Case Studies in Dyslipidemia: Implementing Evidence … Studies in Dyslipidemia: Implementing Evidence-based Strategies to Manage Patients Joseph Saseen, Pharm.D., BCPS, FCCP Associate

Case Studies in Dyslipidemia: Implementing Evidence-based Strategies to Manage Patients


Program Agenda 6:15 a.m. – 6:45 a.m. Registration and Breakfast Buffet 6:45 a.m. – 6:50 a.m. Introductory Remarks Joseph Saseen, Pharm.D., BCPS, FCCP, Program Moderator 6:50 a.m. – 7:00 a.m. NCEP Goals for Managing Dyslipidemia Joseph Saseen, Pharm.D., BCPS, FCCP Mark J. Cziraky, Pharm.D., FAHA 7:00 a.m. – 7:40 a.m. Case Studies in Dyslipidemia: Evidence-based Strategies Joseph Saseen, Pharm.D., BCPS, FCCP Mark J. Cziraky, Pharm.D., FAHA

7:40 a.m. – 7:45 a.m. Question and Answer Discussion

Program Faculty Joseph Saseen, Pharm.D., BCPS, FCCP, Program Moderator Associate Professor Departments of Clinical Pharmacy and Family Medicine University of Colorado Health Sciences Center Denver, Colorado Mark J. Cziraky, Pharm.D., FAHA Executive Vice President HealthCore, Inc. Wilmington, Delaware


Program Description Dyslipidemia is a major risk factor for coronary heart disease (CHD), and its management is important in preventing the occurrence of cardiovascular events. Because many patients are unable to achieve their target lipid goals when treated with statin monotherapy, pharmacists need to be aware of the importance of combination therapy in controlling dyslipidemia. This program will briefly review therapeutic goals based on National Cholesterol Education Panel (NCEP) guidelines. Evidence supporting the rationale, efficacy, and safety data of combination therapy in patients with dyslipidemia will also be presented. Case studies will be used to demonstrate therapeutic strategies, goals, and challenges in managing patients with dyslipidemia. Special patient populations and challenges in identifying appropriate therapeutic goals will be discussed. Learning Objectives At the conclusion of this presentation, participants should be able to:

• Discuss therapeutic goals for managing dyslipidemia based on current NCEP guidelines.

• Identify the role and importance of LDL cholesterol, non-LDL parameters, and other factors in assessing cardiovascular risk.

• Given a summary of three specific patients with dyslipidemia, assess cardiovascular risk and lipid values and identify appropriate goals of therapy.

• Compare and contrast appropriate patient-specific treatment plans to treat dyslipidemia based on a cardiovascular risk assessment.

• Identify evidence to support treatment plans for patients with dyslipidemia.

Continuing Education Accreditation

The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program provides 1 hour (0.1 CEU) of continuing education credit (program number 204-000-05-473-L01). Attendees must

complete a Continuing Pharmacy Education Request online and may immediately print their official ASHP CE statements at the ASHP Advantage CE Processing Center at www.ashpadvantage.com.


Joseph Saseen, Pharm.D., BCPS, FCCP Associate Professor Departments of Clinical Pharmacy and Family Medicine University of Colorado Health Sciences Center Denver, Colorado Dr. Joseph Saseen received his Bachelor of Science in Pharmacy and Doctor of Pharmacy

degrees from the State University of New York (SUNY) at Buffalo, and completed an ambulatory

care research fellowship at the University of Illinois/University of Colorado. He is currently

Associate Professor of Clinical Pharmacy and Family Medicine at the University of Colorado at

Denver and Health Sciences Center. Dr. Saseen practices as a clinical pharmacy specialist in

the Department of Family Medicine. He is a board-certified pharmacotherapy specialist with

added qualifications in cardiology, and is a member of the board of regents and fellow of the

American College of Clinical Pharmacy. Dr. Saseen has published several articles and book

chapters related to cardiovascular pharmacotherapy. He has received several teaching awards

at the University of Colorado, where he most recently was the recipient of the President’s

Excellence in Teaching Award in May 2005.


