lipidspin - national lipid association online · articles online at in this issue: spring 2010...

Volume 8 Issue 2 Spring 2010visit www.lipid.org

Also in this issue: EBM Tools for Practice | Choosing the Proper Dose of Statin and Establishing a Good Lipid Follow-up Schedule

The Official Publication of the National Lipid Association

LipidSpinClinical Feature

Time to Bring Backa Forgotten Statin?

1 From the NLA President

Planning Today for Tomorrow— Vera Bittner, MD

2 From the MWLA President

Get Involved in Your NLA— Peter P. Toth, MD

3 Clinical Feature

Time to Bring Back a Forgotten Statin?— Scott Shurmur, MD

6 Guest Editorial

What is the Significance of Crestor’s New Indication for Primary Prevention?— Eli M. Roth, MD

7 Practical Pearls

Choosing the Proper Dose of Statin and Establishing a Good Lipid Follow-up Schedule— Carl Orringer, MD

9 Member Spotlight

Morton Saunders Jr. DO, Positive Approaches to Smoking Cessation Therapy

11 New Feature

EBM Tools for Practice— Robert Wild, MD

12 Lipid Luminations

Blood Omega-3 Levels Predict the Rate of Cellular Aging— William S. Harris, PhD

14 Case Study

Management of Stable Angina— Gerald T. Gau, MD— Thomas G. Allison, PhD

18 Medication Minute

Is There a Remedy for Lipid Medication Intolerances?— CoraLynn B. Trewet, MS, PharmD

19 Meeting Update

2010 Scientific Sessions

22 News & Notes

24 Education Update

26 Awards and Honors

28 Foundation Update

30 Meetings and Courses Calendar

LipidSpin

Look for the NLA Community logo to discuss articles online at www.lipid.org

In This Issue: Spring 2010 (Volume 8, Issue 2)

EditorsJames A. Underberg, MD, MS, FACPM, FACP, FNLA Preventive CV Medicine, Lipidology and Hypertension Clinical Assistant Professor of Medicine NYU Medical School and Center for CV Prevention New York, NYDiplomate, American Board of Clinical Lipidology

Robert A. Wild, MD, PhD, MPH Professor of Reproductive Endocrinology and Gynecology Oklahoma University Health Sciences Center Oklahoma City, OK Diplomate, American Board of Clinical Lipidology

Co-Editor Kevin C. Maki, PhD President and Chief Science Officer Provident Clinical Research Glen Ellyn, IL Clinical Lipid Specialist

NLA Staff Editor Karen Kent National Lipid Association

NLA Executive Director Christopher R. Seymour, MBA National Lipid Association

Lipid Spin is published quarterly by the National Lipid Association 6816 Southpoint Parkway, Suite1000 Jacksonville, FL 32216 Phone: 904-998-0854 | Fax: 904-998-0855

Copyright ©2010 by the National Lipid Association. All rights reserved.

Visit us on the web at www.lipid.org.

The National Lipid Association makes every effort to provide accurate information in the Lipid Spin at the time of publication; however, circumstances may alter certain details, such as dates or locations of events. Any changes will be denoted as soon as possible and the most recent information regarding NLA activities can be found at www.lipid.org. The National Lipid Association invites members and guest authors to provide scientific and medical opinion, which do not necessarily reflect the policy of the Association.

From the NLA President: Planning Today for Tomorrow

In March, we had our NLA Strategic

Planning Meeting, which gave us an

opportunity to review progress toward

our previous goals and develop new

initiatives for the future. The new strategic

plan requires approval by the board and

will be discussed in detail at our annual

meeting in May 2010. It is thus too early

to provide you with details of this plan,

but I wanted to take the opportunity in my

last president’s column to review with you

accomplishments and challenges relating

to our 2008 strategic goals of enhancing

opportunities for in-training members of

our organization and improving offerings

in the area of continuing education and

professional development. I think we have

made significant progress in both areas.

We now have in-training members on all

regional boards. My hope is that these

members will not only get involved in their

regions, but will also get together at our

national meeting and online at the NLA

Community on www.lipid.org to provide

leadership with input on all aspects of the

NLA. Once organized, I would like to see

a representative of this in-training group

on the national board of directors to help

guide our organization.

Well before the NLA existed, SELA implemented a scientific poster session at its annual meeting specifically to provide a forum for junior investigators and clinicians to share their work. This tradition has continued at our national meetings and travel scholarships are available for junior poster presenters. Accepted abstracts are published in the Journal of Clinical Lipidology, the NLA’s official journal. In contrast to typical scientific meetings, the NLA welcomes not only traditional scientific research posters, but also posters focused on local quality improvement projects and best clinical practices. Learning from each other how to best treat our patients through multidisciplinary teams in various settings has always been a key feature of this organization, but has taken on additional importance because future reimbursements will be increasingly linked to performance. We need our younger colleagues to think “out of the box” and develop new and better treatment approaches, especially those related to the implementation of and long-term adherence to lifestyle modifications.

This year, we have gone a step further and developed special mentoring sessions for trainees in conjunction with our 2010

meetings which provide an opportunity to network with NLA leadership, discuss scientific and clinical practice issues related to our field, obtain guidance relating to career development, and network among trainees. While these Fellows Outreach Programs are currently focused on fellows-in-training, we hope to develop similar sessions for in-training members from all disciplines represented in our organization. Training program directors in the respective hosting regions have been contacted to make them aware of this mentorship opportunity and have been encouraged to nominate their trainees. Registration fees are waived for fellows-in-training who wish to attend these sessions and travel scholarships up to $500 are available.

Last, but not least, the NLA has collaborated with the American College

VERA BITTNER, MD, MSPH, FNLA

National Lipid Association President

Professor of Medicine Division of Cardiovascular Disease

University of Alabama at Birmingham – Birmingham, AL

Diplomate, American Board of Clinical Lipidology

Discuss this article at www.lipid.org

Go to “Topics” and look for “Planning Today for Tomorrow.”

The Official Publication of the National Lipid Association 1

NLA President (continued on 1)

From the MWLA President: Get Involved in Your NLA

It is with great pride that the MWLA is hosting this year’s NLA Scientific Sessions in the Windy City. This year’s theme is The Spectrum of Lipids in Cardiovascular Disease: From Particles to Plaque. Although there will be speakers and sessions with a clinical focus, this year’s meeting will also feature a very strong emphasis on the basic science of atherosclerosis and molecular aspects of dyslipidemia and lipid signaling pathways. A wide range of topics will be presented.

The meeting will kickoff on Thursday with a keynote address by Ira Tabas, MD, PhD. Two symposia of particular interest to our membership are a summit on HDL and another devoted to familial hypercholesterolemia. There will be debates on choice of vascular imaging technology, ezetimibe and LDL lowering, as well as optimal approaches to diet and a variety of breakout sessions. The speakers

will provide fresh and robust insights that will take participants well beyond the familiar. I sincerely hope you will join us in Chicago at such a beautiful time of year.

Encourage your colleagues who are not yet members of the NLA to come and join us as this meeting, which will be a great introduction to the rigor and warmth of our organization.

It is important that we reach out not just to clinicians, but also to basic scientists and clinical trial experts committed to lipid research. They are invaluable allies and greatly expand the breadth and reach of our organization. We must be seen as one body committed to fostering the development and progression of all aspects of lipidology in order to continue to grow and expand our capacity to work with other professional societies.

We continue to face many challenges. It is important that each of us promote the NLA, its goals and mission in order to expand membership. The growth of the NLA has been dazzling, but it must continue. Mention NLA to your colleagues or wherever you may speak.

We would like to see more people take the certification examinations offered by the NLA. If a friend is riding the fence or nervous about taking the test, encourage him or her to just step up and take it. I personally know clinicians who have taken the preparation course a couple of times and are just too scared to take the final examination.

Consider donating to the Foundation of the NLA, as its work is worthwhile. Recent setbacks in clinical trials also warrant that we serve as effective spokespersons for our patients, colleagues and the field of lipidology. Get involved. Other clinicians in your communities regard you as thought leaders and your opinion is valuable. It is important that misinformation about clinical trials be corrected. Write letters to the editor. If the media contact you, talk to them. Strongly consider participating in clinical trials. Without them, our field will not progress and we will not be able to further improve patient care in an evidence-based fashion. I also encourage you to get involved in committee work with the NLA. If you have an idea, please let us know. We want to hear from you.

See you in Chicago! n

PETER P. TOTH, MD, PhD, FNLA

Midwest Lipid Association PresidentSterling Rock Falls ClinicSterling, IL


2 LipidSpin

Discuss this article at www.lipid.org Go to “Topics” and look for “MWLA: Get Involved in Your NLA”


Clinical Feature: Time to Bring Back a Forgotten Statin?

Despite undeniable efficacy,1-3 statin use continues to be plagued by muscle-related side effects. Recent studies suggest intolerance is far more prevalent4 than reported in early statin trials, where a very narrow definition of myositis of creatinine kinase (CK) elevation of greater than 10 times normal was used.5 In this review, we present a case of such a patient, and identify a solution.

Case PresentationA 66-year-old retired pharmacologist was referred to our lipid clinic due to a history of statin intolerance. She experienced exacerbation of chronic muscle soreness on both moderate-dose simvastatin and atorvastatin in the past. She then was placed on a combination of colesevelam and ezetimibe therapy, and achieved LDL cholesterol of approximately 160 mg/dL.

Prior to referral, she discontinued colesevelam and, on the single agent ezetimibe, her LDL again increased to 193 mg/dL. Her complete lipid profile at the time of referral is listed in Table 1. At the time of referral, her Framingham risk score was 19, suggesting an 8% 10-year risk of myocardial infarction. She had no known vascular disease or diabetes. CK values were not obtained prior to referral.

Sustained-release fluvastatin (Lescol XL) was instituted at 80 mg/day. This was well-tolerated, and she was able to resume her avid thrice-weekly fitness swimming. On treatment, laboratory values are listed in Table 2.

DiscussionDid we simply get lucky in trying yet another statin in our patient’s case or is

there a physiologic explanation for our patient’s tolerance of sustained-release fluvastatin after failing atorvastain and simvastatin? Evidence suggests that we made an informed choice. In 2003, Ballantyne and colleagues published a rigorous review of rhabdomyolysis and myosytis in statin trials to date. In that review, fluvastatin (both immediate and sustained release) was the only available statin with no reported cases of fatal rhabdomyolysis.5 Less severe statin side effects were investigated in the landmark PRIMO Study published in 2005 by Brucker et al. This study was an ambitious observation of nearly 8,000 patients receiving outpatient statin therapy in France. Muscular symptoms were reported by approximately 10% of the population, and muscular pain prevented even moderate exertion during everyday activities in more than one-third of

SCOTT SHURMUR, MD

Director of Preventive CardiologyNebraska Medical Center

Omaha, NE



Go to “Topics” and look for “Time to Bring Back a Forgotten Statin?”

Lipid levels on Ezetimibe 10 mg/day

Table 1: Case One

symptomatic patients. And, most relevant to our discussion, fluvastatin XL was associated with the lowest rate of muscular symptoms among individual statins - 5.1%.4 Stein and Ballantyne et al. extended these findings in a randomized trial published in 2008.6 In this study, 199 patients with a history of muscle-related side effects with other statins were randomized to fluvastatin XL 80 mg/day alone, ezetimibe 10 mg/day alone, or the combination of the two for 12 weeks. The agents demonstrated their predicted efficacy in terms of LDL lowering and, remarkably, 85% of patients with prior muscle-related statin intolerance in the single agent and combined fluvastatin groups completed all 12 weeks of therapy without experiencing muscle-related side effects. In the single agent ezetimibe group, 24% of patients experienced muscle-related side effects. There were no occurrences of CK increases greater than 10 times the upper limit of normal. While the 12-week follow-up may seem brief, in the

aforementioned PRIMO study, the median time for onset of muscle-related side effects was one month following the initiation of statin therapy.

So what then is the pharmacologic explanation for this apparent greater degree of tolerance of sustained-release fluvastatin? Several characteristics of the drug may contribute to this increased tolerability. Fluvastatin is largely metabolized through the cytochrome P450 2C9 isozyme with only 20% of its metabolism through the more common cytochrome P450 3A4 metabolism, making it less prone to pharmacologic interaction.5,7 Even when co-administered with cyclosporine, fluvastatin had no effects on cyclosporine levels and

fluvastatin XL levels were increased approximately twofold. This is far less than the increase seen when other statins, more dependent on cytochrome P450 3A4 metabolism, are administered with cyclosporine.5,8 When studied in a renal transplant population, all of whom were also taking cyclosporine, fluvastatin was not associated with serious muscle-related side effects.5 Additionally, the sustained-release characteristics of fluvastatin XL likely contribute to tolerability. According to the drug package insert,7 the Cmax of an extended-release 80 mg tablet is 102ngs/mL. This is far less than the

432ngs/mL seen with a 40 mg twice daily dosing. AUCs however, are similar at 630ng hour/mL for the sustained 80 mg dose and 697ng hours/mL in the immediate-release dosage form.

SummaryThere is good evidence that sustained- release fluvastatin is associated with fewer serious muscle-related side effects and less frequent myalgia than other statin drugs. This is likely due to its lack of reliance on cytochrome P450 3A4 metabolism, a very commonly competed for and inhibited enzyme by co-administered medications, as well as its sustained-release characteristics and lack of peak serum levels. “Statin failures” and “intolerance to statin therapy” seem to be an ever-increasing reason for referral to lipid clinics. With its current market share of less than 2.5% of the US statin market, sustained-release fluvastatin may be an all-but-forgotten solution to a very prevalent problem.9 n

References listed on Page 37.

4 LipidSpin

Lipid levels following the start of Fluvastatin XL 80 mg/day

Lipid levels prior to the start of statin therapy

Lipid levels following the start of Fluvastatin XL 80 mg/day

Table 2: Case One

Table 3: Case Two

Table 4: Case Two


A growing number of medical professionals are talking about the value of

taking the Accreditation Council for Clinical Lipidology exam. They know

their new status as Certified Lipid Specialists makes them stand out in the

field and showcases their commitment to the prevention of cardiovascular

disease.

Nurses, pharmacists, registered dietitians, physician assistants, exercise

physiologists and nurse practitioners who want to enhance their careers

should call or apply online today.

Learn about the exam, prerequisites, testing center locations and

fees. Call (904) 309-6250 or download an application online at:

www.lipidspecialist.org

LET ME TELL YOU WHAT BECOMING A CERTIFIED LIPID SPECIALIST HASDONE FOR MY CAREER.

