provides an opportunity t close these gaps . OBJECTIVES To study the impact of computerized intervention on secondary prevention of CAD . METHODS The CDSS was programmed to automatically detect patients with CAD and to evaluate the availability of an up date d  lipoprotein profile  and treatment with lipid-lowering drugs . The program produced automatic computer-generated monitoring and treatment recommendations . Adjusted primary clinics were r and omly assigned to intervention ( n=56 ) or st and ard care arms ( n=56 ) . Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment . Compliance and lipid levels were monitored . The study group comprised all patients with CAD who were alive at least 3 months after hospitalization . RESULTS Follow-up was available for 7448 patients ( median 19.8 months , range 6 - 36 months ) . Overall , 51.7 % of patients were adequately screened , and 55.7 % of patients were compliant with treatment to lower lipid level . In patients with initial low density lipoprotein  > 120 mg/dl , a significant decrease in LDL levels was observed in both arms , but was more pronounced in the intervention arm : 121.9 + /- 34.2 vs. 124.3 + /- 34.6 mg/dl ( P < 0.02 ) . A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs , 37 % vs. 40.9 % ( P < 0.001 ) . CONCLUSIONS This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines , presenting a major obstacle to implementing effective secondary prevention . Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation BACKGROUND Lowering plasma lipid levels in patients in the months following hospital discharge for a myocardial infa rct ion ( MI ) is clearly beneficial if recurrent cardiac events and mortality are to be prevented ; traditionally , however , there has been a large gap between guidelines and levels achieved in routine practice . OBJECTIVES AND METHODS A r and omized , open-label clinical trial was conducted to assess the impact of nurse-centred surveillance and treatment in achieving nationally recognized lipid targets in post-MI patients . This program had the following features : systematic telephone follow-up of patients discharged from the University of Sherbrooke ( Sherbrooke , Quebec ) after an MI ;  systematic lipid testing three months after discharge ; close liaison with , and guidance of , patients ' primary care physicians to intervene on results of this test if targets were not obtained ; and continued monitoring of patients until lipid profiles consistent with consensus targets were achieved . The impact of this approach was tested and compared with that of a control group that continued to be followed by a primary care physician for up to 18 months . RESULTS A total of 127 patients were r and omly assigned into an intervention group ( n=64 ) or a control group ( n=63 ) . The intervention group was followed by telephone for an average ( + /-SD ) of 4.4+/-2.0 months post-MI . At this point , when intervention was optimized , the mean low-density lipoprotein cholesterol ( LDL-C ) level was 2.19+/-0.65 mmol/L in the intervention group , and 87.3 % of patients had LDL-C levels of less than 2.5 mmol/L. Patients from both experimental groups returned at 12 months and 18 months post-MI for a new blood lipid assessment . In total , 12.5 % of patients in each group were lost to follow-up . At 12 months and 18 months , the mean LDL-C level was not different between the two groups , nor was there a significant difference in the proportion of patients achieving LDL-C levels of less than 2.5 mmol/L ( 51.6 % in the intervention group and 65 % in the control group at 18 months ; P>0.05 ) . When the combined end point of an LDL-C level of less than 2.5 mmol/L , a triglyceride level of less than 2.0 mmol/L and a total cholesterol to high-density lipoprotein cholesterol ratio of less than 4.0 was considered , the proportion of patients achieving this composite at 18 months was low and not different between the two groups ( 23.4 % in the intervention group and 38.3 % in the control group ; P>0.05 ) . Over 95 % of patients in both groups were on a lipid-lowering medication , and more than 90 % had complied with their medication regimen at 18 months . CONCLUSIONS This trial did not support the role of nurse-managers and a system of telephone-based contacts to ensure the continuity of care and aggressive intervention when considering cardiovascular risk factors in post-MI patients . This trial also re-emphasized the important remaining treatment gap in secondary prevention of coronary artery disease , particularly if composite lipid end points are to be targeted Nutrition counselors in the Multiple Risk Factor Intervention Trial ( MRFIT ) were able to help middle-aged men who were at high risk for coronary heart disease change their dietary habits , maintain those changes over time , and decrease their serum cholesterol levels . Most of a 7.5 % mean serum cholesterol reduction achieved after 6 years of nutrition intervention occurred during the first year of the trial and was thereafter sustained . Total cholesterol and low-density lipoprotein cholesterol fraction decreases indicated improvement in terms of coronary heart disease risk . The food record rating , a numerical , semi- objective adherence technique that assesses a 3-day food record with respect to lipid-lowering potential , was used throughout the trial to measure adherence to recommended food patterns . Participants with lower food record rating scores , which indicate better adherence , demonstrated greater reductions in serum total cholesterol , plasma total cholesterol , and low-density lipoprotein fraction cholesterol determinations on a group basis . Subjective evaluations of the suitability of home and working environments , evidence of deviation from the MRFIT food patterns , and overall nutrition program motivation also showed that as ratings in each category became more favorable , lower food record rating scores and greater blood lipid reductions were consistently observed . The subgroup of participants who were non-smokers and not hypertensive demonstrated greater lipid responses and better dietary adherence . Continued smoking and antihypertensive medications appeared to adversely influence dietary adherence and /or lipid reductions . The MRFIT experience , however , demonstrated for the first time that dietary changes and blood lipid reductions can be achieved after the initial intervention effect , despite a continued emphasis on high blood pressure management and smoking cessation Although a large body of epidemiologic evidence suggests that low levels of high-density lipoprotein ( HDL ) cholesterol are strongly associated with an increased risk of coronary artery disease ( CAD ) , no large-scale clinical trials focusing on this association have been reported . This report describes the rationale and design of the Department of Veterans Affairs HDL Intervention Trial ( HIT ) , a multicenter , r and omized , controlled clinical trial design ed to determine whether lipid therapy reduces the combined incidence of CAD death and nonfatal myocardial infa rct ion in men with established CAD who have low levels of HDL cholesterol with " desirable " levels of low-density lipoprotein ( LDL ) cholesterol . Twenty-five hundred men with CAD and HDL cholesterol < or = 40 mg/dl , LDL cholesterol < or = 140 mg/dl , and triglycerides < or = 300 mg/dl are being recruited at 20 Department of Veterans Affairs medical centers , r and omized to either gemfibrozil or placebo  , and followed in a double-blind manner for an average of 6 years . In this population , gemfibrozil is expected to increase HDL cholesterol by 10 to 15 % , have a negligible effect on LDL cholesterol , and lower triglycerides by 30 to 40 % . Because an estimated 20 to 30 % of patients with CAD have a low HDL cholesterol as their primary lipid abnormality , the results of this trial are expected to have far-reaching clinical implication We examined the impact of ambulatory care clinical pharmacist interventions on clinical and economic outcomes of 208 patients with dyslipidemia and 229 controls treated at nine Veterans Affairs medical centers . This was a r and omized , controlled trial involving patients at high risk of drug-related problems . Only those with dyslipidemia are reported here . In addition to usual medical care , clinical pharmacists were responsible for providing pharmaceutical care for patients in the intervention group . The control group did not receive pharmaceutical care . Seventy-two percent of the intervention group and 70 % of controls required secondary prevention according to the National Cholesterol Education Program guidelines . Significantly more patients in the intervention group had a fasting lipid profile compared with controls ( p=0.021 ) . The absolute change in total cholesterol ( 17.7 vs 7.4 mg/dl , p=0.028 ) and low-density lipoprotein ( 23.4 vs 12.8 mg/dl , p=0.042 ) was greater in the intervention than in the control group . There were no differences in patients achieving goal lipid values or in overall costs despite increased visits to pharmacists . Ambulatory care clinical pharmacists can significantly improve dyslipidemia in a practice setting design ed to manage many medical and drug-related problems BACKGROUND Few published data in particular from the United States indicate that the implementation of guidelines for prevention of coronary heart disease ( CHD ) is far from optimal . The objective of our study was to identify the type and prevalence of lipid-lowering medications in a German outpatient CHD population and to examine the impact of applied treatment regimens on serum lipid levels . METHODS Retrospective analysis of the washout phase of 2,856 CHD patients requiring lipid-lowering medication .  