Mark J. Cziraky, Pharm.D., FAHA Executive Vice President HealthCore, Inc. Wilmington, Delaware Dr. Mark Cziraky is Executive Vice President and co-founder of HealthCore Inc., a research organization based in Wilmington, Delaware. Prior to his current position, Dr. Cziraky was Assistant Professor at the Philadelphia College of Pharmacy and Science (PCPS) until 1997. He currently holds an Adjunct Associate Professor appointment at the University of Delaware School of Nursing. He is a graduate of PCPS, receiving both his Bachelor of Science and Doctor of Pharmacy degrees and attaining Summa Cum Laude honors for each degree. After receiving his graduate degree, he completed an ambulatory care residency at Blue Cross and Blue Shield of Delaware (BCBSDE). Dr. Cziraky has been extensively involved in clinical, health economic, and outcomes research for more than a decade with a clinical focus on cardiovascular diseases. While a faculty member at PCPS, Dr. Cziraky initiated a dyslipidemia management program at a large group practice within BCBSDE and eventually transformed it into a multidisciplinary cardiovascular risk-management program. This initiative was recognized by the Delaware Pharmacy Society and earned Dr. Cziraky the Delaware Innovative Pharmacy Practice Award in 1997. Additionally, he was recognized by his peers and American Druggist as one of the 50 Most Influential Pharmacists in 1998. In 1998, the American Heart Association awarded Dr. Cziraky with fellowship on the Council of Arteriosclerosis, Thrombosis and Vascular Biology. Dr. Cziraky was elected a member of the National Heart, Lung and Blood Institute’s (NHLBI) National High Blood Pressure Education Program Coordinating Committee in 2000 representing the American Pharmacists Association and was part of the writing committee for the Joint National Committee (JNC-7) Hypertension Management Guidelines. Additionally, he is currently the chairman of the National Committee on Quality Assurance’s (NCQA) Health Care Practitioner Advisory Committee and a member of the Board of Trustees of both the Institute of Safe Medication Practice and the Wellness Community of Delaware. He was elected to the board of directors of the Northeast Lipid Association, part of the National Lipid Association. Dr. Cziraky is currently a reviewer for numerous medical and pharmacy journals. He is a nationally recognized presenter on both cardiovascular and health economic-related topics and has published original research and book chapters in these same areas.

Case Studies in Dyslipidemia:Implementing Evidence-

based Strategies to Manage Patients

40th ASHP Midyear Clinical MeetingLas Vegas, Nevada

NCEP Goals for Managing Dyslipidemia

Joseph Saseen, Pharm.D., FCCP, BCPSAssociate Professor

Clinical Pharmacy and Family MedicineUniversity of Colorado Health Sciences Center

Mark Cziraky, Pharm.D., FAHAExecutive Vice President

HealthCore, Inc.

Facts, Cardiovascular Disease in the U.S.

• In 2002, accounted for 38.0% of all deaths or 1 of every 2.6 deaths

• CVD mortality was nearly 60% of “total mortality”

• Since 1900 CVD has been the No. 1 killer in every year but 1918 (influenza pandemic)

• Claims as many lives each year as the next 5 leading causes of death combined, including cancer

American Heart Association. Heart Disease and Stroke Statistics — 2005 Update.

NHANES:Serum Lipids and Lipoproteins in Adults

215

49.7

138

114

204

50.7

129118

203

51.3

123 123

0

25

50

75

100

125

150

175

200

225

TotalCholesterol

HDL-Cholesterol

LDL-Cholesterol

Triglycerides

Mea

n Va

lue

(mg/

dL)

1976-1980

1988-1994

1999-2002

JAMA 2005;294:1773-1781.

LDL-C and CV risk

Circulation 2004; 110:227-239.

Circulation 2004; 110:227-239.