“Being credentialed as a Clinical Lipid Specialist has

allowed me to broaden my scope as a nurse practitioner.

I now operate a lipid clinic within my practice two days

per week. I receive referrals from other providers for

the management of their complex dyslipidemic patients.”

Debbie Friedrich, NP, MS, Certified Lipid Specialist

NLA[ACCL_Advanced_8.5x10]ALT_NLA 4/22/10 3:00 PM Page 1

CARL ORRINGER, MD, FACC, FNLA

Assoc. Professor of Medicine and Harrington-McLaughlin Chair in Preventive Cardiovascular MedicineCase Western Reserve University School of Medicine

Director of Preventive Cardiovascular MedicineUniversity Hospitals Harrington-McLaughlin Heart and Vascular Institute

Cleveland, OH


6 LipidSpin

ELI M. ROTH, MD, FACC, FNLA

Professor of Clinical Medicine and Director of Preventive CardiologyUniversity of Cincinnati College of Medicine

Medical Director, Sterling Research GroupCincinnati, OH


Guest Editorial: What is the Significance of Crestor’s New Indication for Primary Prevention?

In February 2010, the Federal Drug Administration (FDA) approved Crestor (rosuvastatin) for use as primary prevention in patients who met criteria based on data from the JUPITER Trial. Specifically, the FDA approved Crestor to reduce the risk of stroke, myocardial infarction and arterial revascularization procedures in individuals without clinically evident coronary heart disease. The individuals must also have an increased risk of cardiovascular disease based on age (men 50 years or older and women 60 years or older), with hs-CRP≥2 mg/L and the presence of at least one additional cardiovascular disease risk factor such as hypertension, low HDL-C, smoking or a family history of premature coronary heart disease.1 The FDA decision was based not only on the published JUPITER Trial,2 but also on additional unpublished data presented on December 15, 2009, to the Endocrinologic and Metabolic Drugs

Advisory Committee of the FDA Center for Drug Evaluation and Research meeting, by the sponsor AstraZeneca, the JUPITER Trial Principal Investigator, Paul Ridker, MD, and the FDA.3

Entry criteria for the JUPITER Trial were: no known history of cardiovascular disease or diabetes, LDL-C <130 mg/dL and hs-CRP ≥2 mg/L. JUPITER enrolled 17,802 participants who were randomized to Crestor 20 mg qD or a placebo and followed for a median of 1.9 years. As a result, there was a 44% reduction in events for the primary composite endpoint (nonfatal MI, nonfatal stroke, hospitalization for unstable angina, an arterial revascularization procedure, or confirmed CVD death) as well as a 54% reduction of any MI, a 48% reduction in stroke and a 47% reduction for arterial revascularization or hospitalization for unstable angina. Of the 17,802 patients enrolled, 41% had metabolic syndrome, 16% were smokers and 11% had a family history of CVD. The study population was diversified and included 38% women, 12.5% blacks and 12.5% Hispanics.

Unpublished data showed study participants meeting age and elevated

hs-CRP criteria and, having demonstrated no additional risk factors, had no benefit from rosuvastatin therapy vs. the placebo. Participants with one or more additional risk factors had significant benefit from statin therapy. If the Framingham risk score was applied instead of risk factors and groups were broken into <5%, 5-10%, and >10% risk, then the <5% risk group showed no significant benefit from statin therapy, whereas all other groups did.

It is important to remember several key facts regarding atherosclerosis, the cause of the CVD considered here. First, atherosclerosis is a lifelong process or chronic disease that starts at an early age — even birth — and continues throughout our lifetime (hence, age is a significant risk factor). Secondly, atherosclerosis and plaque formation are dependent on lipid levels as well as the inflammatory state of the individual based on accepted pathophysiologic mechanisms. Additionally, there are multiple other factors involved in atherosclerosis and plaque formation, including but not limited to genetics and the traditional CVD risk factors. Therefore, it is not appropriate to base risk on one marker alone such as hs-CRP, but to

Guest Editorial (continued on Page 32)


Go to “Topics” and look for “Significance of Crestor’s New Indication for Primary Prevention.”


Many studies have demonstrated that physicians do a good job of starting patients on statin therapy, but often fall short in titrating the statin dose to achieve lipid goals. Lack of titration of the statin dosage on the patient’s side may relate to failure to return for laboratory testing, concern that higher doses will produce more side effects, inability to pay for the medication or medication co-pays, or other personal factors in the patient’s life. Failure on the physician’s side may result from lack of establishment of a definite lipid goal, fear that the patient will experience side effects or adverse drug interactions, or the perception that other medical problems have priority over cardiovascular disease prevention. The first approach to failure to titrate is to know your lipid medications. There are clearly established mean levels of lipid reduction with each lipid medication. In Table 1, data taken from the package inserts of these medications serves as a reminder of the usual LDL-C lowering response expected with statins and statin-ezetimibe therapy. Prescribe the medication and dosage most likely to achieve the goal quickly and

cost effectively. When writing the initial prescription, be sensitive to the patient’s entire medical condition as well as his or her financial concerns. Make every effort to prescribe medications that are covered by the patient’s insurance. As a general rule, it is better to settle for slightly less LDL-C reduction with a drug the patient can afford than to prescribe a more costly drug that they will not take long-term.

Once the proper dose of statin is chosen, the patient must be engaged in adhering to a regular follow-up schedule tracking their response to the medication. The first follow-up fasting lipid profile and ALT is usually obtained in six to eight weeks, although the response to the medication is seen much earlier, often within a week to 10 days. If the lipids are improved, the lipid goal is achieved and the ALT is

CARL ORRINGER, MD, FACC, FNLA

Assoc. Professor of Medicine and Harrington-McLaughlin Chair in Preventive Cardiovascular MedicineCase Western Reserve University School of Medicine

Director of Preventive Cardiovascular MedicineUniversity Hospitals Harrington-McLaughlin Heart and Vascular Institute

Cleveland, OH


Practical Pearls: Choosing the Proper Dose of Statin and Establishing a Good Lipid Follow-up Schedule

Practical Pearls (continued on Page 33)


Go to “Topics” and look for “Choosing the Proper Dose of Statin.”

LDL-C ↓ Medication and Dose Mean LDL Lowering

20% Lescol 20 mg 17%

Zetia 10 mg 18%

Pravastatin 10 mg 19%

20-30% Lovastatin10 mg 21%

Lescol 40 mg 23%


Simvastatin 5 mg 26%


Lovastatin 20 mg 29%

30-40% Lovastatin 40 mg 31%


Lescol XL 80 mg 35%


Pravachol 80 mg 37%

Lipitor 10 mg 38%

40-50% Simvastatin 40 mg 41%

Crestor 5 mg 45%

Vytorin 10/10 45%

Lipitor 20 mg 46%


50-60% Lipitor 40 mg 51%

Crestor 10 mg 52%

Vytorin 10/20 52%

Lipitor 80 mg 54%

Crestor 20 mg 55%

Vytorin 10/40 55%

>60% Vytorin 10/80 60%

Crestor 40 mg 63%

Table 1.

8 LipidSpin

www.lipid.org904-998-0854

Get An Inside Look IntoYour Lipid Community.

LIPIDULSEP

** Coupon may be applied toward the cost of membership dues, online education materials and registration at meetings or courses.Coupon may not be applied toward purchases of items that the NLA does not own, such as sale of textbooks from the NLA Bookshelf.

The Lipid Pulse practice survey is supported in-part by Genzyme.

* To receive a hard copy of the survey, please call the NLA o�ce.

What? The Lipid Pulse…• Is an exclusive online survey of and for members of the National Lipid Association, sponsored by the NLA and Genzyme • Will provide you with the �rst and only comprehensive report at health care professionals focused on lipid management: State of the Lipid Practice: A Summary of Findings from The Lipid Pulse 2010 • Will be an annual survey to track trends in the practice of lipid management

When?• In early May you will receive an e-mail from Dr. Vera Bittner, President of the NLA, with a link to the survey*• We will have a kiosk set up May 13-16 for you to take the survey onsite at the NLA Annual Scienti�c Sessions in Chicago

Why?We need your participation…• To help the NLA best serve your educational and membership needs • To provide members with insights into practice trends

In addition to State of the Lipid Practice, you will receive: • From the NLA, a $25 coupon toward any product or service sold by the NLA** • From Genzyme, 25 copies of Familial Hypercholesterolemia, a 30-page patient educational booklet developed by Dr. Leiv Ose of the University of Norway with support from Genzyme

VERSION #9


Family practice physician Morton “Nick” Saunders graduated from the University of Virginia in Charlottesville, the University of Wisconsin-Milwaukee and the Texas College of Osteopathic Medicine in Fort Worth. He is certified by the American Board of Family Practitioners and is a Diplomate of the American Board of Clinical Lipidologists. He presented his approach to smoking cessation therapies at the 2008 NLA Annual Scientific Sessions in Seattle and we took this opportunity to speak with him about how he developed his expertise in this area — a matter of critical importance to all practitioners who work to reduce cardiovascular disease (CVD) risk.

Several years ago, Dr. Saunders attended a meeting of the Southwest Lipid Association and was impressed with what he learned there. After that meeting, he went to his hospital director and asked about the possibility of opening a lipidology clinic. His timing couldn’t have been better — the director said he was planning to start a metabolic syndrome center, and a year later Dr. Saunders was directing operations at the Metabolic Syndrome Center as part of Premiere Medical Partners.

“Because we are treating the various disorders associated with metabolic syndrome,” Dr. Saunders says, “it was natural to aggressively emphasize therapeutic lifestyle changes (TLC) and that’s why the study of techniques for helping patients with smoking cessation became a focus for me.”

In many ways, the mission of Dr. Saunders’ center goes beyond that of a traditional lipid clinic.

“The internal portal for our patients is the Lipidology/Metabolic Syndrome Center. While I’m predominantly the provider, my assistant is now training in lipidology, and has already taken the Lipid Management

Training Course offered by the NLA,” says Dr. Saunders.

Dr. Saunders has been very active in the NLA and found value in obtaining certification from the ABCL.

“It’s really been helpful to me,” he says. “Board certification has opened every possible door for me to advance. Also, the importance of prevention needs to be more stressed in the public arena — 460,000 women will die this year from heart disease. Everybody knows the pink ribbon and knows about breast cancer, but not everybody realizes the significance of heart disease. It isn’t common knowledge — and the mission of the NLA is to emphasize prevention to address the scourge of CVD in our society.”

Physicians, of course, are one group that

Member Spotlight: Morton Saunders Jr., DO Positive Approaches to Smoking Cessation Therapy


Go to “Topics” and look for “Member Spotlight – Morton Saunders Jr., DO.”

MORTON “NICK” SAUNDERS, DO, MSMedical Director, The Metabolic Syndrome Center

Premiere Medical PartnersCuyahoga Falls, OH


“The mission of the NLA is to emphasize prevention to address the scourge of CVD

in our society.”

10 LipidSpin

is very much aware of this health risk, and Dr. Saunders says he is frequently consulted by peer physicians and partners who have questions about their lipid panels. Word is definitely out about his expertise in lipidology. He was invited to sit on a regional pharmaceutical committee that will allow him to make

recommendations, influence community care standards, and inform the committee on issues regarding cholesterol, blood-pressure and diabetes medications.

The work Dr. Saunders does with smoking cessation programs stems from his desire to help his patients achieve risk reduction.

“During a lipid review with a patient, I like to show them a Framingham risk chart — I use this five times or more a day as a visual aid — and I can tell patients, ‘Here’s your risk with smoking, and your risk without smoking,’ and this is doubly effective because this is a way for patients to entirely eliminate a risk factor, which isn’t the case with things like age or family history,” Dr. Saunders says.

In terms of learning about smoking cessation counseling, Dr. Saunders has access to physician-level resources and, at his request, an industry PharmD provided him and his staff with expert training, and he has taken advantage of opportunities to meet and learn from Mayo Clinic tobacco treatment specialists.

“We still work together,” says Dr.

Saunders. “We’ve designed an ‘office smoking cessation plan,’ and my medical assistant and I are now collecting outcomes data based on initial and follow-up visits with patients, and this will be used in a study to obtain more evidence-based information about the effectiveness of treatment.”

Mayo Clinic specialists taught Dr. Saunders more about the neurotransmitters activated by nicotine. In turn, he found that it can be very helpful during counseling to show patients three balls (see photo). The dimpled one, similar to a golf ball, represents the brain that has never been exposed to tobacco. The second, fuzzy one represents the same brain after exposure.

“This shows how the brain has formed dense blocks of nicotine receptors, and this happens quickly following relatively little exposure,” Dr. Saunders says. “The third ball, colored like a soccer ball, shows the brain of the recovering smoker. The black dots are the receptors waiting to be reactivated. This is why recidivism is so strong among smokers.”

It’s one thing to tell patients what they need to know, but Dr. Saunders finds visual aids like these to be so effective because they add power and impact to cessation counseling.

“You never forget the ‘this is your brain on drugs’ campaign. I wanted something equally effective and ‘this is your brain on

tobacco’ is very compelling and easy for patients to remember. They understand better why withdrawal can be so difficult because they have to lose the receptors they’ve developed.”

This is where medication can become part of a treatment plan. Some patients want to try patches, and Dr. Saunders recommends that they also carry “emergency” supplies of nicotine gum or lozenges, which can be a supplement to the patch if needed to help a patient deal with intense cravings during withdrawal.

“We’re seeing very good results from varenicline (Chantix); it’s a real step up. With bupropion (Wellibutrin, Zyban), you might see three out of ten succeed,” he says. “If I can get a patient to take Chantix, take behavior counseling, join a support group, see me for follow-up visits and use nicotine replacements, it’s not unreasonable to see five, even seven out of ten quit successfully.”

Dr. Saunders notes that success can be very self-reinforcing for patients who receive positive feedback and have good experiences.

“The literature we hand out contains quit cards and quit lines; we direct patients to a non-branded hotline,” Dr. Saunders explains. “Some programs can be set up so that a computer calls the patient daily. It will ask if they’ve smoked that day, and if they answer ‘No,’ it thanks them and hangs up, but if they answer yes they are connected to a live counselor who can help them pinpoint where the failure was and devise strategies to avoid repeat triggers.”

There are also excellent online sources for both patients and physicians looking for ideas and techniques (see sidebar). Dr. Saunders says that it is easy to add a

Member Spotlight (continued on Page 35)

Dr. Saunders uses tools such as these to get patients’ attention and reinforce key messages.