Data are derived from a multicenter , r and omized , open-label , parallel group clinical trial comparing the safety and efficacy of atorvastatin versus simvastatin in 591 centers in Germany . Medical history , physical examination , and serum lipid levels were obtained at the beginning of the washout phase ( Week -6 ) and at the end of the washout phase ( Week -1 , i.e. , 5 weeks after the discontinuation of all prior lipid-lowering medications ) . The data at Week -6 represented the lipid levels under real life conditions . The difference from the data at Week -1 reflected the therapeutic effects achieved by the previous lipid-lowering treatment . RESULTS The mean low-density lipoprotein cholesterol ( LDL-C ) level at Week -6 was 173.4 + /- 42.5 mg/dl . Only 176 ( 6.2 % ) of 2,856 CHD patients were found to meet the target LDL-C level of < 115 mg/dl at Week -6 , only 76 ( 2.7 % ) patients had LDL-C levels < 100 mg/dl , and 363 ( 12.7 % ) patients had LDL-C levels < 130 mg/dl . After discontinuation of all prior lipid-lowering medications , mean LDL-C increased to 187.2 + /- 44.0 mg . This means that only a marginal 7.4 % reduction in LDL-C level was achieved under real life treatment conditions . This limited LDL-C reduction was due mainly to the low prevalence of lipid-lowering treatment ( 65.5 % of patients did not receive any medication at all ) and inadequate dosing . With respect to the effect on LDL-C and total cholesterol , statins alone were superior to fibrates . CONCLUSION The study shows that there is a wide gap between treatment guidelines and real life treatment patterns in Germany . Awareness of the risks of high cholesterol levels has to be increased among both patients and physicians . Available treatment guidelines should be better implemented PURPOSE Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes , yet only a minority of these patients are screened or achieve optimal low-density lipoprotein ( LDL ) cholesterol levels . Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing . METHODS The study cohort comprised 884 diabetic patients at 12 primary care practice s. Practice sites were r and omized to one of three intervention groups : electronic educational detailing , direct ( face-to-face ) educational detailing , or control . Direct and electronic detailing were performed over a 12-month period . All sites were notified of our goal to enhance lipid testing among diabetic patients . Chart abstract ion was performed 15 months after the start of the intervention . For the entire population ( n=884 ) , the proportion of patients with lipid testing was calculated , and changes from pre- to postintervention were compared across groups . We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation . RESULTS Favorable provider actions increased significantly with the intervention ( + 22 % compared with + 6 % in controls , P=.01 ) . By logistic regression , electronic detailing increased the likelihood of lipid testing ( odds ratio 3.0 , confidence interval 1.6 - 5.7 ) , as did direct detailing ( odds ratio 1.8 , confidence interval 0.9 - 3.7 ) in patients with no preintervention LDL test ( n=432 ) . Lipid testing tended to increase to a greater extent at intervention sites ( + 23 % for the combination of electronic and direct detailing vs + 11 % for controls , P=.06 ) . CONCLUSIONS Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients In the United Kingdom , the current recommendation is that lipid-lowering drugs should be prescribed for primary prevention only to subjects with an absolute coronary risk ( AR ) greater than 15 % in 5 years ( i.e. , myocardial infa rct ion or angina ) . However , to achieve greater benefit it may be preferable to direct treatment to those patients showing the greatest absolute risk reduction ( ARR ) . The aim of this study was to compare the characteristics of subjects eligible for lipid-lowering drugs based on the AR criteria or on an ARR of > 4.45 % . A prospect i ve study was carried out over 29 months in primary care in a part of the United Kingdom with a prevalence of coronary disease nearly 20 % above the national average . Risk factors were recorded in men and women aged 30 - 75 years who were being considered by their primary care physician for lipid-lowering drug therapy .  Of the 2351 patients included in the study , 2139 ( 91 % ) and 101 ( 4.3 % ) were , respectively , below and above the criteria for treatment by both AR and ARR criteria . In 111 ( 4.7 % ) subjects , treatment was recommended based on only one of the criteria -82 on AR and 29 on ARR . Comparing these two groups , those treated on AR only were older ( mean age 68.1 years [ SD , 4.1 ] vs. 49.1 years [ SD , 4.6 ] ; p<0.0001 ) and had a lower total cholesterol ( 260 vs. 288 mg/dL ; p=0.015 ) ; higher high-density lipoprotein cholesterol ( 50 vs. 43 mg/dL ; p=0.003 ) , lower low-density lipoprotein cholesterol ( 160 vs. 184 mg/dL ; p=0.03 ) , a lower total to high-density lipoprotein cholesterol ratio ( 5.4 vs. 7.1 ; p<0.0001 ) , and lower triglycerides ( 258 vs. 435 mg/dL ; p=0.007 ) . The AR group also had a higher mean systolic blood pressure ( 170.9 vs. 158.9 mm Hg ; p=0.013 ) , presumably an attribute of their greater age . Although the AR and ARR groups did not show a difference in the proportion of males or diabetics , there was a significantly greater proportion of smokers in the latter group ( 72 % vs. 35 % ; p=0.001 ) . In conclusion , treatment recommendations based on AR alone would result in nontreatment of young subjects with significant hyperlipidemia and at high relative risk of coronary disease , whereas lipid-lowering drugs would be given preferentially to patients whose main coronary heart disease risk factors are age and hypertension but not hyperlipidemia . By contrast , treatment recommendations based on ARR ensure that lipid-lowering drugs are directed to patients who will derive the most benefit . Furthermore , delaying treatment in younger subjects at high relative risk but not high AR results in their accumulating significant coronary risk in the years before their AR exceeds an arbitrary threshold before lipid-lowering drugs are prescribed BACKGROUND Despite the large body of evidence confirming the effectiveness of lipid lowering for the secondary prevention of coronary heart disease ( CHD ) events , undertreatment of hyperlipidemia is common . This study tested the effectiveness of a nurse case management program to lower blood lipids in patients with CHD . METHODS A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention , from a nurse practitioner for 1 year after discharge in addition to their usual care ( NURS ) , or to usual care enhanced with feedback on lipids to their primary provider and /or cardiologist ( EUC ) . RESULTS Significantly more patients in the NURS group than in the EUC group achieved low-density lipoprotein cholesterol ( LDL-C ) levels < 2.59 mmol/dL ( 100 mg/dL , 65 % vs 35 % , P = .0001 ) . Favorable changes in lipids and lipoproteins were accompanied by significant improvements in dietary and exercise patterns in the NURS group . In a multivariate analysis adjusting for other covariates , being assigned to the NURS group ( P = .0001 ) and being on a lipid-lowering medication ( P = .001 ) were significant independent predictors of LDL-C level . CONCLUSIONS Control of hypercholesterolemia in patients who have undergone coronary revascularization can be improved by a nurse case-management program . Because the National Cholesterol Education Program Adult Treatment Panel III guidelines have broadened the definition of high-risk population s that warrant aggressive treatment , nurse case-management programs may offer key opportunities to enhance appropriate application of new treatment paradigms BACKGROUND Siblings of individuals with premature coronary heart disease have a high prevalence of low-density lipoprotein cholesterol ( LDL-C ) levels requiring treatment . OBJECTIVE To evaluate management strategies for high LDL-C levels in apparently healthy 30- to 59-year-old siblings of individuals with documented coronary heart disease prior to age 60 years . METHODS In a 2-year trial of care provided by either a nurse trained in lipid management ( NURS ) or enhanced primary care ( EPC ) , in which physicians received recommendations based on national guidelines , 156 siblings with LDL-C levels of 4.14 mmol/L ( 160 mg/dL ) were r and omized by family . The LDL-C goal levels below 3.36 mmol/L ( 130 mg/dL ) were compared between and within intervention groups . Multiple logistic regression analyses were applied to predict 2-year achievement of the goal . RESULTS The NURS group achieved a significantly greater percentage of goal LDL-C levels than the EPC group ( 26 % vs 10 % ; P=.008 ) . The NURS LDL-C levels decreased an average of 0.91 mmol/L ( 35 mg/dL ) while EPC levels decreased by 0.52 mmol/L ( 24 mg/dL ) ( P=.09 ) . In the final multivariate model , siblings taking lipid-lowering drug treatment were 6.02 times more likely ( 95 % confidence interval , 2.24 - 16.18 ) than those not receiving pharmacotherapy to achieve LDL-C goals ; nurse management ( P=.09 ) was marginally significant . Pharmacotherapy was instituted in 45.2 % of NURS and 16.7 % of EPC siblings ( P=.001 ) . CONCLUSIONS High LDL-C levels in siblings were more effectively treated by a trained nurse , probably related to greater adherence to the application of national guidelines . Nonetheless , the majority of siblings with high LDL-C levels did not meet goal levels 2 years after an index case coronary heart disease event Atherosclerotic cardiovascular disease is the most important public health problem of our time in both Europe and the rest of the world , accounting for the greatest expenditure in