# Very high risk favors < 70 mg/dl, and patients with high TGs or non- HDL >100 mg/dl* High risk or moderately high with lifestyle- related risk should be on TLC regardless of LDL+ LDL Tx based on clinical evidence; ↑ TGs or↓ HDL consider combing with nicotinic acid or fibrate** Achieve at least a 30 to 40% LDL reduction++ LDL Tx to achieve LDL < 100 mg/dl is an option based on clinical trials

ATP III: 2004 UpdateRisk

CategoryLDL-C Goal

(mg/dL)Initiate TLC

(mg/dL)Consider Drug Rx

(mg/dL)High RiskCHD or equivalents(10 yr risk > 20%)

< 100(Optional <70)# ≥100*

≥ 100+

(<100: consider drug options)**

Moderately High Risk2+ risk factors(10 yr risk 10 to 20%)

< 130(Optional <

100)≥ 130*

≥ 130(100-129: consider

drug options)++

Moderate Risk2+ risk factors(10 yr risk < 10%)

< 130 ≥ 130 ≥ 160

Lower Risk0 to 1 risk factors < 160 ≥ 160

≥ 190(160-189: drug

optional)

ATP III: 2004 Update Standard Statin Doses to

Attain 30 - 40% LDL- C Reductions

39 -455 -10Rosuvastatin25 -3540-80Fluvastatin35 -4120 -40Simvastatin

3440Pravastatin3140Lovastatin3910Atorvastatin

LDL - C reduction (%)Dose (mg/d)Drug

Circulation 2004; 110:227-239

AHA/NHLBI Scientific Statement:Metabolic Syndrome Diagnostic Criteria

Circulation. 2005;112:e285-e290

≥ 100 or drug therapy

Elevated fasting glucose (mg/dL)

≥ 130/85 or drug therapy

Elevated BP (mm Hg)

< 40 (men), < 50 (women) or drug therapy

Reduced HDL - C (mg/dL)

≥ 150 or drug therapy

Elevated TGs (mg/dL)≥ 40 (men), ≥ 35 (women)Elevated waist circumference (in)

Categorical Cut Points

Measure (3 of 5 constitutes diagnosis)

AHA/NHLBI Scientific Statement:Metabolic Syndrome Goal Values

• Primary target: LDL- C goal

• Secondary target: Non- HDL- C goal• Only if LDL - C goal met and if TG ≥ 200 mg/dL• Always 30 mg/dL higher than LDL- C goal

• Tertiary target: HDL--C• Only after LDL- C and non-HDL- C goals are met• Raise HDL- C to extent possible with standard

therapies to ≥ 40 mg/dL (men), ≥ 50 mg/dL (women)

Circulation. 2005;112:e285-e290

Lipid-Lowering Therapies

JAMA 2001;285:2486. Zetia [package insert] Merck- Shering- Plough Pharmaceuticals; 2003. Crestor [package insert] Astra- Zeneca; 2003

↓ 7%↑ 1%↓ 18%Cholesterol AbsorptionInhibitor (ezetimibe)

↓ 20-50%↑ 10-20%↓ 5-20 or ↑Fibric Acid Derivatives(benzafibrate, gemfibrozil, fenofibrate)

↓ 20-50%↑ 15-35%↓ 5-25%Nicotinic Acid(ER or IR niacin)

0 or ↑↑ 3-5%↓ 15-30%Bile Acid Sequestrants(colesevelam, cholestyramine, colestipol)

↓ 7-30%↑ 5-15%↓ 18-63%Statins (atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin)

TGHDL - CLDL - C

Case Studies in Dyslipidemia: Evidence-Based Strategies

Evidence-Based Medicine is…

“A conscientious, explicit, and judicious use of current

best evidence to make decisions about the care of

individual patients.”Sackett DL, et al. BMJ 1996;312:71-72.

CASE #1DA is a 69-year-old man who is recovering from an MI that occurred 6 months ago.

PMH: HypertensionSH: does not smoke, exercises 3 times/week,

follows a DASH eating planMeds: Lisinopril 10 mg daily, atenolol 50 mg daily,

aspirin 81 mg dailyVitals: BP: 126/78 mm Hg

wt = 182#, ht = 72”, waist circ: 36”Labs: Fasting Labs:

TC = 150 mg/dL, HDL- C = 35 mg/dLLDL- C = 95 mg/dL, TGs = 100 mg/dLall other labs, within normal limits

CASE #1: Clinical Considerations• High risk – has known CHD

• LDL- C goal of < 100 mg/dL is attained while on no lipid-lowering therapy

• Further risk reduction is needed with statin therapy

Statin-Based Outcomes Trials

Am J Cardiol. 1998;82:3Q-12Q.Lancet. 2002;360:7-22.