During the recent strategic planning session for the NLA, a review of topics found most challenging for ABCL certificate applicants were Epidemiology, Biostatistics and Clinical trials. These are the disciplines that provide some of the tools to help us practice evidenced-based medicine (EBM). EBM practice requires integration of patient values, practitioner expertise and the best science available to inform choice. This is no easy matter given that we should be reading 365 journals daily to keep up with the knowledge! There is a better way! If we can teach ourselves to let clinical questions drive our information gathering then, given access and the proper tools, we can use our expertise to make optimum choices for patients. Without EBM we are somewhat helpless in the face of misguided experts, enthusiastic hype, or drug company hype. Without EBM we are limited in our ability to understand difficult tradeoffs, or to help our patients make difficult decisions. With EBM comes greater understanding and power and greater effectiveness in helping our patients.

In coming versions of Lipid Spin we plan to tackle essential elements of this process. One of the things I like best about the NLA is the celebration that different disciplines

can work together for the common good. I learn so much every time we get together on a regional or national basis, in part because of the multidisciplinary nature of what we do. This implies that, given different backgrounds, there are different levels of integration of EBM into practice.

The EBM “Tools for Practice” section in Lipid Spin will benefit greatly from your

input. We invite you to send in EBM questions (biostatistics, epidemiology and clinical trials). In time, we will endeavor to hit most of the topics. Textbooks, software, and statistical expertise are available everywhere. We encourage each of you to take advantage of all resources

(software is like a car — unless you are licensed, it can be hazardous!). The purpose of this column is to make things practical for clinicians. We invite each of you to join along in the process.

There are seven well-known alternatives to EBM. Not necessarily in rank order: eminence-based medicine, vehemence based-medicine, eloquence-based medicine, providence-based medicine, diffidence-based medicine, nervousness- based medicine, and confidence-based medicine (adapted from Isaacs and Fitzgerald, BMJ 1999; 319:1618).

Our goal is that we all are able to celebrate that we do, indeed, practice EBM. n

11

New Feature: EBM Tools for Practice


Go to “Topics” and look for “EBM Tools for Practice.”

ROBERT WILD, MD, PhD, MPH

Professor of Reproductive Endocrinology, Gynecology and EpidemiologyOklahoma University Health Sciences Center

Oklahoma City, OK

Diplomate, American Board of Clinical LipidologyCo-Editor of Lipid Spin

“Given access and the proper tools we

can use our expertise to make optimum

choices for patients.”

0

-0.05

-0.10

-0.10

-0.15

1 2 3 4Quartiles of Whole Blood EPA+DHA (%) Quartiles of Blood

Omega-3 Fatty ContentOmega-3 Index (%)

Absolute change in telomere length

Abs

olut

e ch

ange

in te

lom

ere

leng

th, m

ean

T/S

units

0

-0.05

-0.10

-0.10

-0.15

1 2 3 4


Abs

olut

e ch

ange

in te

lom

ere

leng

th, m

ean

T/S

units

0

-2

-4

-6

-8

-10

-12

1 4.2 5.3 8.7


Rela

tive

chan

ge in

telo

mer

ele

ngth

, mea

n %

12 LipidSpin

Multiple epidemiologic studies and several randomized controlled trials have demonstrated improved survival in individuals with high dietary intakes of marine omega-3 fatty acids (eicosapentaenoic and docosahexaenoic acids, EPA and DHA). The mechanisms

of this protective effect are not well

understood, but may include anti-

inflammatory, anti-platelet, anti-

hypertensive, anti-arrhythmic, and

triglyceride-lowering effects. Telomere

length has emerged recently as a novel

marker of biological age, and a strong

association between short telomeres and

cardiovascular morbidity and mortality has

been documented in several populations.

Telomeres are tandem repeat DNA

sequences (TTAGGG)n at the ends (telos)

of chromosomes that form a protective

cap, much like aglets (the plastic tips)

that keep shoelaces from fraying. During cell replication, DNA polymerase cannot fully replicate the 3-prime end of the DNA strand (telomeric DNA), resulting in a progressive shrinkage of these segments. Telomere length is believed to be a reflection of the cumulative lifetime burden of environmental stressors on DNA independent of chronological age.

Given the cardio-protective effects of omega-3 fatty acids, the investigators in the Heart and Soul Study sought to

WILLIAM S. HARRIS, PhD, FAHA

Director, Cardiovascular Health Research CenterResearch Professor of MedicineSanford School of MedicineUniversity of South DakotaSioux Falls, SD

Diplomate, Accreditation Council for Clinical Lipidology

Lipid Luminations: Blood Omega-3 Levels Predict the Rate of Cellular Aging


Go to “Topics” and look for “Blood Omega-3 Levels Predict the Rate of Cellular Aging.”

Lipid Luminations (continued on Page 32)

Figure 1. Absolute and relative mean changes in telomere length over five years by quartile of omega-3 fatty acid level, adjusted for age and baseline telomere length.

Error bars indicate 95% confidence intervals. T/S indicates telomere-to-single copy gene ratio. P<.001 for linear trend for both absolute and relative change.

“Becoming a certified lipidologist has helped me to save lives and prevent cardiovascular events in patients that I used to think had normal lipid test results. What can be more gratifying for any physicianinvolved in daily direct patient care?” ~ JOSEPH LILLO, DO

DIPLOMATE, AMERICAN BOARD OF CLINICAL LIPIDOLOGY

For Doctors Serious about Healthier Patients and a Healthier Practice.Earn Your Certification in Lipidology.

More than 500 physicians have achieved certification fromthe American Board of Clinical Lipidology — the onlycertification program of its kind available to licensedphysicians in the United States or Canada.

In addition to improving patient care and enhancing yourprofessional stature and credibility, it demonstrates yourcommitment to continued professional development.

For an application, handbook, eligibility requirements andexamination information, call (904) 674-0752 or visit thewebsite at: www.lipidboard.org

��

13

“Becoming a certified lipidologist has helped me to save lives and prevent cardiovascular events in patients that I used to think had normal lipid test results. What can be more gratifying for any physicianinvolved in daily direct patient care?” ~ JOSEPH LILLO, DO

DIPLOMATE, AMERICAN BOARD OF CLINICAL LIPIDOLOGY

For Doctors Serious about Healthier Patients and a Healthier Practice.Earn Your Certification in Lipidology.

More than 500 physicians have achieved certification fromthe American Board of Clinical Lipidology — the onlycertification program of its kind available to licensedphysicians in the United States or Canada.

In addition to improving patient care and enhancing yourprofessional stature and credibility, it demonstrates yourcommitment to continued professional development.

For an application, handbook, eligibility requirements andexamination information, call (904) 674-0752 or visit thewebsite at: www.lipidboard.org

��

A 52-year-old male was seen over a period of about six months in 1999 with epigastric substernal tightness during moderate exertion. The symptoms lasted only minutes. He noticed this more often postprandial and accompanied by some chest tightness. His physicians at the time could not determine if this was angina or indigestion, and there was not a consistent presentation. While driving home from a restaurant, the patient experienced a five-to-ten minute episode of chest tightness that concerned him and his wife, but no action was taken. While on a walk later that same day, he had some substernal tightness that was relieved by rest. He worked the next day — doing heavy

outside labor — without symptoms, but he was aware that his chest did not feel quite right and he was anxious. He discussed this with his primary care physician, who started him on aspirin, and he was given nitroglycerin to carry with him. He was then referred for a cardiology opinion.

His risk factors included a family history of premature coronary disease, with a younger brother having had percutaneous transluminal coronary angioplasty and stents placed. The patient smoked for 30 years, quitting in 1996. He had moderate obesity, with a height of 69 inches, a weight of 211 pounds, and a BMI of 31.2. He had pre-hypertensive blood pressure of 130/70 mmHg. He had no diabetes or history of hyperlipidemia. At that time, his cholesterol was 203 mg/dL, triglycerides 150 mg/dL, HDL cholesterol 40 mg/dL, LDL cholesterol 133 mg/dL, glucose 93 mg/dL, and Lp(a) was normal at <7. His examination showed his blood pressure to be 130/80 mmHg, with a pulse of

70 per minute. Jugular venous pressure was normal. His heart showed normal S1 and S2. No murmur or gallop was noted. A cardiovascular examination was normal. His electrocardiogram showed sinus rhythm with a rate of 56, a normal electrocardiogram. An exercise sestamibi test showed he exercised a total of eight minutes, Bruce protocol, with mild angina noted at peak stress. His heart rate went from 71 to 148, with his blood pressure going from 130/98 to 170/100 mmHg. His double product was 25,160. The ECG was positive for ischemia with 2.5 mm ST depression in V4-V6. Images showed a large area of ischemia in the anterior wall, lateral wall and apex. Post-stress ejection fraction was 57%. The images displayed here are his baseline images, showing the defects.

A decision was made to proceed with heart catheterization because his mid-left anterior descending had an 80% stenosis with diagonal of 80% and complex

GERALD T. GAU, MD, FNLA

Professor of MedicineMayo Medical SchoolDirector, Cardiopulmonary Exercise Testing LaboratoryConsultant, Cardiovascular Diseases and Internal MedicineMayo ClinicRochester, MN

THOMAS G. ALLISON, PhD, MPH

Consultant, Cardiovascular Diseases and Internal Medicine Mayo Clinic Rochester, MN

Case Study: Management of Stable Angina: What Should We Know for Our Clinical Practice?


Go to “Topics” and look for “Case Study.”

14 LipidSpin

bifurcating lesion, the proximal circumflex was 20% and the right coronary was 50% (Figure 1). The discussion at that time was how to proceed: Should maximum medical therapy be used, should we do

percutaneous transluminal coronary angioplasty and stents to the left anterior descending and diagonals or, because of the complex nature of this lesion, should he have a bypass procedure done? The decision was made to enroll him in the COURAGE trial, and he was randomized to maximum medical therapy. The drugs used included Simvastatin 10 mg/day, Amlodipine 10 mg/day, Metoprolol 50 mg/day, Imdur 15 mg/day, and aspirin 325 mg/day. He was started on an exercise program with a target pulse of 102-109 and Borg scale of 11-13. His goal exercise was for 30-45 minutes, three or four times a week. Diet counseling and weight loss also were stressed.

Participants in the COURAGE trial were followed monthly for three months, then every six months, with an annual physician review at years one and three. The one-year follow-up showed he had no angina and his weight had dropped 21 pounds. His exercise treadmill was 60 per minute without angina. His diet was moderate to strict; however, he did have an occasional glass of red wine. He was working full-time and there was no need to increase his medications. Follow-up one-year data is outlined in the accompanying graph, which shows his LDL cholesterol drop from 133 mg/dL to 58 mg/dL on Simvastatin 10 mg/day, his weight reduction, exercise and dietary program (Figure 3).

He was seen one year later and did a 13-minute Bruce exercise study with no angina. His heart rate went from 54 to 164 with his blood pressure going from 110/70 mmHg to 144/80 mmHg, double product 23,616. The electrocardiogram was negative, and the images showed a small anterior apical area of ischemia. Post-stress ejection fraction was 54% (Figure 4).

The three-year follow-up showed no evidence of any angina. His weight was still down 17 pounds from his baseline. He was exercising for 90 minutes, four days a week. He had no symptoms and was working full-time. An electrocardiogram was normal. His three-year follow-up data, in the accompanying chart, show his cholesterol was 149 mg/dL, HDL cholesterol 43 mg/dL, LDL cholesterol 75 mg/dL, triglycerides 153 mg/dL and he continued on his Simvastatin 10 mg/day. The exercise sestamibi at that time showed

that the patient exercised 10.5 minutes on the Bruce protocol, with his heart rate going from 49 to 149. His blood pressure went from 116/70 mmHg to 164/70 mmHg, double product 24,436. The electrocardiogram was negative and the

images were normal. Post-stress ejection fraction was 66%. Imdur was discontinued on that visit (Figure 5).

Now in his eleventh year of follow-up, the patient remains free of angina. He works full-time, his weight loss has been maintained, and he remains entirely asymptomatic. His recent labs show cholesterol of 137 mg/dL, triglycerides 121 mg/dL, HDL cholesterol 39 mg/dL, LDL cholesterol 74 mg/dL, AST 31 U/L, and glucose 101 mg/dL. He has done very well on medical treatment despite the significant coronary atherosclerosis that was documented on his angiogram.


Figure 2. This still frame image of the patient’s left coronary artery shows a complex lesion involving the LAD and diagonals.

Figure 4. The patient’s follow-up sestamibi at one year shows the nearly complete resolution of ischemia.

Figure 3. Lipid levels are shown across three years of follow-up.

Figure 1. The initial images from the patient’s exercise sestamibi scan show anterior ischemia.

16 LipidSpin

A brief discussion of the COURAGE trial follows.

COURAGE TRIALThe aim of the COURAGE trial was to test the hypothesis that percutaneous coronary intervention (PCI) would have favorable effects on a combined endpoint of survival and non-fatal myocardial infarction (MI) when added to optimal medical therapy (OMT) as initial therapeutic strategy in patients with stable angina.1 A complete description of the COURAGE methods has been previously published. COURAGE was conducted entirely within North America in three types of hospitals: 15 U.S. Veterans Administration (VA) hospitals, 19 U.S. non-VA hospitals, and 16 Canadian hospitals. Subjects included patients with stable angina or Canadian Cardiovascular Society (CCS) Class IV angina that had been stabilized in the hospital. Patients also had to have a critical stenosis of at least 70% in a major epicardial coronary artery plus objective evidence of ischemia or CCS Class III angina with a lesion of at least 80%. All patients had to have an anatomy initially deemed suitable for PCI. An ejection fraction less than 30%, revascularization within the previous six months, ST depression or hypotension during Stage I of the Bruce protocol, anatomy not thought to be suitable for PCI, or persistent CCS Class IV angina resulted in exclusion from the study.

After randomization, subjects assigned to PCI+OMT received clinically appropriate PCI (except for 46 who declined intervention after randomization or had lesions unsuitable for PCI and 27 whose lesions could not be successfully crossed), while those randomized to OMT alone were removed from the cath lab without PCI. All subjects subsequently received aggressive treatment of angina and coronary risk factors, including counseling for behavioral changes (smoking cessation, diet, exercise, weight loss). Though randomization for COURAGE began in June 1999, risk factor goals were aggressive enough to reflect current (2009) practice; for example, the goal for fasting LDL cholesterol was set at 60-85 mg/dL.