most healthcare budgets . Achieving consistency of clinical care , incorporating new evidence and their synthesis into practical recommendations for clinicians is the task of various guideline committees throughout the world . Any change in a set of guidelines therefore can have far reaching consequences , particularly if they appear to be at variance with the existing guidelines . The present article discusses the recent American College of Cardiology (ACC)/American Heart Association ( AHA ) guidelines 2013 on the control of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults . When compared with the ESC/EAS guidelines on lipid modification in 2011 , the ACC/AHA guidelines of 2013 differ markedly . Specifically , ( i ) the scope is limited to r and omized trials only , which excludes a significant body of data and promotes essentially a statin centric approach only ; ( ii ) the abolition of low-density lipoprotein cholesterol ( LDL-C ) targets in favour of specific statin regimens that produce a 30 - 50 % reduction in LDL-C we believe will confuse many physicians and miss the opportunity for medication adherence and patient engagement in self-management ; ( iii ) the absence of target LDL-C levels in very high-risk patients with high absolute risk or residual risk factors will discourage clinicians to consider the addition of lipid modification treatments and individualize patient care ; ( iv ) a reduction in the threshold for treatment in primary prevention will result in a greater number of patients being prescribed statin therapy , which is potentially good in young patients with high life time risk , but will result in a very large number of older patients offered therapy ; and ( v ) the mixed pool risk calculator used to asses CVD risk in the guidelines for primary prevention has not been fully evaluated . This article discusses the potential implication s of adopting the ACC/AHA guidelines on patient care in Europe and beyond and concludes with the opinion that the ESC/EAS guidelines from 2011 seem to be the most wide ranging , pragmatic and appropriate choice for European countries Table . SI Units Systematic modification of coronary risk factors is not integrated into the medical care provided to most of the more than 1 million patients treated annually in the United States for acute myocardial infa rct ion by percutaneous transluminal coronary angioplasty or coronary artery surgery .  Most of such patients have lipoprotein abnormalities [ 1 ] , and nearly one half smoke [ 2 ] . These risk factors , which contribute to subsequent morbidity and mortality , remain highly prevalent after acute cardiac events . Failure to integrate comprehensive risk factor modification into the st and ard medical care provided to patients after acute cardiac events primarily reflects the lack of an organizational framework or system . This deficiency in re source allocation for preventive and rehabilitative aspects of care in turn reflects the predominant orientation of the U.S. health care system to the management of acute illness [ 3 ] . Several clinical research studies have shown the effectiveness of risk factor modification , especially treatment of lipoprotein abnormalities [ 4 - 7 ] , in achieving regression of coronary artery lesions and reducing the clinical consequences of coronary artery disease [ 6 , 7 ] . However , risk factor interventions shown to be effective in clinical trials may not prove equally effective in clinical practice because of a paucity of re sources , especially nonphysician personnel . The lack of effective management systems limits the expected reduction in morbidity and mortality and the corresponding reduction in medical care costs that motivates current efforts to orient the priorities of the American health care system toward preventive and rehabilitative care . This r and omized , controlled trial compared the effectiveness of a physician-directed , nurse-managed , home-based case-management system for coronary risk factor modification with that of usual medical care . Outcomes were measured in both groups immediately after the end of the first year after acute myocardial infa rct ion . The term case-management system has been used in various context s. As used here , it refers to a system in which a nurse case-manager , working with different health care specialists ( a psychiatrist , a cardiologist , a lipid specialist , a nutritionist , and a nurse coordinator ) , managed coronary risk factors . Methods Enrollment and Orientation Program nurses enlisted patients on hospital day 3 or as soon as their medical condition stabilized . Study participants gave written informed consent to be r and omly assigned to a treatment group . Immediately after r and omization , program nurses introduced patients to the special intervention with the aid of a videotape . Usual Care The 585 patients in our study were cared for by 215 internists and 34 cardiologists in the five participating medical centers who were organized into practice groups of 5 to 10 physicians each . Cardiology consultation was often provided during hospitalization , but primary responsibility for follow-up care was generally assumed by internists . The usual care offered by the Kaiser Permanente Medical Care Program included physician counseling on smoking cessation and nutritionist counseling on dietary change during hospitalization and physician-managed , lipid-lowering drug therapy after hospital discharge . Group outpatient smoking cessation programs were available for a $ 50 fee . Group exercise rehabilitation , not generally provided by the Kaiser Permanente Medical Care Program during this study , was available to patients at various community facilities at an average cost of $ 1800 to $ 2700 for 3 months ' participation . Special Intervention The behavioral interventions in our case-management system , which were offered to the 293 patients in the intervention group in addition to usual care , were derived from social learning theory [ 8 , 9 ] and modified for medical problems [ 10 ] . In this model , persons must learn how to monitor the health habits they seek to change , set attainable sub goals to motivate and direct their efforts , use feedback of progress in ways that promote health , and enlist incentives and social support to sustain the effort needed to succeed [ 8 , 9 ] . In the hospital , patients were instructed on how to complete  self-reports [ status reports ] of smoking , dietary intake , and exercise .  Scheduled interactions between case managers and patients after discharge took three forms : 1 ) nurse-initiated telephone contacts ; 2 ) computer-generated progress reports mailed to patients based on question naires completed by patients and mailed to the nurses ; and 3 ) visits to the program nurse for treadmill exercise testing , initiation of lipid-lowering drug therapy , if indicated , and a single counseling session after a smoking relapse . The maximum number of treatment contacts during the year , including outcome measurement at 6 and 12 months , was as follows : 14 nurse-initiated telephone contacts , 8 patient visits to the blood chemistry laboratory , and 4 patient visits to the nurse case manager . Smoking Intervention Smoking was defined as the use of cigarettes , cigars , cigarillos , pipe tobacco , or any other form of tobacco in the 6 months before admission . Forty-three percent of patients were smokers . Patients who had smoked during the 6 months before hospitalization received the same intensive smoking cessation intervention during hospitalization ; this intervention has been described previously [ 11 ] . Physicians used a written script that enabled them to provide st and ardized counseling in less than 2 minutes . The hospital-based smoking cessation counseling focused on relapse prevention . Nurses conducted a st and ardized smoking history to evaluate patients ' addiction to smoking . Patients ' reported self-efficacy or confidence to resist smoking in each of 28 potentially high-risk situations was measured ; patients were then counseled on how to manage the situations in which they reported less than 70 % confidence . Patients also received a relapse prevention manual and a relaxation audiotape . They were advised that the nurse would telephone them 48 hours and 1 week after hospital discharge and at monthly intervals for as long as 6 months . Patients who relapsed were offered one additional visit with the nurse for further counseling . Nicotine polacrilex or transdermal nicotine patches were reserved for highly addicted patients who relapsed after hospital discharge . Nutritional Counseling A computer-based expert system developed by the investigators was used to provide nutritional counseling on a National Cholesterol Education Program [ 12 ] Step 2 diet that was low in cholesterol and saturated fat . A food frequency question naire design ed by the investigators was scored using the Cholesterol and Saturated Fat Index developed by Connor and colleagues [ 13 ] . Calculations of cholesterol and saturated fat totals were based on weekly rather than daily average food intakes . Data from the food frequency question naires , mailed by patients to the Stanford coordinating center and entered into a microcomputer , were used to generate progress reports that characterized patients ' dietary patterns , prioritized dietary change goals , and provided guides for managing difficult situations by directing patients to relevant sections of a nutrition workbook entitled Good Eating for Good Health developed by the program nutritionist . Patients in the intervention group completed a food frequency question naire during hospitalization that described their eating habits in the previous month . Patients also completed