% o

f Pat

ient

s W

ith

CH

D E

vent

s

Mean LDL - C Level at Follow-Up (mg/dL)50

4S-Rx

LIPID-Rx

LIPID-PL

AFCAPS-RxAFCAPS-PL

WOSCOPS-RxWOSCOPS-PL

70 90 110 130 150 170 190 2100

5

10

15

20

25

CARE-Rx

CARE-PL

PL = PlaceboRx = Treatment

4S-PL

HPS-PL

HPS-Rx

Secondary Prevention

Primary Prevention

30

Cholesterol Treatment Trialists’ Collaborators• Meta-analysis,14 randomized controlled trials (n=90,056)

Lancet 2005;366:1267-1278

Major Vascular Events (per 1 mmol/L LDL-C reduction)

0 5 10 15 20 25 30

Post

-MI*

No

CH

D*

Event Rate (% )

ControlStatin

*p<0.001

• Cancer incidence– RR 1.00 (0.95-1.06)

• Rhabdomyolysis– Statin: 9 of 39,884

(0.023%) – Control: 6 of 39,817

(0.015%)P=0.4

Risk ratio and 95% CISimvastatin Placebo(n=10,269) (n=10,267) Simva better Simva worse

Baseline LDL-C(mg/dL)

< 100 285 360≥ 100 to < 130 670 881

≥ 130 1087 1365

0.6 0.8 1.0 1.2

The Heart Protection Study (HPS)

Lancet 2002;360:7-22

VASCULAR EVENTSVASCULAR EVENTS

• Double-blind trial in 20,536 patients at high risk for vascular events (CHD, stroke, diabetes)

• Randomized to placebo or simvastatin 40 mg daily for 5 years

CASE #1: Pharmacotherapy Options

• Statin therapy needed to reduce CV risk

• Dose sufficient to lower LDL - C 30-40%

• Potential additions:– Statin monotherapy (e.g., atorvastatin 10 mg daily,

lovastatin 40 mg daily, rosuvastatin 10 mg daily, simvastatin 20 mg daily)

– Ezetimibe/simvastatin 10/10 mg daily– Extended-release niacin with statin

CASE #2DT is a 49-year-old man who started statin therapy last year.

PMH: Hypertension, dyslipidemiaSH: 1-2 beers/daily, smokes, no exercise,

2400 KCal diet (low fat and cholesterol)Meds: HCTZ 25 mg daily,simvastatin 20 mg dailyVitals: BP: 136/84 mm Hg

wt = 190#, ht = 70”, waist circ: 39”Labs: Fasting Labs:

TC = 187 mg/dL, HDL- C = 40 mg/dLLDL- C = 120 mg/dL, TGs = 125 mg/dLglucose 105 mg/dLhs - CRP = 4.1 mg/Lall other labs, within normal limits

http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=pub

http://hin.nhlbi.nih.gov/atpiii/evalData.asp

CASE #2: Clinical Considerations• Moderately high risk - - Multiple CV risk factors with

a Framingham Risk Score of 15%

• Metabolic syndrome, elevated hs- CRP

• LDL - C goal should be which of the following:< 130 mg/dL

or < 100 mg/dL (therapeutic option)

Moderately High-risk• Therapeutic option: LDL -C goal <100 mg/dL• Utilize drug therapy that lowers LDL C - by 30-40%• Factors that influence using an LDL lowering drug

when LDL- C is <130 mg/dL– Advancing age– More than 2 risk factors or severe risk factors– High TG with elevated non- HDL- C– Low HDL- C– Metabolic syndrome– Presence of “emerging risk factors” (hs - CRP >3 mg/L)

Circulation 2004;110:227-239.

ASCOT-Lipid Lowering Arm

Lancet 2003;361:1149-58.