There no difference between groups in the primary outcome of death from any cause or non-fatal MI, as seen in Figure 6 below, reproduced from the original publication. Follow-up was from two to seven years with a mean of 4.6 years.

An underappreciated aspect of COURAGE was that it was the first randomized clinical

trial to attempt to treat all of the traditional coronary risk factors by protocol. Clinical trials generally leave treatment of risk factors to usual care while focusing on one or, at most, two factors (such as blood pressure and lipids in the ALL-HAT2 and ASCOT3 trials) by protocol. In terms of lipid control, 70% of subjects had an LDL-cholesterol of <85 mg/dL (2.20 mmol/L) at five years with statin-usage rates of 93% in both groups and rates of use of other lipid agents at approximately 50%. Blood pressure goals of <130 mmHg systolic and <85 diastolic were achieved in 65% and 94% of subjects, respectively. Beta blocker use was approximately 85%, ACE-inhibitor use more than 60%, and calcium channel blocker use 42% in PCI+OMT versus 52% in OMT alone.

Our COURAGE team at Mayo employed registered nurses to manage risk factors and adjust anti-anginal therapy, all according to study guidelines. Many other COURAGE sites employed similar nurse-delivered follow-up. This was driven in part by necessity — the reimbursement per patient was insufficient to cover the

Figure 5. The follow-up sestamibi at three years shows complete resolution of the patient’s ischemia.

Figure 6. This Kaplan-Meier survival curve from the COURAGE trial shows the estimated 4.6-year rates of the composite primary outcome of death from any cause and non-fatal myocardial infarction was 19% in the PCI+OMT group versus 18.5% in the OMT-only group.


extensive protocol-determined follow-up (monthly for the first three months, again at six months, and every six months thereafter; a cardiologist saw the patient yearly) if performed by a cardiologist, but it also was driven by solid evidence that registered nurses could manage coronary risk factors by protocol at least as effectively as physicians. The initial study comparing nurse-delivered risk-factor management to usual physician-delivered care was conducted by Robert DeBusk within the Kaiser-Permanente Health System in the San Francisco area.4 In this study, 585 patients were followed for 360 days after a myocardial infarction. Risk factors were managed either through a special intervention consisting of registered nurse case managers or usual care (physicians). Outcomes included LDL-cholesterol, smoking rates and exercise capacity. RN management proved superior to usual care on all outcomes.

BEYOND COURAGEIn many respects, the BARI 2D trial5 was confirmation of COURAGE, albeit it just in type 2 diabetics. The number of subjects in COURAGE versus BARI 2D was similar (2,287 versus 2,368), as was the randomization to OMT alone versus OMT plus revascularization; aggressive treatment of all modifiable risk factors was carried out in both studies. Unlike COURAGE, however, both CABG and PCI were revascularization options in BARI 2D, and subjects were randomized separately to OMT alone versus revascularization + OMT in patients for whom PCI (N = 1605) or CABG (N = 763) was considered clinically indicated. Overall, there was no difference between OMT alone and revascularization in terms of survival (87.8% versus 88.3%) or freedom from major cardiac events (75.9% versus 77.2%). In the CABG stratum, however, CABG+OMT appeared to be associated with greater freedom from major cardiovascular events (77.6% versus 69.5%) compared to OMT

alone (Accordingly, freedom from major cardiovascular events was slightly but not significantly lower in PCI+OMT (77%) versus OMT alone (78.9%) within the PCI stratum).

As with COURAGE, later revascularization in patients initially assigned to OMT alone was permitted by protocol, and 42% of patients assigned to OMT alone did receive some form of revascularization during three years of follow-up.

BARI-2D, like COURAGE, defined the severity of disease by angiography before randomization, so there is no solution to the problem of deciding on guidelines for choosing OMT alone versus combined revascularization + OMT after clinical assessment and stress testing.

Analysis of outcomes based on stress test results could similarly be performed with the BARI-2D data to determine — or, more correctly, hypothesize — which patients will do well with an initial strategy of OMT alone, reserving angiography for those patients who may more likely need combined revascularization + OMT.

We now offer our coronary heart disease management to all patients with coronary heart disease. Virtually all patients who undergo coronary artery bypass surgery or elective PCI are provided with a referral to cardiac rehabilitation, and all of the patients in cardiac rehabilitation are offered the extended disease management program (with an historical 83% response rate). Individual physicians also can choose referral for their patients to our Mayo-COURAGE disease management program through our electronic orders system.

SUMMARYCOURAGE tested an initial treatment strategy of OMT alone versus PCI+OMT in patients with stable angina. Results indicated that PCI could be safely

postponed in one-third of patients and was unnecessary in two-thirds of patients randomized to OMT alone with only minimal differences in control of angina and no excess deaths or myocardial infarctions. As part of those results, we were able to present a case with moderately severe coronary artery disease that has been successfully managed for 11 years without percutaneous intervention or coronary bypass surgery. COURAGE was not only a trial of initial treatment strategies, but also a demonstration of the feasibility and benefits of a coronary heart disease case management system and treatment of all modifiable coronary risk factors. Our patient has maintained excellent control of lipids and other risk factors through a program of appropriate medical therapy, aggressive lifestyle changes, and case management follow-up. The more recently published BARI-2D study appears to confirm the COURAGE findings in type 2 diabetics, especially as they related to patients thought to be appropriate for elective PCI. Despite advances in PCI since COURAGE, initial use of OMT alone in appropriate patients still seems to be a viable and economically sound alternative to immediate revascularization. Systems should be created — they are being developed at Mayo — to provide case management of coronary artery disease, including aggressive treatment of all modifiable risk factors. Individual physicians are encouraged to consider an initial trial of OMT for patients with stable angina. This could free up medical resources that could be directed toward extending health care coverage without increasing overall health care costs and without decreasing the benefit to patients served. n


18 LipidSpin

Susan was referred to my clinic and her medical record listed seven “allergies.” She was diagnosed with high triglycerides, low high-density lipoprotein cholesterol (HDL-C) and suboptimal low-density lipoprotein cholesterol (LDL-C) levels. Our discussion about drug therapy began with the statement “medications don’t work in me like other people, I cannot tolerate any of them.”

We have all treated patients like Susan whose lipid management is challenged by adverse effects of pharmacologic therapy. Statins, niacin and omega-3 fatty acids are particularly troublesome. Management options for these drug-class intolerances will be reviewed (Table 1).

StatinsCurrent guidelines indicate the use of statins as first-line treatment for LDL-C lowering and prevention of cardiovascular

events. A recent review of statin adherence in the community setting found low adherence rates between 21-87% with an average rate of 50% at five years of treatment.1 The most common reason for discontinuation of statins is muscle symptoms, with 5-10% of patients reporting muscle symptoms while taking a statin. It is important to identify if the symptoms are actually related to statin therapy, identify possible risk factors (i.e., advanced age, female gender, decreased renal and hepatic function, hypothyroidism) and drug interactions (i.e., gemfibrozil, ketoconazole, amiodarone, diltiazem) that may increase the likelihood of this reaction.3 Muscle symptoms usually occur within the first weeks to months, although they may present at any time during treatment. Symptoms may present with or without elevations in creatine kinase (CK) with the majority presenting without CK elevations.2,3

When muscle symptoms occur with statin therapy, the first step is to discontinue the statin. Symptoms should partially or completely resolve within two months of drug discontinuation. At this point, the patient should be rechallenged with a lower dose of the same statin or a

low dose of another statin.2 Fluvastatin, while less potent, has the most favorable pharmacokinetics with a short half-life, low lipophilicity and favorable metabolism. The relatively hydrophilic pharmacokinetic profiles of pravastatin and rosuvastatin

theoretically may decrease the risk of muscle symptoms. Many believe trying different statins should be continued until one is found that the patient can tolerate, however, many patients look to other options.

Medication Minute: Is There a Remedy for Lipid Medication Intolerances?

CORALYNN B. TREWET, MS, PharmD, BCPS, FNLAUniversity of Iowa College of PharmacyBroadlawns Medical CenterDes Moines, IA


Go to “Topics” and look for “Is There a Remedy for Lipid Medication Intolerances?”

Medication Minute (continued on Page 33)

Winter Clinical Update ReviewThe Winter Clinical Update in mid-February was a great success in that more than 220 attendees expanded their knowledge of clinical lipidology in San Francisco. Meeting chairs Matthew Ito, PharmD, and Carl Rubenstein, MD, pulled together an excellent scientific program with a focus on putting the latest research into best practices for patients.

The meeting began with lipid thought leaders presenting cutting-edge assessments of HDL cholesterol, managing special populations, atherosclerosis, and lipid clinic operations. Other hot topics included the ATP-IV guidelines and case presentations on pediatric patients, pregnancy, and HIV patients.

The Foundation of the NLA hosted its first gala event, Vines & Vessels. The evening’s festivities began with a wine tasting and silent auction, followed by the Renaud Society’s Tedd Goldfinger, DO, who presented, “Beyond the French Paradox: An Objective Look at Wine and Health.”

2010 Scientific SessionsThe Annual NLA Scientific Sessions, hosted by the Midwest Regional Chapter, are being held in Chicago from May 13 to 16. An outstanding program has been prepared by program chairs Drs. Peter Toth, Vera Bittner, Michael Davidson and Carl Orringer. The sessions kick off with the keynote address by Dr. Ira Tabas, who will explore, “The Macrophage and Atherosclerosis.” A worldwide lecturer, Dr. Tabas is a Professor of Medicine and

Anatomy and Cell Biology at the Columbia University College of Physicians and Surgeons. A highlight will be the Third Annual NLA Summit on HDL Therapeutics on Friday, May 14. The summit will cover HDL Particles, CAD and Niacin, Insight from the Recent Meta-Analysis, Dynamics of HDL Proteome and a Panel Discussion and an Interactive Keypad Question Session. This lively session will be hosted by Drs. Peter Toth and Michael Davidson.

Summer Clinical UpdateWe hope you are making plans to attend the Summer Clinical Update from August 27 to 29 in Washington, D.C., jointly sponsored by the Southeast and Northeast Regional chapters. Attend this meeting and gain insight and firsthand knowledge you can put to work immediately in your practice.

Program highlights include:

Current controversies in lipid • management and atherosclerosis

Applications and limitations of • biomarkers, imaging and advanced lipid testing

Management of residual risk•

The latest therapies and outcomes • trials for dyslipidemia and cardiometabolic conditions

Evidence-based diet and lifestyle • guidelines

Challenging case presentations•

Accesing the intermediate risk patient•

Don’t forget the NLA professional development courses held in conjunction with the clinical update: Lipid Management Training, Cardiometabolic Risk Reduction Through Weight Management and the Masters in Lipidology.™

To register or view the full program, visit www.lipid.org/summer. We look forward to seeing you there.

Meeting Update: 2010 Scientific Sessions andRegional Clinical Updates


To view select presentations from the NLA scientific

meetings, go to www.lipid.org/education.

Winter Clinical Update highlights are available now.

The Annual Scientific Sessions highlights will be

available at the end of June.

Registration

Credit Card # Exp. Date

Signature

Name on Card

Payment method

VISA MC AMEX Check

Make checks payable to the NLA

First Name Middle Initial Last Name

Mailing Address

City State or Province ZIP Country

Phone Emergency Contact/Phone

E-mailCheck all that apply: MD DO PhD RN NP PA RPH PharmD RD Other _____________

Guest name(s), if attending meeting:

Membership status:

I am currently a member. My application for membership has been submitted and confirmed. I will apply at www.lipid.org. Please send me membership information.

1

2

3

4

5

ImPortant InformatIon

*Masters CourseTo purchase related study materials or the NLA-SAPs: www.lipid.org/education/nlasap.

Registration: Registration and payment must be received no later than August 12, 2010. After this date a syllabus and name badge cannot be guaranteed — so register TODAY!

Cancellation: Telephone cancellations will not be accepted. A written notice of cancel-lation must be received no later than August 12, 2010. This includes Social Events and Guest Fees.

Special Needs:

ADA Compliance:Attendees who need additional reasonable accommodations or who have special needs should contact the NLA at 904-998-0854.

3 easy Ways to regIster

Mail To: National Lipid Association 6816 Southpoint Parkway, Suite 1000 Jacksonville, FL 32216

Fax to: NLA at 904-998-0855 Fax with credit card number and signature

Online: www.lipid.org

Circle fee based on attendee type

Clinical Lipid Update $395 $695 $75 $695 Summer 2010August 27–29, 2010 Includes course syllabus and one admission badge to Exhibit Hall for all food functions.(Saturday Night Dinner NOT Included) Join NLA and register for Clinical Lipid Update N/A $495 $75 N/A(If selecting this option, register online at www.lipid.org)

Ancillary CoursesLipid Management Training CourseAugust 26–27, 2010 $395 $595 $0 $900

Masters in Lipidology™ Course*August 26–27, 2010 $695 $895 $595 $1,200 Comprehensive Cardiometabolic Risk Reduction Program August 27, 2010 $0 $0 $0 $0 Registration Fee Total $_____ $_____ $_____ $_____

Social Events and Guest FeesSaturday Night Gala–Registrant $125 $_______

Saturday Night Gala–Guest(s) $125 X____ $_______

Exhibit Hall Pass–Guest(s) $80 X____ $_______

Social Events and Guest Total $_______

Combined Total Sections 2,3 & 4 $_______

ClInICal lIPId UPdate – sUmmer 2010 JoIntly hosted by the soUtheast and northeast regIonal ChaPters

aUgUst 27–29, 2010Mayflower Hotel • wasHington, D.C.

NLA MemberDiscount Rate

TraineeRate

IndustryRate

RegistrantRate

22 LipidSpin

News & Notes: From the NLA Office

Michael H. Davidson, MD, FACC, FACP, FNLA Becomes President of NLA

Michael H. Davidson, MD,is being installed as the new President of the National Lipid Association (NLA) at the Annual Scientific Sessions in Chicago this

May. A Clinical Professor at the University of Chicago, he also serves as Director of Preventive Cardiology and Associate Vice Chairman for Continuing Medical Education at the university. In addition, he is Founder, President, and Chief Executive Officer of the Chicago Center for Clinical Research, currently part of Radiant Research.

Dr. Davidson earned his medical degree from The Ohio State University College of Medicine in Columbus. He then fulfilled his residency in internal medicine at Rush-Presbyterian-St. Luke’s Medical Center in Chicago, where he later completed a fellowship in cardiology.