food frequency question naires 6 , 11 , and 26 weeks after admission . Progress reports were mailed to patients within 48 to 72 hours after the food frequency question naires were received . Detailed strategies for maintenance of dietary change were incorporated into the 26-week progress report . Question naires to evaluate outcomes were also completed at 36 and 52 weeks . Lipid-Lowering Drug Therapy The therapeutic goal of a plasma low-density lipoprotein (LDL)-cholesterol value of 2.46 mmol/L ( 95 mg/dL ) adopted for this trial was based on the mean post-treatment level of LDL cholesterol found in patients in the study by Blankenhorn and colleagues [ 4 ] . Patients with mean plasma LDL cholesterol values ( based on measurements in two separate blood sample s drawn 75 and 90 days after infa rct ion ) that exceeded this value were given initial drug therapy according to the four algorithms shown in Table 1 . Patients unable to tolerate bile acid-binding resin or nicotinic acid because of comorbid conditions or potentially adverse interactions with these agents received lovastatin or gemfibrozil . During a visit 90 days after discharge , the nurses did a brief physical examination and obtained a history relevant to hyperlipidemia . They provided detailed counseling to patients regarding the rationale for lipid-lowering drug therapy and ways to maximize drug efficacy and minimize drug side effects , and they advised patients on the schedule of laboratory visits and nurse-initiated follow-up telephone contacts . Table 1 . Initial Drug Therapy * Changes in drug therapy at 120 , 150 , and 180 days , which were coordinated by nurse-initiated telephone contacts , were based on three types of responses to initial therapy : 1 ) if lipoprotein levels returned to normal , the effective drug therapy was continued ; 2 ) if the response was incomplete , the dose of the effective medication was increased or another drug was added , or both ; and 3 ) if comorbid conditions worsened or blood chemistry abnormalities or intolerable side effects occurred , drug dosage was reduced or the patient was switched to another agent or both . A physician lipid specialist and a Stanford-based senior nurse-coordinator provided telephone consultation to the case managers . Before initiating lipid-lowering drug therapy at 90 days and at each subsequent step , nurses review ed the patients ' blood chemistry and lipoprotein values and elicited any symptoms requiring a change in therapy . The Purpose : To evaluate the cost‐effectiveness of case management by a nurse practitioner ( NP ) to lower blood lipids in patients with coronary heart disease ( CHD ) from a managed care perspective . Data sources : A total of 228 consecutive , eligible adults with hypercholesterolemia and CHD were recruited during hospitalization after coronary revascularization . Patients were r and omized to receive lipid management , including individualized lifestyle modification and pharmacologic intervention from an NP for 1 year after discharge in addition to their usual care ( NURS ) or to receive usual care ( EUC ) enhanced with feedback on lipids to their primary provider and /or cardiologist . A cost‐effectiveness ratio was calculated using incremental costs of the NURS group per unit change and percent change in low‐density lipoprotein cholesterol ( LDL‐C ) for 1 year at 2004 values . Conclusions : The annual incremental cost‐effectiveness of NP case management was $ 26.03 per mg/dL and $ 39.05 per percent reduction in LDL‐C. When costs of NURS care for the second 6 months of management were compared to the first 6 months of management , nursing salary costs were lower as patients were established on cholesterol management regimens , but the reduction in costs was offset by the increase in incremental costs of drug treatment as the NP titrated the patient to higher drug dosages that were more costly . Implication s for practice : The findings suggest that case management by an NP is a cost‐effective approach for a managed care organization to consider in improving the care of patients with cardiovascular disease OBJECTIVES To identify patients at risk for coronary artery disease ( CAD ) through a search of a community pharmacy 's prescription data base , to screen and identify patients with elevated cholesterol and at risk for CAD , to enroll patients in a pharmacist-directed lipid management program , and to evaluate selected clinical and humanistic outcomes . DESIGN R and omized , pretest-posttest control groups . SETTING Independent community pharmacy in a suburban metropolitan area . PATIENTS 51 patients who were not at National Cholesterol Education Program low-density lipoprotein cholesterol ( LDL-C ) or defined triglyceride goals and who met inclusion criteria . INTERVENTION Pharmacist-directed lipid management program . MAIN OUTCOME MEASURES Clinical outcome measures included total cholesterol , LDL-C , high-density lipoprotein cholesterol ( HDL-C ) , and triglyceride levels ; achievement of LDL-C goal ; and risk factor prediction scores . Humanistic outcome measures included patient satisfaction with pharmaceutical care and patient knowledge of hyperlipidemia . RESULTS LDL-C was decreased in the pharmacist intervention group ( n = 25 ) , compared with an increase in the control group at study end . HDL-C levels increased and triglyceride levels decreased in both groups . Of treatment group patients , 32 % achieved their cholesterol goals , compared with 15 % of control group patients . Risk factor prediction scores improved in the treatment group and worsened in the control group . The treatment group 's hyperlipidemia knowledge scores improved significantly from pretest to posttest . Both treatment and control group patient satisfaction scores for the pharmacist investigator were favorable at study end . CONCLUSION Both treatment and control patients benefited from participating in this study . Patients enrolled in the lipid management program made greater improvements in their knowledge of hyperlipidemia , risk factor scores , and cholesterol levels Low levels of statin adherence may compromise treatment outcomes . The aim of this study was to investigate whether nurse-led cardiovascular risk-factor counseling could improve statin adherence and lipid levels without increasing patients ' anxiety .  Patients with indications for statin therapy for primary or secondary prevention of cardiovascular disease were r and omly assigned to receive routine care or extended care ( EC ) at baseline and at months 3 , 9 , and 18 . Patients in the EC group received a personalized risk-factor passport , showing modifiable and unmodifiable individual risk factors and a graphical presentation of their calculated absolute 10-year cardiovascular disease risk as well as the target risk that could be reached if all modifiable risk factors were optimally treated . Lipid levels were assessed at each visit . Carotid intima-media thickness was measured at baseline and at month 18 . Adherence , anxiety , quality of life , symptoms , and smoking status were assessed using a self-administered question naire at each visit . A total of 201 patients were included in the study .  Statin adherence was significantly higher ( p < 0.01 ) and anxiety was significantly lower ( p < 0.01 ) in the EC group than in the routine care group . Low-density lipoprotein cholesterol was statistically significantly lower in the EC group than in the routine group ( 2.66 vs 3.00 mmol/L , respectively , p = 0.024 ) in primary prevention patients only . Intima-media thickness improved significantly from baseline ( p < 0.01 ) in all patients , irrespective of group assignment . In conclusion , cardiovascular risk-factor counseling result ed in improved lipid profiles in primary prevention patients and higher levels of adherence to statins and lower levels of anxiety in all patients Background Evidence -based r and omized clinical trials have shown significant benefit of statin treatment with regard to cardiovascular disease . In anticipation of the National Cholesterol Education Program Adult Treatment Panel IV guidelines , we wanted to assess the current state of lipid goal attainment in the high-risk secondary prevention population in the United States . The objectives of the study were to estimate the proportion of high-risk patients treated with statin monotherapy  who achieved Adult Treatment Panel III – recommended low-density lipoprotein cholesterol ( LDL-C ) goals ( < 100 mg/dL ; optional < 70 mg/dL ) as well as non – high-density lipoprotein cholesterol goals ( < 130 mg/dL ; optional < 100 mg/dL ) . Methods and Results This is a cross-sectional , retrospective study of 3 data sources : electronic medical records ( 2003–September 2010 ) , administrative cl aims data ( 2003–2010 ) , and National Health and Nutrition Examination Survey data ( 2007–2008 ) . High-risk patients ( ≥18 years of age ) were defined as those with a history of coronary heart disease or coronary heart disease risk equivalent who had the latest complete lipid panel measurement and had been treated with statin monotherapy for > 90 days at the time of the lipid panel . Cardiovascular disease , coronary heart disease , and coronary heart disease risk equivalents were defined on the basis of availability , specific to each data source . Across the 3 data sources , 20 % to 26 % of high-risk patients treated with statin monotherapy for > 90 days had LDL-C < 70 mg/dL , and 67 % to 77 % had LDL-C < 100 mg/dL. The percentages of those attaining both LDL-C goals and non – high-density lipoprotein cholesterol goals were quantitatively smaller ( 13.5 % to 19.0 % and 46 % to 70 % ) . Conclusions Across the 3 data sources , there was consistency in the proportion of high-risk