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Treatment of Hyperlipidemia in Men With Ischemic Heart Disease

P. Anthopoulos, G. Filippatos, K. Tsilias, O. Polychronopoulou, E. Karambinos, D. Efstathiou, V. Tsekouras, L. Anthopoulos.

1st Department of Cardiology, «The Evangelismos» General Hospital
and the Programme of Postgraduate Studies, Faculty of Nursing, University of Athens,
Athens, Greece.

Abstract
Purpose of this study was to examine the frequency with which Greek cardiologists (Athens area) follow practice guidelines in screening and treating hyperlipidemia in men with ischemic heart disease (IHD).
Methods: Personal interviews were conducted with 341 Cardiologists (40% of the Cardiologists in Athens). The completion rate (number of completed interviews divided by the total number of conducted cardiologists) was more than 70%. Questions were designed by the National Heart, Lung and Blood Institute, Bethesda, USA.
Results: In men with IHD, 85.9% of the cardiologists believe that cholesterol lowering will have large effect on their risk for future coronary events. The 42.2% of cardiologists initially treat these patients with diet only, 6.2% with drugs only and 50.7% with both. The cardiologists who start treatment with diet only shift to drugs after 2.7 months of diet failure. They start drug therapy in patients with LDL cholesterol >142.3+/-27.5 mg/dl. The desirable LDL level is reported to be 118+/-24 mg/dl. Statins are the drug of choice for the majority of the cardiologists. According to 46% of them, the main reason why an estimated large number of patients eligible for cholesterol lowering drugs are not actually receiving appropriate therapy is that they are treated by non cardiologists.
Conclusion: Greek cardiologists are convinced that cholesterol lowering is essential for IHD secondary prevention, while inappropriate therapy is attributed to non specialist treatment. Greater effort should be dedicated to educating non cardiologists, in Greece, regarding lipid lowering benefit in IHD. That applies to a considerable minority of the cardiovascular specialists too.

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Many studies have established1-8 that an elevated blood cholesterol level is a major cause of other vascular and coronary artery disease and that lowering these elevated levels will lead to significant reduction of cardiovascular events, fatal or non-fatal. Based on this knowledge, enormous efforts and large sums of money are being spent around the world in order to educate physicians, especially cardiologists, as well as the public, on the effects of cholesterol and lipids in general2,9. The recommendations include diet instructions and guidelines for pharmacological management. Despite the clear advice that several committees and organisations publish, cardiologists, the ones mainly responsible for treating hypercholesteremia seem to express different opinions and maintain different attitudes on handling patients with dislipidemia.

The purpose of this study was to examine the frequency with which Greek cardiologists from the greater Athens area follow practice guidelines in screening and treating hyperlipidemia in male subjects with ischemic heart disease. This study was organised on the same pattern that an American study was carried out by the NIH and was undertaken by the first Department of Cardiology in «The Evangelismos» General Hospital with the Programme of Postgraduate Studies of the Faculty of Nursing of the University of Athens.

Permission was asked and was kindly granted by the National Heart, Lung and Blood Institute, Bethesda USA to use the same questionnaire that was used in their survey10. After effecting slight modifications in order to better fit the Greek mentality and reality , the questionnaire was ready for use. It consisted of 40 main questions with two-to-three subquestions for each main one. The questionnaire was completed after a personal interview of 25 to 35 minutes duration. The interviews were conducted by specially trained post-graduate students from the above Postgraduate Programme. The training of the students was based on extensive discussion of the questionnaire as well as rehearsal interviews that were performed under the supervision and guidance of the main investigators. The investigators would meet every 15 days (more often at the beginning) in order to solve problems or answer questions that might have risen after the interviews were completed. Initially 850 letters to all the members of the Hellenic Cardiological Society, residing in the greater Athens area were sent informing them about the study and explaining its purposes. Then, a telephone contact was made and an appointment of the investigator (student) with the cardiologist was arranged.

After this first contact and within a time period of 4-months 341 cardiologists (40% of those to whom the letter had been sent to) responded and answered the questionnaire.

Almost 86% (85,9%) of the cardiologists believe that cholesterol lowering in men with IHD, will significantly affect the risk for future coronary events. One hundred and forty four (42,2%) of the cardiologists initially handle these patients with diet advice only, 6,2% prescribe drugs only and 50,7% will advise both. The cardiologists who advised treatment with diet only, would turn to drugs after 2,7 months of diet failure. Cardiologists in Athens would advise drug therapy in patients with LDL cholesterol > 142,3 ± 27,5 mg/dl. The desirable LDL level is reported to be 118 ± 24 mg/dl. Statins are the drug of choice for the majority of the cardiologists. Almost half (46%) of the cardiologists believe that the main reason why an estimated large number of patients eligible for treatment with cholesterol lowering drugs are not actually receiving appropriate therapy is the fact that they are treated by non cardiologists.