An active researcher, Dr. Davidson’s clinical research background encompasses both pharmaceutical and nutritional clinical trials. His extensive research on statins, novel lipid-lowering drugs, and nonpharmacologic risk factor reduction has established him as a key opinion leader in this area. His research also includes extensive work with food additives, dietary supplements, and health claim petitions to the US Food and Drug Administration. A prolific author and lecturer on lipid disorders, nutrition, and atherosclerosis, Dr. Davidson has coordinated more than

700 clinical trials in areas of preventive cardiology and published more than 200 articles for leading medical journals.Dr. Davidson is board-certified in internal medicine, cardiology, and clinical lipidology. He is a Fellow of the American College of Cardiology and the American College of Chest Physicians. He was listed in America’s Top Physicians by the Consumers’ Research Council of America, 2004-2005, and named three times in The Best Doctors in America.

Since joining the NLA in 2003, Dr. Davidson has served in many leadership positions such as Treasurer for the national association from 2008 to 2009 and President for the Midwest Chapter from 2006 to 2007. In addition to these roles, he has chaired the NLA Programs Committee, founded the Masters in Lipidology™ course, and continues to serve on the board for the Foundation of the NLA.

Kathleen L. Wyne, MD, PhD, FNLA Installed as President of SWLA

Kathleen L. Wyne, MD, PhD, was elected to serve as President of the Southwest Lipid Association (SWLA) at the Association’s Winter 2010 Clinical Lipid Update

meeting held in San Francisco in February. Dr. Wyne earned her medical degree from the Pritzker School of Medicine at the University of Chicago in 1990. After serving a residency in internal medicine at Baylor College of Medicine in Houston, Tex., she completed her fellowship in endocrinology, diabetes and metabolism

at the University of Texas Southwestern Medical Center in Dallas. She is board-certified in endocrinology, diabetes and metabolism and also is a Diplomate of the American Board of Clinical Lipidology. Dr. Wyne is a Fellow of the American College of Endocrinology and of the National Lipid Association.

Given her background and current research interests in the role of inflammation and lipid metabolism in the etiology of diabetes, Dr. Wyne is a reviewer for numerous medical journals. She is a member of the Medical Professional Advisory Subcommittee to the Texas Diabetes Council. She also serves as Director of Clinical Research for the Diabetes Research Center at The Methodist Hospital Research Institute (TMHRI) in Houston.

A participant in a number of basic science and clinical research projects, Dr. Wyne has widely published journal articles and abstracts on her work in endocrinology, lipid metabolism, and diabetes treatment. She has presented at the annual meetings of major medical societies, and also serves on the Board of Directors for the Texas AACE chapter.

Take the Lipid Pulse!

By now, members have received an invitation from Vera Bittner, MD,to take the Lipid Pulse,

an exclusive online survey of and for NLA members. By taking 10 minutes to complete the online survey, the NLA will gain valuable knowledge about the


community of health care professionals managing patients with lipid disorders. Members also can take the survey from May 13 to 16 at a kiosk at the Annual Scientific Sessions in Chicago.

In appreciation for your time and support, participating members will receive:

State of the Lipid Practice: A Summary • of Findings from the Lipid Pulse 2010A $25 coupon toward any product or • service offered by the NLATwenty-five copies of • Familial Hypercholesterolemia, a 30-page patient education booklet developed by Dr. Leiv Orso of the University of Norway with support from Genzyme

Save These Dates in 2011!

Mark your calendars for 2011 NLA Clinical Lipid Updates and Annual Scientific Sessions!

March 11–13, 2011Clinical Lipid Update – SpringJointly hosted by the Southwest and Pacific Lipid associations Hyatt Lost PinesLost Pines, Texas

May 19–22, 20112011 NLA Annual Scientific Sessions Hosted by the Northeast Lipid Association Sheraton Hotel and Towers New York, New York

August 26–28, 2011 Clinical Lipid Update – Summer Jointly hosted by the Midwest and Southeast Lipid associations Bonnet Creek Orlando, Florida

More information will be available soon on www.lipid.org or call the NLA office and ask for the meetings department.

Join Us in Washington, D.C.

Our second Clinical Lipid Update for 2010 will be held in Washington, D.C. at the Mayflower Hotel from August 27 to 29. Jointly hosted

by the Southeast and Northeast Regional chapters, program highlights include:

Current controversies in lipid • management and atherosclerosis preventionApplications and limitations of • biomarkers, imaging and advanced lipid testingManagement of residual risk• The latest therapies and outcomes • trials for dyslipidemia and cardiometabolic conditionsEvidence-based diet and lifestyle • guidelinesChallenging case presentations•

Log onto lipid.org/summer to register.

Experience an Improved Lipid.org

Last summer we launched NLA Community — an online workspace for members at lipid.org. Since its launch, the NLA Community has averaged 50 visitors a day who have created blogs, posted topics and formed groups. While pleased with the site and the activity from members, we realized there was room for improvement. Our new version features a cleaner design, consolidated features, better performance and easier navigation. The Communications and IT departments will host online tutorials for those who want to learn more beginning May 20. Contact Clark Morgan at [email protected] or 904-309-6202 for tutorial information or with questions about the NLA Web site.

NLA Staff Corner

Adam Beamer accepted to run the New York City Marathon – Adam

Beamer, Assistant Director of NLA Programs, was among the lucky participants selected for the 26.2 mile run out of a race

lottery pool with more than 120,000 entrants. Race day will begin on Sunday, Nov. 7, with a special marathon breakfast at Fort Wadsworth on Staten Island. Good luck, Adam!

Maggie Schaefer inducted in Volleyball Hall of Fame – NLA Event Coordinator Maggie Schaefer was inducted into Loyola University’s Athletic Hall of Fame in February. She played four years of volleyball for the university and led her team to the national competition. Maggie is the most decorated athlete at Loyola University and continues to play beach volleyball in an intramural league. Congratulations, Maggie!

Megan Seery joins staff – Megan Seery recently was appointed as NLA Communications Manager. She previously worked as a healthcare writer in the public affairs office at the University

of Chicago Medical Center and as a staff reporter for several Florida-based news publications, and currently is a board member for the Jacksonville Chapter of the American Marketing Association. Welcome aboard, Megan!

Education Update: From the NLA Office

24 LipidSpin

NLA Virtual Lipid Clinic www.lipid.org/vclinic

In the vClinic™, you’ll have the opportunity to work-up and manage virtual patients over multiple visits while earning CME/CE credit. Please be sure to share your opinions regarding key clinical decisions with other learners. Make sure that you also utilize the CME Companion toolset that accompanies these activities to assess your clinical mastery over time and to compare your performance with your peers.

Please log into your vClinic™ and assess the four patients currently waiting to be seen by you: Howard

Age 45, Ht. 5’11, Wt. 175 lbs•

Reason for visit – Routine physical•

MargyAge 47, Ht. 5’8”, Wt. 200 lbs•

Reason for visit – Follow-up on diet • and exercise

RajAge 50, Ht. 5’8”, Wt. 230 lbs.•

Reason for visit – Worried that • being overweight can cause diabetes mellitus and long-term complications such as heart disease

JosephAge 52, Ht. 6’, Wt. 214 lbs.•

Reason for visit – Trouble with sexual • performance for more than a year

Summit Conference Highlights Available Online Now

The NLA Fourth Annual Summit Conference, co-sponsored by the American Society of Preventive Cardiology, was held on November 14, 2009, prior to the American Heart Association’s Scientific Sessions. Video excerpts focusing on Overcoming Challenges in CVD Prevention: A Focus on the Cardiometabolic Risk Continuum are now available on www.theHeart.org and also on www.lipid.org. This multimedia CME activity provides presentations on CVD prevention from multiple perspectives, while translating current data on the impact of inflammation, diabetes, hypertension and obesity on atherosclerotic cardiovascular disease. Hear Drs. Caroline Apovian, William Boden, James de Lemos, Robert Eckel and Kenneth Jamerson present insights and strategies for your practice.

To view the activity, go to www.theHeart.org directly, or you can access it at www.lipid.org/education/webinars. Participants will need to log in or create a new account on www.theheart.org prior to viewing this activity.

NLA Comprehensive Cardiometabolic Risk Reduction Program – A QI Success Story

The NLA’s educational strategy is focused on improving the performance of members practicing in lipid clinics to enhance patient care. The Comprehensive Cardiometabolic Risk Reduction Program (CCRR) is designed

to establish a new standard of care for patients with cardiometabolic risk factors. This program, chaired by Drs. Louis Aronne and Christie Ballantyne, has been ongoing since 2007 and is currently in Phase III of the curriculum. The program teaches more aggressive standards and broadens treatment protocols for the effective management of dyslipidemia patients with diabetes, hypertension and obesity. Rewards and incentives have been built into the programming to encourage active involvement in the quality improvement process, while professional tools are provided that encourage best-practice clinical steps in the treatment of individual patients.

The impact of the program on participant performance was followed each year through post-activity case scenario surveys, and the impact of the activities on patient outcomes were recorded via patient data tracking sheets distributed to all enrollees.

Dr. Peter Jones, Chairman of the NLA CME Committee and a core CCRR faculty member, is pleased to report that participants in 2008-2009 courses showed a 45% improvement in their ability to assess/manage obesity-related conditions and to perform cardiometabolic risk assessment (as derived from case-based test questions). Even more encouraging was the impact of the educational programming on patient outcomes. Patient chart audit data collected showed an improvement on all measures (i.e., blood pressure, LDL-C, HDL-C, Triglycerides, Weight, Waist, and Fasting Plasma Glucose).


Phase III of the Comprehensive Cardiometabolic Risk Reduction program launched in February 2010 and now offers an enhanced focus on obesity and weight management. Courses are scheduled for Thursday, May 13, during the NLA Annual Scientific Sessions and Friday, August 27, in conjunction with the NLA Summer Clinical Lipid Update meeting in Washington, D.C. The courses also will go on the road to five regional venues in partnership with leading lipid centers.

Don’t miss this opportunity to enhance your knowledge, skills and practice in this important area. Online programming, resources and tools are added regularly to lipid.org and these materials are available to all NLA members with no fee. Visit www.lipid.org/cardiometrisk to explore future course dates and the resources available to you.

NLA Holds 3rd Summit on HDL Therapeutics

This half-day summit conference held at the NLA Scientific Sessions on Friday, May 14, in Chicago will provide insight and clarity on the latest research on HDL and HDL–C raising therapies. Chaired by Drs. Peter Toth and Michael Davidson and led by a panel of renowned experts, this conference will assess current HDL-C therapy options as well as those

in development and discuss insight from recent clinical trials. To register and learn more visit www.lipid.org/summit. If you miss the live conference, the proceedings will be published in the Journal of Clinical Lipidology in the fall, and presentation highlights will be posted as a CME-certified web activity on lipid.org and theHeart.org in late summer.

Screening and Treatment for Familial Hypercholesterolemia: How Can We Do Better?

A special symposium will be held in conjunction with the NLA Scientific Sessions on Saturday, May 15, and is co-sponsored by the Foundation of the NLA and MEDPED (Make Early Diagnosis to Prevent Early Death). The symposium, co-chaired by Drs. Mary McGowan and Paul Hopkins, will discuss the challenges of screening, diagnosis and management of familial hypercholesterolemia (FH), with a focus on unmet needs and novel approaches to therapy.

A key public health initiative of the Foundation of the NLA, FH is often overlooked and under-diagnosed. Come learn more

about this important topic from our collection of well known specialists in the field, including Foundation President, Dr. Anne C. Goldberg. To register and learn more visit www.lipid.org/sessions. After the meeting, visit www.lipidfoundation.org to learn more about the Foundation and its FH initiatives.

Lipid Insights Virtual Journal Club – An Examination of the ACCORD Trial

The Pacific Lipid Association recently sponsored a Lipid Insights Virtual Journal Club webcast featuring “An Examination of the ACCORD Trial.” The program was well attended with more than 100 participants. Program faculty included Dr. Eliot Brinton and lead investigator, Dr. Henry Ginsberg. The session was moderated by PLA President, Dr. Matthew Ito. If you missed the live webcast, it is not too late. This Virtual Journal Club presentation, along with many past broadcasts, has been archived and is available for viewing on-demand at www.lipid.org/education. These activities are available at no charge as a member benefit.

Professional Development Pathway

Did you know the NLA offers a robust professional development pathway in clinical lipidology? This pathway paves the way for you to be recognized as a

leader with advanced specialized knowledge in clinical lipidology. The pathway is open to physicians as well as nurses, physician assistants, registered dietitians and pharmacists. The program consists of five levels of learning with each one building upon the previous level and participants can begin at the level that best fits their current knowledge. Each level addresses the approved core competency areas and allows participants to select from a variety of formats including live and online. Our professional development pathway culminates in certification by the American Board of Clinical Lipidology for physicians or the Accreditation Council for Clinical Lipidology for allied health. Our unique array of programs will enhance your performance and expand your knowledge and practice.

For additional details on the NLA’s professional development pathway visit www.lipid.org/education/pathway

HDLTherapeutics3rd Annual Summitat NLA Scienti�c Sessions

May 14, 2010

26 LipidSpin

2010 Awards and Honors

As part of Annual Scientific Sessions, the NLA recognizes outstanding individuals and applauds their commitment to medicine, research, and the highest levels of patient care.

We congratulate the following winners for 2010.

2010 NLA Honorary Lifetime Membership Award Recipient

John A. Glomset, MD Professor Emeritus of Medicine and Biochemistry Division of Metabolism, Endocrinology and Nutrition University of Washington School of Medicine

John A. Glomset, MD, is currently Professor Emeritus of Medicine and Biochemistry at the University of Washington School of Medicine in Seattle. He received degrees in medicine and biochemistry from the University of Uppsala in Sweden in 1960 and then joined the Department of Medicine at the University of Washington. He was appointed Research Assistant Professor of Medicine at the University of Washington in that year, Research Associate Professor in 1964, Research Professor and Investigator of the Howard Hughes Medical Institute at the University of Washington from 1971 to 1974, Professor of Medicine and Biochemistry in 1974, and Professor Emeritus of Medicine and Biochemistry in 2009. He received an honorary medical degree from the University of Oslo in1981

for his discovery of a plasma enzyme, lecithin:cholesterol acyltransferase (LCAT), and is currently a member of the National Academy of Sciences, the American Academy of Arts and Sciences, and the Washington State Academy of Science.