patients treated with statin monotherapy who were at LDL-C goal . A significant number of these statin-treated patients had additional dyslipidemias BACKGROUND Pharmacists have been shown to positively impact the outcomes of care for treatment of many different kinds of disease states . In particular , pharmacist-run lipid clinics have enjoyed varying degrees of success , depending on the outcome assessed . At our hospital , when a patient is transferred to the pharmacist-coordinated lipid clinic , the primary care pharmacist is responsible for ordering and interpreting labs and prescribing and monitoring lipid-altering therapy . OBJECTIVE This study was design ed to assess if there is a statistically significant difference between the magnitude of serum cholesterol reduction for patients receiving lipid-altering pharmacotherapy  when clinical ly trained pharmacists are actively prescribing and adjusting the drug therapy compared to other health care practitioners ( usual care ) . METHODS Patient records from the hospital computer data bases were retrospectively and r and omly selected for analysis . Following evaluation for inclusion s and exclusions , 41 patient records remained for statistical analysis for the cohort group , and 47 records remained from the group of patients managed by a clinical pharmacist . RESULTS Management of dyslipidemia by a clinical pharmacist was associated with a significant reduction in overall mean low-density lipoprotein ( LDL , 18.5 % ) compared to the cohort that did not have a clinical pharmacist as the primary manager of dyslipidemia ( 6.5 % , P=0.049 ) . This suggests improved clinical outcomes , defined as greater LDL reduction , when clinical pharmacists participate in lipid management , including drug prescribing . The magnitude reduction in LDL was found to be related to the number of clinical pharmacy visits ( 11.4 % for 1 visit , 23.2 % for 2 visits , and 23.7 % for > 3 visits ) , compared to the usual care group ( -11.0 % , 18.0 % , and 7.4 % ; statistically significant , P=0.038 , for > 3 visits only ) . These results occurred even though the group of dyslipidemic patients managed primarily by a clinical pharmacist contained a statistically greater number of patients with 2 or more risk factors and high-density lipoprotein ( HDL ) levels less than 40 mg/dL. CONCLUSION Interdisciplinary medical teams that include clinical pharmacists who are actively prescribing and adjusting lipid drug therapy may achieve greater reductions in LDL for patients who have been assessed with multiple risk factors compared to patients managed without clinical pharmacists . Active participation by clinical pharmacists in lipid management for patients with elevated LDL result ed in improved treatment success as measured by the magnitude reduction in LDL . The reduction in LDL was between 5 % and 22 % per visit greater for patients being treated by clinical pharmacists versus usual care , even in a patient population with more risk factors . These intermediate outcomes may translate into long-term outcomes in fewer cardiovascular events , improved quality of life for patients with dyslipidemia , and lower costs associated with sequelae of dyslipidemias Background : Optimization of systolic blood pressure and lipid levels are essential for secondary prevention after ischemic stroke , but there are substantial gaps in care , which could be addressed by nurse- or pharmacist-led care . We compared 2 types of case management ( active prescribing by pharmacists or nurse-led screening and feedback to primary care physicians ) in addition to usual care . Methods : We performed a prospect i ve r and omized controlled trial involving adults with recent minor ischemic stroke or transient ischemic attack whose systolic blood pressure or lipid levels were above guideline targets . Participants in both groups had a monthly visit for 6 months with either a nurse or pharmacist . Nurses measured cardiovascular risk factors , counselled patients and faxed results to primary care physicians ( active control ) . Pharmacists did all of the above as well as prescribed according to treatment algorithms ( intervention ) . Results : Most of the 279 study participants ( mean age 67.6 yr , mean systolic blood pressure 134 mm Hg , mean low-density lipoprotein [ LDL ] cholesterol 3.23 mmol/L ) were already receiving treatment at baseline ( antihypertensives : 78.1 % ; statins : 84.6 % ) , but none met guideline targets ( systolic blood pressure ≤ 140 mm Hg , fasting LDL cholesterol ≤ 2.0 mmol/L ) . Substantial improvements were observed in both groups after 6 months : 43.4 % of participants in the pharmacist case manager group met both systolic blood pressure and LDL guideline targets compared with 30.9 % in the nurse-led group ( 12.5 % absolute difference ; number needed to treat = 8 , p = 0.03 ) . Interpretation : Compared with nurse-led case management ( risk factor evaluation , counselling and feedback to primary care providers ) , active case management by pharmacists substantially improved risk factor control at 6 months among patients who had experienced a stroke . Trial registration : Clinical Trials.gov , no. BACKGROUND Patients with chronic kidney disease ( CKD ) are at significant risk for cardiovascular disease ( CVD ) . The National Kidney Foundation developed clinical practice guidelines ( Kidney Disease Outcomes Quality Initiative ) for targeting low-density lipoprotein cholesterol ( LDL-C ) goals . OBJECTIVE This study evaluated the extent to which these guidelines were adhered to among patients with CKD and to examine factors associated with the attainment of LDL-C goals . METHODS In this cross-sectional study we evaluated patients with a glomerular filtration rate of 15 to 59 mL/min per 1.73 m² . Patients with previous CVD , who were receiving dialysis , or were post kidney transplant were excluded . Administrative data bases were used to determine the percentage of patients with a fasting lipid profile performed within the previous year , the percentage who attained a LDL-C goal less than 100 mg/dL , and to determine lipid-lowering medications prescribed . Logistic regression analysis was used to identify factors associated with LDL-C goal attainment . RESULTS Of the 4541 patients evaluated , 3157 ( 69.5 % ) had a fasting lipid profile performed within the previous year . Overall , 60.8 % attained a LDL-C less than 100 mg/dL. Among patients at goal , 72.2 % were taking lipid-lowering therapy compared with 37.9 % of those not at goal ( P < .01 ) . Characteristics independently associated with LDL-C goal attainment were increasing age , male gender , increasing chronic disease score , history of diabetes , and statin use . CONCLUSION Although most patients were screened and attained LDL-C goal , there was room for improvement . Statin use was independently associated with LDL-C goal attainment . Future prospect i ve studies should focus on evaluating clinical outcomes of lipid-lowering interventions within the CKD population ABSTRACT Objective : The use of Framingham equations to determine 10-year absolute coronary risk ( “ global risk ” ) represents an accepted strategy to target coronary prevention measures and enhance clinical outcomes . The aim of this study was to determine the effects of providing global risk scores to physicians on the prescription of lipid-lowering therapy for patients at increased coronary risk . Research design and methods : This prospect i ve , r and omized controlled trial enrolled 368 primary -care patients without a history of coronary heart disease and not on therapy with a hydroxymethylglutaryl coenzyme A reductase inhibitor ( i.e. statin ) .  The study was conducted in the general medical clinics of an academic US teaching hospital . In the intervention group ( n = 186 ) patients ’ charts were review ed , 10‐year absolute coronary risk computed , and this information conveyed via a simple educational tool appended to charts . In the control group ( n = 182 ) , charts were accompanied by a form with general information on coronary prevention goals and strategies . Main outcome measure : The primary endpoint was the proportion of high-risk patients receiving a new statin prescription . Secondary and tertiary endpoints included ( 1 ) the proportion of moderate-risk patients receiving a statin prescription ; and ( 2 ) the proportion of patients in the whole cohort who had other coronary prevention measures recommended . Results : There was no significant difference in statin prescription to high-risk individuals in the intervention group ( 40.0 % ) compared with the control group ( 37.9 % ; p = 0.86 ) . Moderate-risk individuals who were not eligible for treatment according to the National Cholesterol Education Program Adult Treatment Panel II guidelines were more likely to receive a statin prescription in the intervention group versus the control group ( 28.8 % vs. 12.5 % . p = 0.036 ) Conclusions : Although a simple global risk educational tool did not improve the targeting of statin therapy to patients at high absolute coronary risk , it may be of benefit in targeting moderate-risk individuals who do not have markedly elevated low-density lipoprotein cholesterol ( LDL‐C ) levels . Future research should evaluate the effects of physicians performing their own Framingham risk calculations on statin prescribing and on cholesterol goal attainment Since the last publication of the recommendations for the management and treatment of dyslipidemia , new clinical trial data have emerged that support a more vigorous approach to lipid lowering in specific patient groups . The decision was made to up date the lipid guidelines in collaboration with the Canadian Cardiovascular Society . A systematic electronic