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Discussion
Despite the existing data showing the strong and direct link between cholesterol levels and atheromatous diseases
11-14 some physicians follow a different approach to the problem of hypercholesterolemia in their practice, often falling short of the recommendation of the committees and panels15 who usually are the experts on the subject. The 86% of the cardiologist who answered, believe in lowering the cholesterol levels in ischemic heart disease patients. Although this maybe considered as satisfactory, it should be contrasted with the fact that almost 15% of the cardiologist do not believe in the beneficial effect of lowering the cholesterol levels in ischemic patients.

The mean value of LDL cholesterol at which Athenian cardiologists would start drug therapy is 142,3± 27,5 mg/dl and the mean value of LDL levels that is characterised as desirable is 118± 24 mg/dl. Both these values are impressively higher than what is being recommended in the current literature13,15,16. There are several possible explanations for the lack of more aggressive treatment of hyperlipidemias. There is a good number of physicians who doubt the role of cholesterol levels lowering on life expectancy17. Other physicians point out the need for lifelong pharmacological therapy and raise questions about how cost-effective this might be18.

Another reason that physicians may project as a factor for not treating patients more aggressively is that many times, they are not responsible for the long-term care of these patients. Of course aggressive treatment doesn’t necessarily mean drug therapy alone; it also includes quiding and constantly advising, but even then, cardiologists devote little time in counselling patients to change their life-style.

Unfortunately physicians are not trained to meticulously advise patients on diet which is of great importance in treating hypercholesterolemia. An estimated large number of patients who are not receiving the appropriate therapy are treated by non-cardiologists. Cardiologists deal with the ravages of coronary artery disease daily and have been bombarded with the cholesterol doctrine longer than others. For these reasons they should be in the forefront of the medical community on the hyperlipidemia problem, always with the collaboration and the assistance of the generalists, the family physician, the dietician, and the nursing personnel. If this attitude is adapted even the asymptomatic patients with hyperlipidemia will receive the appropriate care.

Greater efforts should be dedicated to educate a considerable minority of cardiovascular specialists as well as non cardiologists regarding lipid lowering benefit in ischemic heart disease patients.

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References
[1] Faggiotto A, Ross R, Harker L: Studies of hypercholesterolemia in the nonhuman primate: I. Changes that lead to fatty streak formation. Arteriosclerosis 1984; 4:323-340.
[2] Doyle JT, Heslin AS, Hilleboe HE, Formel PF: Early diagnosis of ischemic heart disease. N Engl J Med 1959; 261:1096-1101.
[3] Taylor HL, Blackburn H, Keys A, Parlin RW, Vasquez C, Puchner T: Coronary heart disease in seven countries: IV. Five-year follow-up of employees of selected U.S. railroad companies. Circulation 1970; 41(suppl I): I-20-I-39.
[4] Kannel WB, Castelli WP, Gordon T, McNamara PM: Serum cholesterol, lipoproteins and the risk of coronary heart disease: The Framingham Study. Ann Intern Med 1971; 74:1-12.
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[9] Keys A, Aravanis C, Blackburn H et al: Probability of middle-aged men developing coronary heart disease in five years. Circulation 1972; 45:815-828.
[10] Schucker B, Wittes TJ, Santanello CN et al: Change in cholesterol awareness and action: Results from National, Physician and Public Surveys. Arch Intern Med 1991; 151:666-673.
[11] Fortmann SP, Sallis JF, Magnus PM, Farquar JW: Attitudes and practices of physicians regarding hypertension and smoking: The Stanford Five City Project. Prev Med 1985; 14:70-80.
[12] Amsterdam EA, Walker N, Ridgeway M, Tanji J, Baker L, Vera Z: Physician recognition of coronary risk factors: A disparity between approach to hypertension and hypercholesterolemia in patients hospitalized on a medicine service (abstract). J Am Coll Cardiol 1987; 9:79A.
[13] Superko HR, Desmond DA, de Santos VV, Vranizan KM, Farquhar JW: Blood cholesterol treatment attitudes of community physicians: A major problem. Am Heart J 1988; 116:849-855.
[14] Wynder EL, Field F, Haley NJ: Population screening for cholesterol determination: A pilot study. JAMA 1986; 256:2839-2842.
[15] The Expert Panel: Report of the National Cholesterol Education Program Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults. Arch Intern Med 1988; 148:36-69.
[16] Lenfant C: A new challenge for America: The National Cholesterol Education Program. Circulation 1986; 73:855-856.
[17] Taylor WC, Pass TM, Shepard DS, Komaroff AL: Cholesterol reduction and life expectancy: A model incorporating multiple risk factors. Ann Intern Med 1987; 106:605-614.
[18] Oster G, Epstein AM: Cost-effectiveness of antihyperlipemic therapy in the prevention of coronary heart disease: The case of cholestyramine. JAMA 1987; 258:2381-2387.

 

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Update
02/Nov/1999