His first paper on cholesterol esterification involved studies of the blood plasma of humans and rats and appeared in 1962 in Biochimica et Biophysica Acta. His path-breaking paper describing the esterification of free cholesterol in plasma by lecithin-cholesterol acyl-transferase (LCAT) appeared in the Journal of Lipid Research in 1966, and his finding that LCAT could catalyze the esterification of free cholesterol in HDL provided a basis for the hypothesis that HDL is a vehicle for cholesterol transport. Dr. Glomset also contributed to subsequent studies of the many plasma lipoprotein abnormalities of the Norwegian patients who had been found to have Familial LCAT deficiency.

Dr. Glomset is known for his charismatic communication of the amazement of basic research in general and for the unlimited possibilities for discoveries related to the roles of phospholipids in diverse biological processes. He has abundantly earned his Honorary Lifetime Membership Award from the National Lipid Association for a career in lipid research that spans more than 60 years. His research formed the basis for the concept of reverse cholesterol transport, an idea that is still being developed at both basic and clinical levels.

About the Awards

The NLA Honors and Awards Committee established three categories in which to recognize outstanding member contributions. The honors include the NLA Honorary Lifetime Member Award, the Distinguished Achievement Award, and the Fellow of the NLA designation.

Honorary Lifetime Membership Award This award is granted on special occasions to a scientist or clinician who, although unlikely to become a regular NLA member, would lend prestige to the NLA by being given Honorary Lifetime Membership by virtue of his/her extraordinary expertise and contributions to the field of clinical lipidology. Nominations for this award are made by the NLA Board and the Annual Scientific Sessions Committee.

Distinguished Achievement Award This award is the highest honor conferred by the NLA. Candidates must be widely known for a major contribution to clinical lipidology (research, teaching, publishing, or service), whether as a single accomplishment or through lengthy career work.

Fellow of the NLA Fellowship in the National Lipid Association recognizes the excellence, innovation and leadership of health professionals in the NLA with respect to clinical lipidology in private practice or academic settings. Fellowship is reserved for NLA members who have made significant regional and/or national contributions to the science and practice of clinical lipidology. Fellows of the NLA are entitled to append their names with the designation, “FNLA.”


2010 NLA Distinguished Achievement Award Recipient

Scott M. Grundy, MD, PhD, FNLAProfessor, Department of Internal MedicineUniversity of Texas Southwestern Medical Center at DallasDiplomate, American Board of Clinical Lipidology

Scott M. Grundy, MD, PhD, is Director of the Center for Human Nutrition and Chairman of the Department of Clinical Nutrition at the University of Texas (UT) Southwestern Medical Center in Dallas, Texas, and Chief of the Metabolic Unit for the Veterans Affairs Medical Center, which also is in Dallas. In recognition of his academic endeavors, he has earned the title of Distinguished Professor of Internal Medicine at the UT Southwestern Medical School. Dr. Grundy received his medical degree from the Baylor College of Medicine and his doctorate from Rockefeller University.

Dr. Grundy’s research interests primarily focus on nutrition and cholesterol and lipoprotein metabolism. Notable research achievements include developing methods for measuring cholesterol balance and biliary lipid secretion in humans; identifying the metabolic causes of cholesterol gallstones; defining effects of saturated and unsaturated fats, especially monounsaturated fatty acids, on cholesterol and lipoprotein metabolism; uncovering genetic defects underlying elevated blood cholesterol and other lipid disorders; identifying metabolic defects of elevated blood cholesterol, high triglycerides, and low HDL; and

defining mechanisms of action of several lipid-lowering drugs, notably fibrates and HMG CoA reductase inhibitors (statins). Complementing his research endeavors, Dr. Grundy is a prolific contributor to medical literature, having published more than 300 original papers and numerous solicited articles and chapters.

Dr. Grundy has served in various capacities on a number of AHA committees, including Chairmanship of the Nutrition Committee; the Council of Arteriosclerosis, Thrombosis, and Vascular Biology; the Council on Nutrition, Physical Activity, and Metabolism; the Task Force on Risk Reduction and the Task Force on Cholesterol. He chaired Adult Treatment Panels II and III of the National Cholesterol Education Program (NCEP) and belongs to the American Society for Clinical Investigation, the American Association of Physicians, and the National Academy of Sciences (Institute of Medicine).

Dr. Grundy has served on the board of directors of the NLA since 2005 and on the SWLA board from 2006 to 2008. He was named a Fellow of the NLA in 2009.

In recognition of his lifetime career achievements in establishing and furthering the science of clinical lipidology, the National Lipid Association names Dr. Grundy the Distinguished Achievement Award recipient.

Fellows of the NLA

The NLA recognizes the following members as Fellows of the NLA. The 2010 class join their colleagues who earned Fellowship status in 2009.

2010 Fellows of the NLAMohammad Abuannadi, MD Clinton Brown, MDSonja Conner, MS, RDBrian Edwards, MDSusan Fujii, PharmDThomas Haffey, MDYehuda Handelsman, MD, FACP, FACEAlan F. Helmbold, MDIshwarlal Jialal, MD, PhDSteven Jones, MDMoti Kashyap, MDKevin C. Maki, PhDStephen Nash, MDRoda Plakogiannis, PharmDJohn C. Tapp, MD, FAAFP, CCD, DABCLGail Underbakke, RDKrishnaswami Vijayaraghavan, MDC. Michael Wright, MDSchott Shurmur, MDDavid Meyers, MDThomas Repas, MDRamakrishnan Iyer, MD

2009 Fellows of NLANicola Abate, MDGeorge S. Abela, MDFiras Al Badarin, MDLori A. Alexander, MSHSSidney, Alexander, MDJerilyn K. Allen, RNThomas G. Allison, PhDBenjamin J. Ansell, MDChristie Mitchell Ballantyne, MDThomas Avery Barringer, MDSeth Joshua Baum, MDDiane M. Becker, ScDThomas P. Bersot, MDKim K. Birtcher, PharmDVera A. Bittner, MDPiers Rupert Blackett, MDThomas Craig Blevins, MDRoger Scott Blumenthal, MD

2009 Fellows (continued on Page 36)

28 LipidSpin

Foundation Update: Recognizing Our Donors

Our ContributorsThe membership of the NLA is a uniquely collegial and supportive group of professionals who know the value of teamwork. We asked for donations from members to help launch our Foundation and, to date, we have received more than $14,000. Our thanks go to the following contributors, and we hope you will take an opportunity to join them in supporting your Foundation.

Founding DonorsThomas Bersot, MD, PhDAnne Goldberg, MDCarl Orringer, MDCarl Rubenstein, MDKevin Winfield, MD

Contributing DonorsDavid Akin, MD Petar Alaupovic, PhDVirginia Bailey, RNPaul Bekx, MDKenneth Bescak, MDVera Bittner, MDJ. Chris Bradberry, PharmD, CLSLynne Braun, PhD, CNP, CLSAlan Brown, MDW. Virgil Brown, MDStephen Byrne, MDLynn Cofer-Chase, RN, MSN, CLSJerome Cohen, MD

Michael Conlin, MDJames Crandell, MDThomas Dayspring, MDKhaleel Deeb, MDAndrew Dick, MDGeorge Douglass, MDMichael Doyle, MDGerald Fletcher, MDSusan Fujii, PharmDJose Garcia, MDRobert Gleeson, MDEdward Goldenberg, MDNaila Goldenberg, MDRobert Greenfield, MDThomas Haffey, DORichard Havel, MDLinda Hemphill, MDWm. James Howard, MDDonald Hunninghake, MDPeter Jones, MDJoEllen Kaufman, MS, CLSShahram Khorsidi, MDRaymond Kordonowy, MDPenny Kris-Etherton, PhD, RD, CLSDarwin Labarthe, MD, PhDRobert Lending, MDMaria Lopes-Virella, MD, PhDBeth Malasky, MDJulian Marsh, MDJames McKenney, PharmD, CLSBasant Mittal, MDPatrick Moriarty, MDTome Nascimento, MDJohn Nelson, MDLori Neri, CRNP, MSN, CLSThomas Pitts, MDKarl Pfuetze, MDDaniel Preud’Homme, MDAdela Robinson, RN, CLSMiguel Rodriguez, Sr., MD

Susan Roseburg, RN, CNPCharles Russo, MDJudith Schipper, MS, NPCharlie Schaeffer, MDJ. Orson Smith, MDAllan Sniderman, MDDaniel Soffer, MDTonimarie Swartz, PharmD, CLSRobert Talbert, PharmD, CLSJose VazQuez-Tanus, MDLuis Villamon, MDSteven von Elten, MDThomas R. White, MDGordon Wolfe, MDThomas Zoch, MD

Vines & Vessels The Foundation of the National Lipid Association hosted its inaugural gala event at the Palace Hotel during the Winter 2010 Clinical Lipid Update in San Francisco. Dr. Tedd Goldfinger of the Renaud Society (www.renaudsociety.org) presented

on the health impact of moderate wine consumption. Eight wineries and distributors presented their wines for a private tasting, and the event was supported by several donations of wine and hospitality packages. A big thank-you goes out to all of our supporters!


Looking to Organize a Journal Club? Look no further! The Foundation has established a small grants program where you can apply for up to $5,000 to assist with holding a Journal Club in your area. This will allow you to form a community education and outreach program that enables members to organize free-standing Lipid Journal Clubs in your local community. The funds requested for your program can be used to offset common expenses related to local programs and administration.

Foundation Grant ProgramThe Foundation’s grant program provides education, research and community outreach grants to applicants who meet the criteria. In 2009–2010, we have already helped to support these local CME/CE programs and research project. To apply for a grant, please go to lipidfoundation.org and click on “grants” to set up an account and submit an application.

Support the FNLAReplenishing the funds for the FNLA grant program is essential to future viability and health of our organization. You can help by donating to the FNLA. Take a moment now to invest in the future of the FNLA. Your donation will help support professional outreach and education and promote public awareness of critical issues in public health.

Three easy ways to donate to the FNLA:

• Log onto www.lipidfoundation.org and click on “Donate”

• Call 904-309-6260 and ask for Cindy Moore

• Mail your donation to: Foundation of the NLA 6816 Southpoint Parkway, Suite 1000 Jacksonville, FL 32216

The goals of the Foundation grants submission system are to:

• Support local Journal Clubs through a small grants process ($5,000 or less) for worthy educational activities

• Promote discussion on new or more effective treatments for dyslipidemia and related disorders and improve patient management strategies

• To provide education that fosters the improvement of public health in the local community To learn more about the grant process visit www.lipidfoundation.org/grants/home.

Contact UsTo learn more about the Foundation, please contact the Associate Director, Shannon Sheridan, at 904-309-6260 or [email protected].

Grant Name Grant Applicant

16th Annual Clinical Management of Heart Disease:Cardiology Update 2009

Cardiovascular Institute of Philadelphia

2nd Annual CVD Update: Strategies for Successful Care of the Cardiovascular Patient

UMC Native American Cardiology Program

CVD Protection Through Clinical Lipidology: A Primer with Contemporary Issues

Orange County Membership of the Pacific Lipid Association

Future Cardiovascular Risk Assessment and Treatment: Now! NPN Health Improvement Foundation

Research GrantThe College of Health and Human Development at The Pennsylvania State University

Grants Awarded by the Foundation of the NLA from 2009–2010

30 LipidSpin

Lipid Insights Virtual Journal ClubLipid Insights from AHA 2009: Implications for Clinical PracticeSponsored by the NLAModerator: Michael H. Davidson, MD

Implications of the ARBITER-6 HALTS trialSponsored by the NLAHosted by the SWLAModerator: Kitty Wyne, MD, PhD

Examination of the ACCORD TrialSponsored by the NLAHosted by the PLAModerator: Matthew Ito, PharmD

2010 Meetings & CoursesJune 11–13American College of Cardiology The West Coast Cardiovascular ForumSan Francisco, CA www.acc.org

June 19–22Endocrine SocietyENDO 2010: 92nd Annual MeetingSan Diego, CAwww.endo-society.org

June 25–29American Diabetes Association70th Scientific SessionsOrlando, FLwww.diabetes.org

August 27–29NLA Summer Clinical UpdateHosted by the NELA and SELAMayflower HotelWashington, D.C.www.lipid.org

November 13–17American Heart AssociationScientific Sessions 2010Chicago, IL scientificsessions.americanheart.org

NLA Professional Development CoursesAugust 26–27

Lipid Management Training Course• Comprehensive Cardiometabolic Risk • Reduction Course – Phase IIMasters in Lipidology™ Course•

Mayflower HotelWashington, D.C.www.lipid.org/education

2011 NLA MeetingsMarch 11–13, 2011Clinical Lipid Update – SpringHosted by SWLA and PLA Hyatt Lost PinesLost Pines, TX

May 19–22, 2011 NLA Annual Scientific Sessions Hosted by NELA Sheraton Hotel and Towers New York, NY

August 26–28, 2011 Clinical Lipid Update – Summer Hosted by MWLA and SELA Bonnet Creek Orlando, FL

2011 NLA Professional Development CoursesMarch 10–11, 2011

Lipid Management Training Course• Masters in Lipidology™ Course•

Hyatt Lost PinesLost Pines, TX

May 18–19, 2011Lipid Management Training Course• Masters in Lipidology™ Course•

Sheraton Hotel and TowersNew York, NY

August 25–26, 2011Lipid Management Training Course• Masters in Lipidology™ Course•

Bonnet CreekOrlando, FL

Come to Washington, D.C. for the Summer Clinical Lipid Update.

Online ActivitiesAvailable at www.lipid.org/education

Meetings and Courses Calendar


Articles continued

of Cardiology and developed a Web-based self-assessment and learning program for cardiology fellows that went live in December 2009. The program consists of approximately 50 questions and answers taken from Volume 1 of the NLA SAP. The Web site provides individual pre-test and post-test scores to the trainees, individual and aggregate training program scores to their program directors, and national benchmarking by comparing participating programs. This program is thus not only designed to enhance knowledge in the area of clinical lipidology among cardiology fellows and meet COCATS requirements for preventive cardiology, but also helps individual training programs to enhance their trainees’ learning portfolios and meet ACGME requirements for outcomes assessment and ongoing program improvement through such outcomes assessment. At last check, 126 fellows from 16 cardiology training programs had been registered on the site. The need for such a program is evident at my site: among the UAB fellows who have taken the module so far, pre-test scores were 53+/-10, post-test scores 93+/-6. Our goal is to expand this program to include endocrinology fellowships, internal medicine residency training programs and family practice training programs in the future. I would love to hear feedback from fellows and program directors who have chosen to participate at this inaugural stage. How can we enhance the

experience for the fellows? Are the reports useful to you? Would you like to see more than aggregate scores (e.g., averages by content area)? With input from our ACCL-certified members, I am hoping that similar programs can be made available in the future to nursing, nurse practitioner, dietitian, exercise physiology and pharmacy students to enhance their respective curricula.