search of medical literature for original research consisting of blinded , r and omized controlled trials was performed . Meta-analyses of studies of the efficacy and safety of lipid-lowering therapies , and of the predictive value of established and emerging risk factors were also review ed . All recommendations are evidence -based , and have been review ed in detail by primary and secondary review panels . Major changes include a lower low-density lipoprotein cholesterol ( LDL-C ) treatment target ( lower than 2.0 mmol/L ) for high-risk patients , a slightly higher intervention point for the initiation of drug therapy in most low-risk individuals ( LDL-C of 5.0 mmol/L or a total cholesterol to high-density lipoprotein cholesterol ratio of 6.0 ) and recommendations regarding additional investigations of potential use in the further evaluation of coronary artery disease risk in subjects in the moderate-risk category Background There are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes ( ACS ) . Smartphone technology may provide an innovative platform to close these gaps . This paper describes the study design of a r and omized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS . Methods We have developed a multi-faceted , patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission . The program incorporates ; physical activity tracking through the smartphone ’s accelerometer with interactive feedback and goal setting ; a dynamic dashboard to review and optimize cardiovascular risk factors ; educational messages delivered twice weekly ; a photographic food diary ; pharmacotherapy review ; and support through a short message service . The primary endpoint of the trial is change in exercise capacity , as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline . Secondary endpoints include improvements in cardiovascular risk factor status , psychological well-being and quality of life , medication adherence , uptake of cardiac rehabilitation and re-hospitalizations . Discussion This r and omized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS . It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention . Trial registration The trial was retrospectively registered in the Australian New Zeal and Clinical Trials Registry ( ANZCTR ) on April 4 , 2016 . The registration number is ACTRN12616000426482 BACKGROUND Dyslipidemias are a modifiable risk factor for coronary heart disease . The benefits of cholesterol reduction drug therapies are limited by poor patient compliance with drug regimens . OBJECTIVES To determine the impact of a community pharmacist pilot disease-management program on patient compliance with lipid-lowering drug therapy and on serum cholesterol levels . METHODS One hundred forty-nine patients who were nonadherent to prescribed hypolipidemic drug regimens were recruited for this six-month prospect i ve study . Each subject served as their own control . Pharmacists educated these patients on lipid disorders , the benefit of medication compliance and lifestyle modifications that reduce the risk for coronary heart disease . Pharmacists followed up participants by telephone at two-month intervals . Drug renewal rates were monitored throughout the study and plasma lipid levels were measured at study outset and study end . RESULTS Pharmacist intervention and patient-education programs significantly increased medication compliance , as shown by a 15.3 % increase ( P<0.05 ) in the number of compliant patients and an 11 day ( P<0.001 ) reduction in the average number of days to prescription renewal . Concurrently , levels of total cholesterol , triglycerides and low-density lipoprotein ( LDL ) cholesterol , were reduced by 6 % , 16.2 % , and 8.5 % ( P<0.001 , 0.01 , 0.01 ) , respectively . High density lipoprotein ( HDL ) cholesterol remained relatively unchanged ( + 0.7 % ) so that the LDL to HDL ratio was improved by 17.2 % overall ( P<0.01 ) . Almost all of the patients ( 99.2 % ) were satisfied with the program and expressed a willingness to pay an average $ 34.50 per 30 min consultation for the pharmacist services offered . CONCLUSION Pharmacists can contribute significantly to disease management of dyslipidemic individuals BACKGROUND Secondary prevention is an important goal of cardiac rehabilitation in patients with coronary heart disease ( CHD ) . Dyslipidemia is one of the major risk factors that is important to control to reduce the incidence of future ischemic coronary events . The aim of the present study was to assess whether control of dyslipidemia , in secondary prevention , could be improved by a comprehensive cardiac rehabilitation program . METHODS Fifty-two newly diagnosed hyperlipidemic men , who had experienced a recent CHD event , were separated in two equal groups of 26 patients : group CR+ , in which patients were included in a 2-month cardiac rehabilitation program including an extensive educational program on cardiovascular risk factors , lipids , and diet , and group CR-without any cardiac rehabilitation . Mean age , body mass index , initial levels of total cholesterol , triglycerides , high-density lipoprotein ( HDL ) cholesterol , low-density lipoprotein ( LDL ) cholesterol , and LDL/HDL ratio were not significantly different between the 2 groups . In both groups , each patient was referred to a dietitian and to the same lipidologist to start an appropriate hypolipidemic treatment . Treatment of coronary event , type of hyperlipidemia , and hypolipidemic treatment were not different between the two groups . RESULTS Lipid measurements , performed 3 months after the beginning of the hypolipidemic treatment , showed that patients from the CR+ group , compared with those from the CR-group , had a significantly greater reduction of total cholesterol ( 23 % versus 13 % ; P < 0.001 ) , of LDL cholesterol ( 28 % versus 12 % ; P < 0.001 ) , of LDL/HDL ratio ( 34 % versus 13 % ; P < 0.01 ) and of triglycerides ( 33 % versus 21 % ; P = 0.05 ) . CONCLUSIONS Patients with CHD included in a comprehensive cardiac rehabilitation program showed a significantly better response to the hypolipidemic treatment than patients without cardiac rehabilitation . These results could be attributable to the extensive educational program on secondary prevention performed during cardiac rehabilitation , leading to optimized knowledge on lipid-lowering diet and to improved diet and drug adherence . A secondary prevention educational program must be an important part of any comprehensive cardiac rehabilitation program in patients with CHD CONTEXT Evidence is conflicting regarding the performance of apolipoproteins vs traditional lipids for predicting  coronary heart disease ( CHD ) risk .  OBJECTIVES To compare performance of different lipid measures for CHD prediction using discrimination and calibration characteristics and reclassification of risk categories ; to assess incremental utility of apolipoproteins over traditional lipids for CHD prediction . DESIGN , SETTING , AND PARTICIPANTS Population -based , prospect i ve cohort from , Framingham , Massachusetts . We evaluated  serum total cholesterol , high-density lipoprotein cholesterol ( HDL-C ) , low-density lipoprotein cholesterol ( LDL-C ) , non-HDL-C , apolipoprotein ( apo ) A-I and apo B , and 3 lipid ratios ( total cholesterol : HDL-C , LDL-C : HDL-C , and apo B : apo A-I ) in 3322 middle-aged white participants who attended the fourth offspring examination cycle ( 1987 - 1991 ) and were without cardiovascular disease . Fifty-three percent of the participants were women . MAIN OUTCOME MEASURE Incidence of first CHD event ( recognized or unrecognized myocardial infa rct ion , angina pectoris , coronary insufficiency , or coronary heart disease death ) . RESULTS After a median follow-up of 15.0 years , 291 participants , 198 of whom were men , developed CHD . In multivariate models adjusting for nonlipid risk factors , the apo B : apo A-I ratio predicted CHD ( hazard ratio [ HR ] per SD increment , 1.39 ; 95 % confidence interval [ CI ] , 1.23 - 1.58 in men and HR , 1.40 ; 95 % CI , 1.16 - 1.67 in women ) , but risk ratios were similar for total cholesterol : HDL-C ( HR , 1.39 ; 95 % CI , 1.22 - 1.58 in men and HR , 1.39 ; 95 % CI , 1.17 - 1.66 in women ) and for LDL-C : HDL-C ( HR , 1.35 ; 95 % CI , 1.18 - 1.54 in men and HR , 1.36 ; 95 % CI 1.14 - 1.63 in women ) . In both sexes , models using the apo B : apo A-I ratio demonstrated performance characteristics comparable with but not better than that for other lipid ratios . The apo B : apo A-I ratio did not predict CHD risk in a model containing all components of the Framingham risk score including total cholesterol : HDL-C ( P = .12 in men ; P = .58 in women ) . CONCLUSIONS In this large , population -based cohort , the overall performance of apo B : apo A-I ratio for prediction of CHD was comparable with that of traditional lipid ratios but did not offer incremental utility over total cholesterol : HDL-C. These data do not support measurement of apo B or apo A-I in clinical practice when total cholesterol and HDL-C measurements are available Context Most trials that address lipid management focus on reducing low-density lipoprotein ( LDL ) cholesterol levels rather than increasing high-density lipoprotein ( HDL ) cholesterol levels . Contribution In this double-blind trial , 143 military retirees with low HDL cholesterol levels and coronary artery disease were r and omly assigned to placebo or aggressive HDL cholesterolincreasing therapy with gemfibrozil , niacin , and cholestyramine for 30 months . All participants received diet and exercise counseling . Compared with the placebo group , the treated group had a 20 % decrease in total cholesterol level ; a 36 % increase in HDL cholesterol level ; less focal