Continuing education for physicians and multidisciplinary members of the clinical lipidology care team has always been a major focus of the NLA. The association was last accredited by ACCME in 2006 for four years and is currently undergoing its re-accreditation survey. I am sure the education committee chairs, Drs. Peter Jones and John Guyton, and Nicola Sirdevan will summarize the results of the required self-assessment in a future column. Mimi Holman from AKH Inc. has joined NLA in a consulting role to provide expertise and logistics for CE accreditation. This year, as in past years, live and Web-based programs have been well attended and feedback has been very positive. The curricula for our core courses (Lipid Management Training Course, Cardiometabolic Risk Reduction Course, and the Masters in Lipidology Course) have been updated. Dr. Robert Wild, co-editor of the Lipid Spin, is in the process of assembling a working group to develop a course designed to provide practicing clinicians with the

basic tools in biostatistics, cardiovascular disease epidemiology, clinical trial design and interpretation, and design and interpretation of outcomes research and comparative effectiveness research studies to successfully negotiate the medical literature in the era of evidence-based medicine. If you would like to contribute to this working group, please contact Dr. Wild at 405-271-1075 or [email protected]. While NLA has been successful in providing traditional CME and CE, we clearly need to move forward to remain relevant to our membership.

Ideally, any future offerings should be competency based, have measurable outcomes, become part of lifelong learning portfolios, and be acceptable to the ABIM and other certifying bodies for maintenance of certification.

It was my privilege to serve as your president for the past year. Despite the economic and regulatory challenges of the past 12 months, our organization remains on a solid foundation. Our members are our key assets and, thanks to their talent, innovation and dedication, this organization is ready to adapt to the challenges of the future. My thanks go to Chris Seymour and his dynamic team for all their hard work during the last year and my thanks go to you, the membership, for your support and active participation in our association. n

NLA President (continued from Page 1)

32

consider it in context with other risk factors. JUPITER demonstrates that inflammation as reflected by an elevated hs-CRP level may be an important marker of atherogenesis, but by itself is not predictive of cardiovascular events. JUPITER has not proven that lowering hs-CRP is beneficial by itself, because the population tested was biased by entry criteria, and even though hs-CRP was lowered 37%, LDL-C was also lowered by 50%, to significantly lower levels than ever attained previously in other statin trials. Event rates in the trial were higher than expected based on the Framingham risk, which further suggests that the presence of inflammation, as suggested by hs-CRP, indicates that atherogenesis is occurring. Subsequent data published from JUPITER shows that to achieve significant benefit from statin, LDL had to be reduced to <70 mg/dL but, once LDL was lowered, increasing benefit was obtained as

hs-CRP was lowered to <2 mg/L and <1 mg/L.4 Remember, increased levels of LDL-C alone are atherogenic and lowering these levels with a statin lowers CV risk proportionately, but at lower LDL-C levels, the presence of inflammation (reflected by hs-CRP) suggests that atherogenesis is occurring and that further lowering LDL-C and hs-CRP with statin therapy may offer additional benefit. In reality, LDL-C and hs-CRP probably have a continuum of interaction over certain ranges for each factor, and hs-CRP may be an important signal that more aggressive LDL-C lowering may be beneficial. An alternative explanation consistent with the above may be that the elevated hs-CRP is a reflection of metabolic risk factors known to be associated with small, dense LDL resulting in an apoB level in a much higher risk category than the LDL-C or non-HDL-C levels would suggest.

How should this information be applied for patient care today? In conclusion, if

you currently use the Framingham risk score (FRS) to guide therapy, changing to the Reynolds Risk Score (www.reynoldsriskscore.org) may be more appropriate, because it incorporates all the FRS factors plus hs-CRP and family history. Our current knowledge base supports checking hs-CRP in men over 49 and women over 59 who have LDL<130 mg/dL and one additional risk factor, the so-called moderate risk patient group who have a 5-20% 10-year CHD risk. The data continues to support aggressive LDL-C lowering with a statin in addition to diet, exercise and weight loss. Lastly, these data support following our current treatment guidelines.

As one presenter recently said, “Better implementation of existing knowledge will save more lives than all of the novel biomarkers in the world.”5 n


Guest Editorial (continued from Page 6)

determine whether blood EPA+DHA levels were associated with changes in leukocyte telomere length over five years in a prospective cohort of outpatients with coronary artery disease.1

A total of 608 outpatients with stable coronary artery disease were recruited in the San Francisco Bay Area. Blood samples were collected at baseline and again five years later. Omega-3 levels were measured at baseline, whereas leukocyte telomere length was measured at both exams. Patients in the lowest quartile of blood DHA+EPA experienced the fastest rate of telomere shortening, whereas those in the highest quartile experienced the

slowest rate (p<0.001 for linear trend across quartiles; Figure 1). Each standard deviation increase in DHA+EPA levels was associated with a 29% reduction in the odds of telomere shortening (adjusted OR 0.71; 95% CI 0.52, 0.96). The association was linear and persisted after adjustment for potential confounders. The whole blood EPA+DHA quartile values of 2.3%, 3.3%, 4.3%, and 7.3% would be equivalent to 3.1%, 4.2%, 5.3%, 8.7%, respectively, for the more familiar RBC-based metric, the omega-3 index.2 Generally speaking, an intake of 1-2 g of EPA+DHA/day will produce an omega-3 index of 8% or greater.

These findings raise the possibility that omega-3 fatty acids may protect against

cellular aging in patients with coronary heart disease. One possible explanation for the findings may have been a reduction in systemic oxidative stress, a powerful driver of telomere shortening and organismal aging, although adjusting for inflammatory markers did not alter the relations between omega-3 and telomere shortening. A second potential mechanism could be increased activity of the enzyme telomerase, which lengthens telomeres. To definitively address the question of whether omega-3 fatty acids inhibit cellular aging, a double-blind, randomized, placebo-controlled trial would be necessary. n


Lipid Luminations (continued from Page 12)


normal, a reasonable approach is to re-check lipids at three months, six months, and then twice yearly thereafter. The ALT should be checked six months after the initial “on-medication” blood test, and then once a year thereafter.

If the patient has not reached the desired outcome level, the medication dose is generally further titrated or a second drug is added. Lipid and ALT testing should be done approximately every six weeks following each medication adjustment until the patient’s lipid goal is achieved. Once at goal, the same follow-up plan should be taken as noted above.

As simple as these recommendations sound, there are often patient impediments to long-term adherence, and some of these are the same factors that resulted in failure to titrate to the LDL-C goal:

1. Patients may take medication during the first prescription period, have follow-up blood testing and, upon receiving their results, stop the statin because they

believe their improved values mean, “the medication has done its job.”

2. They may feel that their diet and exercise program is no longer important because they are on medication. When follow-up testing shows deterioration in lipid parameters, they may become discouraged and stop their medication.

3. They may stop their lipid medication over time because they do not like the idea of taking medication, or the need for repeated venipunctures for a condition “that does not hurt.”

4. Medication cost concerns may play an important role. Most studies have shown that about 50% of patients begun on a statin stop taking it within one year. In many cases this is discovered when the clinician sees the patient for an unrelated acute illness and notes that the patient is no longer taking the prescribed lipid-altering medication.

A few simple steps can help minimize the likelihood that these common problems will become an “epidemic” in your practice:

1. When first prescribing the medication, tell the patient you are prescribing a heart attack and stroke reduction medication that also happens to lower cholesterol levels.

2. Remind the patient that the medication works only so long as it is taken regularly.

3. Ask the patient about his or her diet and exercise program every time he or she returns for follow-up and remind the patient that the lipids will be more favorably altered in those who do better on their dietary and exercise programs.

4. Establish an understanding with the patient from the start that he or she will require regular follow-up to assure the medication is working and safety issues are being addressed.

5. Ask the patient to feel comfortable informing you if he or she decides to stop taking medication. This request may provide you with an opportunity to get them “back on track.” n

Practical Pearls (continued from Page 7)

Other options to consider include intermittent dosing options with the most potent statins, rosuvastatin and atorvastin, which also have a long half life. Rosuvastatin in doses of 2.5-20 mg has been tolerated when dosed once weekly, twice weekly or every other day. Rosuvastatin once weekly dosing was found to lower LDL-C by 25% and was tolerated by up to 70% of patients who previously were intolerant of statins.4 Intermittent dosing using atorvastatin twice weekly with ezetimibe also showed promising results with most patients tolerating the combination and 77% of patients reaching their LDL-C goals.5 Ezetimibe may also be

used alone as an option for patients who fail various statin regimens. Colesevelam and other bile acid sequestrants also offer an option for refractory patients.

Patients often explore herbal and non-prescription remedies with and without physician guidance, so it is important to discuss the use of such agents. Coenzyme Q10 levels are known to be reduced on statin therapy, thus, the theoretical benefit of using coenzyme Q10 for patients who experience muscle symptoms.6 It is important to communicate with patients because many different formulations and dosing options are available, often with doses much different from the recommended 100-200 mg daily. Trials

with this agent have not shown a clear benefit, however anecdotally many physicians and patients strongly believe in this option.7

Red yeast rice, with components of lovastatin, plant sterols and isoflavones has recently been compared to pravastatin in patients with previous statin intolerance.7 While this may be another favorable option, large doses are needed to see LDL-C-lowering effects. Physicians should be aware, however, that many patients self-treat with red yeast rice while taking statins and, thus, increasing their risks for adverse effects. Vitamin D deficiency and supplementation is gaining attention in cardiovascular literature, however, clinical

Medication Minute (continued from Page 18)

34 LipidSpin

trials have yet to study this proposed treatment for statin intolerance.

NiacinRecent niacin trials, such as ARBITER 6-HALTS, and an increased focus on HDL-C and triglycerides have caused many prescribers to return to the use of niacin.8 Unfortunately, this drug comes with the infamous side effect of flushing for more than half of patients taking the medication and a discontinuation rate of close to 20%.9 Flushing symptoms start within 10-20 minutes and last for 60-90 minutes.10 This side effect often improves over time. Unfortunately, many patients will quit taking the medication first. The development of extended-release niacin formulations has improved this side effect, but this formulation causes more liver toxicity.11

This flushing is mediated by prostaglandins, thus making aspirin (ASA) useful in the

treatment of flushing. Low dose ASA (81mg) may not be effective and a higher dose of 325 mg is needed.10,11 The package insert for Niaspan® recommends administration of extended-release niacin at bedtime with ASA 325 mg taken 30 minutes prior with a slow 12-week titration to the optimal dose of 2000 mg.12 One recent study examining the effectiveness of ASA to reduce flushing included a one-week run with daily ASA 325 mg as well as a step-wise titration starting at 500 mg going up to 2000 mg by Weeks 3 and 4. Beginning ASA one week prior to initiation of niacin and titrating to optimal doses were both successful in decreasing the incidence and severity of flushing.12 Additional tips for success with niacin therapy include taking the medication with food to help with gastrointestinal side effects; avoiding alcohol, spicy foods or hot beverages; and uninterrupted therapy to aid in developing tolerance. There may also be success with pre-treatment

administration of NSAIDs.10,11 Success with the use of laropiprant in combination with niacin has been promising but is not yet FDA approved.

Fish OilOmega-3 fatty acids are indicated for the treatment of elevated triglycerides in patients with documented coronary heart disease. These medications, like previously discussed medications, have decreased adherence because of their side effects. At doses recommended by the American Heart Association (AHA) of between 1-4 grams of EPA+DHA, more than half of patients experience dyspepsia and taste perversion.14 The non-prescription formulations may cause the worst side effects and patients should try different formulations to find an agent that may cause less adverse effects. This medication should be slowly titrated over several weeks and is much better tolerated with food.14 Freezing or keeping the capsules cold may also decrease this side effect, however, enteric coated capsules should not be frozen. The prescription formulation Lovaza® has been shown to have less incidence of this side effect and may improve adherence.15

SummaryFor Susan, and many of our patients, it is important to have an open dialogue about medication adherence and side effects to enhance patient compliance to a given regimen. An approach of patient-focused care utilizing these tips to prevent discontinuation of lipid medications will ultimately improve patient outcomes. n


Statins

Avoid or decrease risk factors and drug interactions

Discontinue statin x 2 months and rechallenge with lower dose or alternate statin

Consider fluvastatin, rosuvastatin or pravastatin

Intermittent dosing (every other day, once or twice weekly) with rosuvastin or atorvastatin

Ezetimibe with/without low dose statin or intermittent dosing

Coenzyme Q10 at doses of 100-200 mg daily

Niacin

ASA 325 mg 30 minutes prior to dose (avoid 81 mg ASA)

Consider starting ASA 1 week prior to initiating niacin

Slow titration of dose taking 4-12 weeks to maximum dose of 2000 mg

Take with food but avoid alcohol, spicy foods and hot beverages

Build tolerance through continuous dosing and optimal adherence

Omega-3 Fatty Acids

Take with food

Slowly titrate dose over weeks to months

Freeze or refrigerate capsules

Consider prescription formulation

Table 1

Options to prevent and reduce lipid medication intolerances


smoking cessation component to almost any kind of practice.

“Ideally, a program should be streamlined and practical for use in a busy practice. We start by using pamphlets and posters that encourage patients to ask us about quitting. My intake staff will ask, ‘are you a smoker,’ and if they are they get additional information and I can address cessation in the context of our visit. We raise awareness,” Saunders says. “We don’t have to carve out an entire smoking cessation clinic (although we can refer to a tobacco treatment specialist).”

He notes that the AHA, AAFP, ADA, and CDC, just to name a few, all have programs for cessation.

“It didn’t take me much time to find great materials online, such as the AAFP (www.aafp.org), which has a powerful, hard-hitting pamphlet on what smoking does to children and spouses in the home,” Dr. Saunders says. “It’s available in our waiting room.”

Of course, patients who manage to quit smoking see improvement in their lipid profiles, with a 10 to 20% rise in HDL not uncommon.

The region of Ohio where Dr. Saunders practices (Akron and Canton) is predominantly populated by working-class and middle-class residents who mostly work in physical labor environments. His patient base tends to be people who are smokers and overweight, and at-risk for metabolic syndrome’s more serious complications.

“I’ve learned from the NLA that it’s a mistake for us to tell patients, ‘you need to eat better and get more exercise,’” Dr. Saunders says. “Rather, I give patients very specific diet advice, and I go over NCEP exercise guidelines, showing how they can add movement and exercise in specific ways.”

Going forward, Dr. Saunders hopes to eventually focus exclusively on high-risk people at his Metabolic Syndrome Center. He always looks to strengthen his

relationships with local endocrinologists, he says.

“We are often asked about diabetes management,” Dr. Saunders says. “So, this would be a natural development. We want to be a central clearinghouse for heart disease reduction, treatment of diabetes and pre-diabetes.”

Trends in demographics suggest that Dr. Saunders’ practice is well positioned for the future, because one in three adults already meets the criteria for metabolic syndrome. We wish Dr. Saunders well in his thriving practice. n

Member Spotlight (continued from Page 10)

Smoking Costs More Than Your HealthAverage Cost of Smoking in OhioPrice Per Pack 4 weeks 12 weeks 1 year 5 years$5.63 $157.64 $472.92 $2,054.95 $10,280.38

The average price per pack of cigarettes continues to increase. Stop smoking and see how much you can save.

Dr. Saunders distributes materials, such as this sample smoking costs certificate, to patients at his Ohio practice.

Source: Centers for Disease Control and Prevention. State-specific prevalence and trends in adult cigarette smoking — United States, 1998-2007.

Patient Resources

Along with Dr. Saunders’ handouts, including a self-referral form to a tobacco treatment specialist, there are several Web sites that patients can use for information regarding smoking cessation. In the future, he plans to develop a full-fledged Metabolic Syndrome Center Web site for patient education, but he currently directs patients to the public service Web sites shown below. Doctors looking for physician-driven resources may find www.familydoctor.org especially helpful.

smokefree.govmytimetoquit.comaskandact.orgfamilydoctor.orgsurgeongeneral.gov/tobacco/cdc.gov/tobacco/quit_smoking/cancer.org/docroot/PED/ped_10_3.aspahrq.gov/consumer/tobacco/

36 LipidSpin

B. Alan Bottenberg, DOMichael B. Bottorff, PharmDJ. Chris (Jack) Bradberry, PharmDDean A. Bramlet, MDLynne T. Braun, PhDH. Bryan Brewer Jr., MDEliot A. Brinton, MDAlan S. Brown, MDB. Greg Brown, MDW. Virgil Brown, MDRandy W. Burden, PhC, PharmDAnthony J. Busti, PharmDDavid M. Capuzzi, MDMichael Clearfield, DOMichael E. Cobble, MD Lynn Cofer-Chase, RNJerome D. Cohen, MDGregory Scott Cohn, MDCindy Conroy, RDStephen R. Crespin, MDWilliam C. Cromwell, MDJohn Robert Crouse III, MDKenneth Cusi, MDMark J. Cziraky, PharmDTara Lynn Dall, MDMichael H. Davidson, MDThomas D. Dayspring, MDMark Deeg, MDRolando L. deGoma, MDCarlos A. Dujovne, MDRobert H. Eckel, MDWendy H. Everhart, PharmDFred H. Faas, MDJames M. Falko, MDSergio Fazio, MDMary Felando, MSKeith C. Ferdinand, MDEdward Fisher, MDBarbara J. Fletcher, RNGerald F. Fletcher, MDJeffrey S. Freeman, DOKaren Elizabeth Friday, MDDrew A. Garcia, PA-C

Gerald T. Gau, MDEdward A. Gill, MDAnne Carol Goldberg, MDIra Goldberg, MDRonald B. Goldberg, MDEdward Mark Goldenberg, MDAntonio M. Gotto Jr., MDConnie Grantham, RNRobert Greenfield, MDScott M. Grundy, MDJohn R. Guyton, MDCharles R. Harper, MDWilliam S. Harris, PhDLinda C. Hemphill, MDBob Melbert C. Hillert, MDDavid Harold Hoisington, MDW. James Howard, MDMatthew Katsutoshi Ito, PharmDElizabeth J. Jackson, CNS, MSNTerry A. Jacobson, MDKathy B. Jones, ACNPPeter H. Jones, MDDean George Karalis, MDWahida Karmally, RDKenneth A. Kellick, PharmDAvedis K. Khachadurian, MDJack Joseph Kleid, MDRobert H. Knopp, MDJohn B. Kostis, MDSandra J. Kreul, ARNPPenny Kris-Etherton, PhDRalph La Forge, MScBetsy H. La Forge, MPHKellyAnn Light-McGroary, MDJanet Long, MSNMaria F. Lopes-Virella, MDJ. Antonio G. Lopez, MDTimothy J. Lyons, MDKevin P. Maguire, DOBeth Malasky, MDCarol M. Mason, ARNPJanet L. Maxson, PhDTheodore Mazzone, MDMary P. McGowan, MDDarren K. McGuire, MD

James M. McKenney, PharmDRichard Martin Moe, MDJohn M. Morgan, MDVijay Nambi, MDDavid T. Nash, MDJohn Ronald Nelson, MDCarl E. Orringer, MDThomas A. Pearson, MDJorge Plutzky, MDBryan C. Pogue, MDGregory S. Pokrywka, MDDonna Polk, MDDaniel J. Rader, MDConnie K. Reifenberger, CNPJennifer Robinson, MDAdela Esther Robinson, RNPaul D. Rosenblit, MDJoyce Ross, NPEli M. Roth, MDMelvyn Rubenfire, MDCarl J. Rubenstein, MDFrank M. Sacks, MDJoseph J. Saseen, PharmDAngelo M. Scanu, MDErnst J. Schaefer, MDJudith E. Schipper, MSRoss J. Simpson Jr., MDDonald A. Smith, MDTerry Thomas, RNPeter Paul Toth, MDCoraLynn B. Trewet, PharmDWayne S. True, MDThomas N. Tulenko, PhDJames A. Underberg, MDKarol E. Watson, MDPerry J. Weinstock, MDBarbara S. Wiggins, PharmDRobert Allen Wild, MDCraig Williams, PharmDPeter W. Wilson, MDKevin Scott Winfield, MDDaniel E. Wise, MDKathleen L. Wyne, MDPaul E. Ziajka, MD

2009 Fellows (continued from Page 27)


Clinical Feature (Pages 3–4)

1. Randomized Trials of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994; 344:1383- 1389. Abstract.

2. The MRC/BHF Heart Collins R, Peto R, Arbitrage J. Protection Study: preliminary results. Int J Clin Pract. 2002;56:53-56.Abstract.

3. LaRosa JC, He J, Vupputuri S. Effects of Statins on risk of coronary disease: meta-analysis of randomized controlled trials. JAMA.1999;282:2340-2346.

4. Bruckert E, Hayem G, Dejager S, Yau C, Begaud B. Mild to moderate muscular symptoms with high-dosage statin therapy in hyperlipidemic patients – The PRIMO Study. Cardiovasc Drugs Ther.2005;19:379-81.

5. Ballantyne CM, Corsini A, Davidison MH, Holdaas H, Jacobson TA, Leitersdorf E, Marz W, Reckless JPD, Stein EA. Risk of Myopathy with Statin Therapy in High-Risk Patients. Arch Intern Med. 2003;163:553-564.

6. Stein EA, Ballantyne CM, Windler E, Sirnes PA, Sussekov A, Yigit Z, Seper C, Gimpelewicz CR. Efficacy and tolerability of Fluvastatin XL 80 mg Alone, Ezetimibe Alone, and the Combination of Fluvastatin XL 80 mg with Ezetimibe in Patients with a History of Muscle- Related Side effects with other Statins. Am J Cardiol. 2008;101:490-496.

7. Novartis Drug Insert. Lescol XL.

8. Holdaas H, Hagen E, Asberg A, Lund K, Hartman A, Vaidyanathan S, Prasad P, He YL, Yeh CM, Bigler H, Rouilly M, Denouel J. Evaluation of the pharmacokinetic interaction between fluvastatin XL and cyclosporine in renal transplant recipients. Inter. J of Clinical Pharmacology and Therapeutics 2006;44:163-71.

9. Winslow R. Cholesterol Drug Cuts Heart Risk in Healthy Patients. WSJ.com. http://online.wsj.com/article/ SB122623863454811545.html: accessed 2/11/2010.

Guest Editorial (Pages 6, 32)

1. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm199891.htm.

2. Ridker, P et.al: Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein. N Engl J Med 2008;359:2195-207.

3. Transcript of Endocrinologic and Metabolic Drugs Advisory Committee, December 15, 2009 http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/EndocrinologicandMetabolicDrugsAdvisoryCommittee/UCM200611.pdf.

4. Ridker, P et.al: Reduction in C-reactive protein and LDL cholesterol and cardiovascular event rates after initiation of rosuvastatin: a prospective study of the JUPITER trial. Lancet 2009; 373: 1175–82.

5. Talk title by Donald M. Lloyd-Jones on March 5, 2010 at 50th Cardiovascular Disease Epidemiology and Prevention Annual Conference, San Francisco, CA.

Lipid Luminations (Pages 12, 32)

1. Farzaneh-Far1 R, Lin J, Epel ES, Harris WS, Blackburn EH, Whooley MA. Association of marine omega-3 fatty acid levels with telomeric aging in patients with coronary heart disease. JAMA. 2010;303(3):250-257.

2. Harris WS. The Omega-3 Index: From biomarker to risk marker to risk factor. Curr Athero Rept 2009;11:411-417.

Case Study (Pages 14–17)

1. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, Chaitman BR, Shaw L, Gosselin G, Nawaz S, Title LM, Gau G, Blaustein AS, Booth DC, Bates ER, Spertus JA, Berman DS Mancini GBJ, Weintraub WS for the COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503-1516.

2. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to Pravastatin versus usual care. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT). JAMA 2002;288:2998-3007.

3. Sever PS, Dahlöf B, Poulter NR, Wedel H, Beevers G, Caulfield M, Collins R, Kjeldsen SE, Kristinsson A, McInnes GT, Mehlsen J, Nieminen M, O’Brien E, Ostergren J; ASCOT investigators. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial – Lipid Lowering Arm (ASCOT-LLA): a multicentre randomized, controlled trial. Lancet 2003;361(9364):1149-1158.

4. DeBusk RF, Miller NH, Superko R, Dennis CA, Thomas RJ, Lew HT, Berger WE III, Heller RS, Rompf J, Gee D, Kraemer HC, Bandura A, Ghandour G, Clark M, Shah RV, Fisher L, Taylor CB. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med 1994;120:721-729.

5. BARI 2D Study Group, Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, MacGregor JM, Orchard TJ, Chaitman BR, Genuth SM, Goldberg SH, Hlatky MA, Jones TL, Molitch ME, Nesto RW, Sako EY, Sobel BE. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009;360(24):2503-15.

Medication Minute (Pages 18, 33-34)1. Shroufi A, Powles JW. Adherence and chemoprevention

in major cardiovascular disease: a simulation study of

the benefits of additional use of statins. J Epidemiol community Health 2010;64:109-113.

2. Vandenber BF, Robinson J. Management of the patient with statin intolerance. Curr Atheroscler Rep DOI 10.1007/s11883-009-0077-8.

3. Jacobson TA. Toward “pain-free” statin prescribing:clinical algorithm for diagnosis and management of myalgia. Mayo Clin Proc 2008;83(6):687-700.

4. Ruisinger JF, Backes JM, Gibson CA, Moriarty PM. Once-a-week rosuvastin (2.5 to 20mg) in patients with a previous statin intolerance. Am J Cardiol 2009;103:393-394.

5. Athyros VG, Tziomalos K, Kakafika AI, et al. Effectiveness of ezetimibe alone or in combination with twice a week atorvastatin (10 mg) for statin intolerant high-risk patients. Am J Cardiol 2008;101:483-485.

6. Marcoff L, Thompson PD. The role of coenzyme Q10 in statin-associated myopathy: a systematic review. J Am Coll Cardiol 2007;49:2231-2237.

7. Halbert SC, French B, Gordan RY, et al. Tolerability of red year rice (2,400 mg twice daily) versus pravastatin (20mg twice daily) in patients with previous statin intolerance. Am J Cardiol 2010;105:198-204.

8. Taylor AJ, Villines TC, Stanek EJ, et al. Extended-release niacin or ezetimibe and carotid intima-media thickness. N Engl J Med 2009;361:2113-22.

9. Oberwittler H, Baccara-Dinet M. Clinical evidence for the use of acetyl salicyclic acid in control of flushing related to nicotinic acid treatment. Int J Clin Pract 2006;60(6):707-715.

10. Sood A, Arora R. Mechanisms of flushing due to niacin and abolition of these effects. J Clin Hypertens 2009;11:685-689.

11. McKenney J. New perspectives on the use of niacin in the treatment of lipid disorders. Arch Intern Med 2004;164:697-705.

12. Niaspan® prescribing information. http://www.niaspan.com. Accessed 5 March 2010.

13. Thakkar RB, Kashyap ML, Lewin AJ, Krause SL, Jiang P, Padley RJ. Acetylsalicylic acid reduces niacin extended-release-induced flushing in patients with dyslipidemia. Am J Cardiovasc Drugs 2009;9(2):69-79.

14. Park Y, Harris WS. Dose-response of n-3 polyunsaturated fatty acids on lipid profile and tolerability in mildly hypertriglyceridemic subjects. J Med Food 2009;12(4):803-808.

15. Lovaza® prescribing information. http://www.lovaza.com. Accessed 5 March 2010.

References

6816 Southpoint PkwySuite 1000Jacksonville, Florida 32216

Through the NLA you can access a comprehensive professional development program.

Upon completion, you will be recognized by your peers as a leader in the field.

August 26-27The Mayflower HotelWashington, DC

Lipid Management Training Course

Comprehensive Cardiometabolic Risk Reduction Course

Masters in Lipidology Course™

2010 Professional

DeveloPment Pathway

Lifelong Learning in Lipidology

The NLA offers a robust Professional Development Pathway

for healthcare professionals seeking to advance their

knowledge and competency in managing lipid disorders.

Lipidology is a young, evolving field that demands your

diligent efforts to stay current on the latest research and

treatment guidelines. Learn from thought-leaders, develop

your skills, and open doors to recognition of your distinct

and specialized expertise in the lipidology field.

For more information and to register visit: www.lipid.org/education/pathway

Comprehensive CardiometabolicRisk Reduction Program

CME/CE CERTIFIED SHORT COURSE

lipidspin - national lipid association online · articles online at in this issue: spring 2010...

Documents