coronary stenosis ; fewer total cardiovascular events ; and more flushing , skin rashes , and abdominal symptoms . Caution s The small trial had limited ability to assess clinical outcomes . The Editors Large epidemiologic studies have repeatedly demonstrated that cardiovascular risk increases proportionally with increasing total cholesterol and low-density lipoprotein ( LDL ) cholesterol levels and decreasing high-density lipoprotein ( HDL ) cholesterol levels ( 1 , 2 ) . Although many studies have documented that statins , drugs that primarily reduce LDL cholesterol levels , significantly reduce the risk for cardiovascular events ( 3 - 7 ) , prospect i ve studies that examine the clinical effects of increasing HDL cholesterol levels have been more limited . The Coronary Drug Project first reported evidence of a mortality benefit in patients treated with niacin ; however , the difference was seen long after withdrawal of the study drug , making the mechanism of benefit less clear ( 8) . The Helsinki Heart Study ( 9 ) examined the use of gemfibrozil in primary prevention . Coronary events were reduced by 34 % , but the increase in HDL cholesterol level was modest ( only 11 % ) . The Bezafibrate Infa rct ion Prevention Trial failed to show a reduction in cardiovascular events in the composite population , although a recent re analysis of the data suggests an improved outcome in patients experiencing a greater increase in HDL cholesterol level ( 10 ) . The Veterans Affairs HDL Intervention Trial ( VA-HIT ) ( 11 ) demonstrated a modest reduction in coronary events when gemfibrozil was used in patients with normal levels of LDL cholesterol and low levels of HDL cholesterol . The authors ascribed most of the reduction in clinical events to the improvement in HDL cholesterol , although the overall improvement was only approximately 6 % with drug therapy . More recently , a combination of a statin ( simvastatin ) with niacin was found to favorably modify both HDL cholesterol and LDL cholesterol levels and reduce cardiovascular events compared with both placebo therapy and underlying treatment with antioxidants in a cohort of 160 patients with coronary disease ( 12 ) . Despite a significant increase in mean HDL cholesterol levels , the overwhelming treatment effect in this study was the reduction in LDL cholesterol level ( 42 % in the treatment group ) . The most suggestive evidence of benefit from an increase in HDL cholesterol level has come from trials assessing the effect on coronary stenosis . Trials of quantitative angiography after monotherapy with fibrates ( 13 ) , as well as combinations of medications that both reduce LDL cholesterol levels and increase HDL cholesterol levels ( 14 - 18 ) , have shown an attenuation in angiographic progression . Nissen and colleagues ( 19 ) recently took this theory a step further by demonstrating that an infusion of a recombinant form of HDL , apolipoprotein A-I Milano , can lead to regression of angiographic stenosis as assessed by intravascular ultrasonography . We undertook the Armed Forces Regression Study ( AFREGS ) in 1993 to determine whether coronary atherosclerosis , assessed by quantitative coronary angiography and clinical coronary events , would improve when combination drug therapy focused on increasing HDL cholesterol levels in a sample of patients with fairly normal LDL cholesterol levels and low HDL cholesterol levels . A pilot study by Whitney and colleagues ( 20 ) showed the feasibility of this trial design , and the safety of using these drugs in combination has been previously established ( 21 ) . Methods Patients Participants living within a 150-mile radius of Wilford Hall Medical Center in San Antonio , Texas , who could provide written informed consent were eligible for enrollment . We recruited men and women younger than 76 years of age who had established or suspected coronary artery disease ( positive results on an exercise treadmill test or classic angina ) and did not have unstable symptoms . We allowed LDL cholesterol levels up to 4.1 mmol/L ( 160 mg/dL ) with HDL cholesterol levels less than 1.0 mmol/L ( 40 mg/dL ) after adherence to the American Heart Association ( AHA ) step II diet for at least 6 months . We set no lower limit to either HDL cholesterol or LDL cholesterol level . Each patient was required to have measurable stenosis between 30 % and 80 % of the luminal diameter within the coronary tree by caliper inspection . Patients with stenosis greater than 80 % were eligible if they had a favorable prognosis based on functional testing ( ability to exercise for > 9 minutes on a full Bruce protocol exercise treadmill test ) . Exclusions included a major vascular event ( myocardial infa rct ion , cerebrovascular accident , coronary artery bypass grafting , or other coronary catheterbased intervention ) within 6 months , a history of congestive heart failure ( other than in the setting of myocardial infa rct ion ) , or a left ventricular ejection fraction less than 0.4 on ventriculography . Other exclusion criteria included alcohol or substance abuse within the past year , uncontrolled arrhythmias , resistant hypertension , diabetes , uncontrolled gout , uncontrolled thyroid disease , liver or gall bladder disease , renal dysfunction ( creatinine concentration > 176.8 mol/L [ > 2.0 mg/dL ] or proteinuria greater than 2 + by dipstick or 500 mg/24 h ) , uncontrolled peptic ulcer disease , or pancreatic disorders . In addition , we excluded patients taking any lipid-modifying medications within 4 weeks of r and omization , heparin or coumarin-type anticoagulants , long-term oral corticosteroid therapy , or other immunosuppressive agents . We also excluded patients if they had hypersensitivity to or history of intolerance that required cessation of therapy for any component of gemfibrozil , nicotinic acid , cholestyramine , aspirin , or nitrates . Other exclusion criteria were the potential for childbearing , technically inadequate coronary arteriography for stenosis quantification , or any serious condition that we thought would compromise participation in the study or preclude survival for the duration of the study . We thoroughly informed participants of the details of the study . Each patient voluntarily enrolled and signed an informed consent statement that the Wilford Hall Medical Center Institutional Review Board review ed and approved . From screening laboratory records , we identified 1290 participant c and i date s and invited them to participate ( Figure 1 ) . Of the 847 patients who attended the introductory briefing , 671 met LDL cholesterol and HDL cholesterol entry criteria on fasting lipid analysis . Of the 269 participants who eventually provided informed consent , 55 subsequently withdrew for personal reasons , most commonly citing a fear of cardiac catheterization , and an additional 27 met an exclusion criterion . Of the 187 participants who completed the 6-month lifestyle modification phase and underwent coronary angiography  , 44 were excluded after initial coronary arteriography ; 27 had extensive coronary disease necessitating revascularization ( percutaneous coronary intervention in 3 patients and coronary artery bypass grafting in 24 patients ) , and 17 had insignificant coronary disease on angiography . Thus , we eventually r and omly assigned 143 patients ( 11 % of those initially contacted ) to either pharmacologic therapy or placebo . Figure 1 . Flow of patients through the study . Protocol After inclusion and exclusion criteria were met , a 6- to 8-month run-in period was performed to ensure that patients could adhere to the prescribed diet . During this phase , all patients received diet counseling from a study dietitian , exercise guidance from an exercise specialist , and smoking cessation advice . All study participants committed to attending a bimonthly food show for training in the AHA step II diet , with reinforcing presentations from the dietitian , exercise specialist , and cardiologist that discussed cardiac risk factor modification . We r and omly assigned each participant by using a computer-generated r and omization schedule . The central pharmacy held the code , and the information was not shared with physicians or patients until the completion of the protocol . Patients were r and omly assigned to 1 of 2 treatment groups : pharmacologic therapy with gemfibrozil , niacin , and cholestyramine or conventional therapy . The goal of therapy was to increase HDL cholesterol level by at least 25 % . The study was double-blind and placebo-controlled . The pharmaceutical company prepared all medications and placebos , and the central pharmacy dispensed them at 30-day intervals . The pharmacologic therapy group began receiving gemfibrozil , 600 mg twice per day . Short-acting niacin was added in the third month at a dosage of 250 mg/d and was titrated to 3000 mg/d as tolerated . Cholestyramine was added in the sixth month , and the dosage was titrated to 16 g/d as tolerated . The conventional therapy group was maintained on the AHA step II diet and applicable matching placebos for the duration of the investigation . If LDL cholesterol levels exceeded 4.14 mmol/L ( 160 mg/dL ) during the trial , cholestyramine was administered in an open-label fashion . Participants visited 1 clinic on a monthly basis for the duration of the study . At each monthly visit , clinicians measured vital signs and weight , counted unused study drugs , review ed changes in medications or medical status , provided BACKGROUND Cardiovascular disease ( CVD ) is the leading cause of death , and principal reason for the large difference in life expectancy between indigenous Māori and the non-indigenous population in New Zeal and . CVD guidelines recommend that people who are at high risk or who have had previous CVD should be offered aspirin , blood pressure lowering and lipid lowering therapies . However , prescribing and adherence rates are low and CVD events remain high . AIM To assess whether a medication strategy using a fixed dose combination pill ( ' polypill ' ) could improve prescribing and adherence to recommended medications , lower blood pressure and improve lipids compared with current care over 12 months . METHODS IMProving Adherence using Combination Therapy ( IMPACT ) is an open-label r and omised controlled trial comparing a once-daily polypill containing four preventive medications with usual care .  Six hundred participants who have had previous CVD events or are at high risk of CVD will be enrolled , including 300 Māori . Participants are identified , enrolled and prescribed either the polypill or current medications at their usual primary health care practice , with medications ( including the polypill ) dispensed through local community pharmacies . The polypill contains 75 mg aspirin , 40 mg simvastatin , 10 mg lisinopril and either 12.5 mg hydrochlorothiazide or 50 mg atenolol . Primary outcomes are adherence to guidelines -recommended medications and changes in systolic blood pressure and low density lipoprotein at 12 months . Secondary outcomes include other lipids , medication dispensing , barriers to adherence , CVD and other serious adverse events , quality of life and prescriber acceptability . The trial is registered with the Australian New Zeal and Clinical Trial Registry ( ACTRN12606000067572 ) BACKGROUND Creative , cost-effective interventions to improve the quality of care of chronic illnesses are needed . This study was design ed to evaluate the impact of remote physician-pharmacist team-based care on cholesterol levels in patients with diabetes mellitus ( DM ) . METHODS This 2-year prospect i ve , cluster r and omized controlled trial was conducted within the Providence Primary Care Research Network in Oregon . Participants at least 18 years of age were identified by a diagnosis of DM . The intervention included remote physician-pharmacist team-based care focused on cholesterol management in DM . All clinicians in the study had access to the health information technology tool CareManager , which provided automated DM-related point-of-care prompts , a Web-based registry , and performance feedback with benchmarking . Study outcomes included the difference in low-density lipoprotein cholesterol ( LDL-C ) goal attainment , mean LDL-C , prescribed lipid-lowering therapy , and patient satisfaction between the intervention and control arms . RESULTS A total of 6963 patients with DM cared for by 68 physicians in 9 clinics were evaluated . Patients in the intervention arm were more likely to achieve their target LDL-C levels compared with controls ( 78 % vs 50 % ; P = .003 ) . The mean LDL-C level was 12 mg/dL lower in the intervention arm compared with the control arm ( P < .001 ) . The rate of LDL-C testing was significantly higher in the intervention arm compared with the control arm . Patients in the intervention arm were also 15 % more likely to receive a prescription for a lipid-lowering medication ( P = .008 ) . There was no significant difference in patient satisfaction between study arms ( P = .15 ) . CONCLUSION Remotely located physician-pharmacist team-based care result ed in significantly improved LDL-C levels and goal attainment among patients with DM Background The application of disease management algorithms by physician extenders has been shown to improve therapeutic adherence in selected population s. It is unknown whether this strategy would improve adherence to secondary prevention goals after acute coronary syndromes ( ACSs ) in a largely indigent county hospital setting . Methods Patients admitted for ACS were r and omized at the time of discharge to usual follow-up care versus the same care with the addition of a physician extender visit . Physician extender visits were conducted according to a treatment algorithm based on contemporary practice guidelines . Groups were compared using the primary end point of achievement of low-density lipoprotein treatment goals at 3 months after discharge and achievement of additional evidence -based practice goals . Results One hundred forty consecutive patients were r and omized . A similar proportion of patients returned for study follow-up in both groups at 3 months ( 54 [79%]/68 in the usual care group vs 57 [79%]/72 in the intervention group ; P = 0.97 ) . Among those completing the 3-month visit , a low-density lipoprotein cholesterol level less than 100 mg/dL was achieved in 37 ( 69 % ) of the usual care patients compared with 35 ( 57 % ) of those in the intervention group ( P = 0.43 ) . There was no statistical difference in implementation of therapeutic lifestyle changes ( smoking cessation , cardiac rehabilitation , or exercise ) between groups . Prescription rates of evidence -based therapeutics at 3 months were similar in both groups . Conclusion The implementation of a post-ACS clinic run by a physician extender applying a disease management algorithm did not measurably improve adherence to evidence -based secondary prevention treatment goals . Despite initially high rates of evidence -based treatment at discharge , adherence with follow-up appointments and sustained implementation of evidence -based therapies remains a significant challenge in this high-risk cohort Purpose This article presents results of a r and omized clinical trial evaluating the effectiveness of the Medicare Coordinated Care Demonstration , Illinois site , on selected clinical outcomes over 36 months . Primary Practice Setting s Interdisciplinary teams , located at primary care practice s , provided case and disease management services to 999 patients . Results  Intervention group patients had higher lipids-testing rates during the first 2 years than control  group patients . Once tested , more than 80 % of patients in both groups were retested in subsequent years . There were no differences in the percentage of intervention group patients who were in low-density lipoprotein cholesterol ( LDL-C ) control at program entry and at the end of 36 months as compared with control group patients ( maintained control ) . However , a higher percentage of intervention group patients who were not in the LDL-C control at baseline were in control after 36 months as compared with control group patients ( achieved control ) . Implication s for Case Management Practice This study suggests that physician — nurse case management team care has the potential to augment the effectiveness of primary care by increasing adherence to testing protocol s among elderly patients with multiple chronic illnesses , but this effect diminishes over time as guidelines are adopted into general practice . It suggests that LDL-C therapeutic control can be improved through increased lipids testing and the use of lipid-lowering medications . The results also indicate that care management strategies targeting more intensive patients versus less intensive patients are cost-effective strategies that can be exp and ed beyond lipids testing and control to other clinical health status measures In the Lipid Research Clinics Coronary Primary Prevention Trial ( LRC-CPPT ) , a 19 % lower incidence of coronary heart disease ( CHD ) in  cholestyramine-treated men was accompanied by mean falls of 8 % and 12 % in plasma total ( TOTAL-C ) and low-density lipoprotein ( LDL-C ) cholesterol levels relative to levels in  placebo-treated men . When the cholestyramine treatment group was analyzed separately , a 19 % reduction in CHD risk was also associated with each decrement of 8 % in TOTAL-C or 11 % in LDL-C levels ( P less than .001 ) . Moreover , CHD incidence in men sustaining a fall of 25 % in TOTAL-C or 35 % in LDL-C levels , typical responses to the prescribed dosage ( 24 g/day ) of cholestyramine resin , was half that of men who remained at pretreatment levels . Adherence to medication was associated with reduced incidence of CHD only when accompanied by falls in TOTAL-C and LDL-C levels . Small increases in high-density lipoprotein cholesterol levels , which accompanied cholestyramine treatment , independently accounted for a 2 % reduction in CHD risk . Thus , the reduction of CHD incidence in the cholestyramine  group seems to have been mediated chiefly by reduction of TOTAL-C and LDL-C levels
There was mixed evidence that provider-level computerized decision support improves outcomes .
There was more evidence in support of patient-level tools that provide connectivity to the healthcare system , as well as system-level interventions that involve data base monitoring and outreach by central ized care teams .
R and omized controlled trials show wide variability in the effects of HIT on lipid management outcomes .
Evidence suggests that multilevel HIT approaches that target not only providers but include patients and systems approaches will be needed to improve lipid treatment , adherence and quality
BACKGROUND Large gaps in lipid treatment and medication adherence persist in high-risk out patients in the United States .
Health information technology ( HIT ) is being applied to close quality gaps in chronic illness care , but its utility for lipid management has not been widely studied .
OBJECTIVE To perform a qualitative review of the impact of HIT interventions on lipid management processes of care ( screening or testing ; drug initiation , titration or adherence ; or referrals ) or clinical outcomes ( percent at low density lipoprotein cholesterol goal ; absolute lipid levels ; absolute risk scores ; or cardiac hospitalizations ) in out patients with coronary heart disease or at increased risk .