0

1

2

3

4

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5Years

36% reductionp=0.0005

Atorvastatin 10 mg

Placebo

Non

fata

l MI &

CH

D D

eath

(%

)

ARR = 1.1%NNT = 91

• 10,305 primary prevention patients, multiple CV risk factors randomized to placebo or atorvastatin 10 mg daily for 3.3 yrs

• Mean baseline LDL 133 mg/dL decreased to 90 mg/dL

CASE #2: Pharmacotherapy Options

• Will require 20% additional LDL- C reduction to attain goal of < 100 mg/dL

• Potential regimen modifications:– Change to a higher potency statin regimen– Add ezetimibe– Add a bile acid sequestrant– Add nicotinic acid

STELLAR Trial

-60

-50

-40

-30

-20

-10

0Pravastatin Simvastatin Atorvastatin Rosuvastatin

% L

DL-

C C

hang

e fr

om B

asel

ine

.

10mg20mg40mg80mg

Am J Cardiol 2003;93:152-160.

• 6 - week, parallel groups, open - label study (n=2431)

Ezetimibe added to a Statin

• Double b l i nd controlled trial

• 769 patients not at LDL goal while on statin monotherapy

• Randomized to placebo or ezetimibe 10 mg daily

Am J Cardiol 2002;90:1084-91.* P < 0.001 for differences

3.7

25.118.9

71.5

0

20

40

60

80

Mean % LDLReduction

% at Goal

Placebo Ezetimibe

Am J Cardiol 2004;93:1487-1494.

Ezetimibe/Simvastatin vs Atorvastatin

EZ/Simv 10

/20mg

EZ/Simv 10

/20mg

EZ/Simv 10

/40mg

Atorva40

mg

EZ/Simv 10

/40mg

Atrova

80mg

Atorva10

mg

EZ/Simv 10

/10mg

Atorva20

mg

EZ/Simv 10/8

0

-60

-50

-40

-30

-20

-10

0

49.152.5

37.2

46.1 44.3

59.4

50.3

55.6

50.254.3

LDL-

C R

educ

tion

(%)

* p< 0.05 vs placebo

# p< 0.05 vs individual agents alone Am J Med 2001;110:352-360

Bile Acid Sequestrant added to Statin

-4

-26*

-34*

-42*# -42*#-45

-40

-35

-30

-25

-20

-15

-10

-5

0

Mea

n LD

L -C

Cha

nge

(%)

Placebo (n=33)

Simvastatin 10 mg/d(n=37)

Simvastatin 20 mg/d(n=35)

Colesevelam 2.3 g/d +Simvastatin 20 mg/d(n=37)Colesevelam 3.8 g/d +Simvastatin 10 mg/d(n=34)

Bile Acid Sequestrant Outcomes Data

• LRC - Primary Prevention Trial (n=3086):– Cholestyramine reduced fatal CHD + nonfatal

MI 19% versus placebo over 7.4 yrs (7.0 vs. 8.6%, p<0.05)

• FATS Trial (n=146):– Intensive LDL -C lowering in CHD patients

using colestipol with lovastatin or niacin lowered CV event risk versus conventional therapy (HR= 0.27, 0.10 to 0.77)

LRC-CPP Trial. JAMA 1984;251:351-374.FATS Trial. N Engl J Med 1990; 323:1289-1298.

-8 -8

23

-24

-16

-23

24

-30-30

-20

-10

0

10

20

30TC LDL-C HDL-C TG

Mea

n C

hang

e (%

)

Niacin 1 g/day(n=66)Niacin 2 g/day(n=29)

Am J Cardiol 2001;87:476-479.

Adding ER Niacin to a Statin

HATS Trial• Randomized,

double- b l ind, trial in 160 patients with CHD for 3 years

• Primary end point: – First CV event (CV

death, nonfatal MI, stroke, or revascularization)

23.7

2.6

0

5

10

15

20

25

Placebo Simvastatin+ Niacin

Prim

ary

clin

ical

end

poi

nt (%

)

N Engl J Med 2001;345:1583-92.

ARR = 21.1%NNT = 5

p=0.04

CASE #2:Pharmacotherapy Options

• Potential regimen modifications:– Higher potency statin regimen– Add ezetimibe– Add a bile acid sequestrant– Add nicotinic acid

CASE #3OB is a 62-year-old woman on statin therapy for 2 years.

PMH: Hypertension, dyslipidemia, type 2 DM, chronic stable angina

SH: no ethanol or smoking, 2000 Kcal ADA diet Meds: HCTZ/irbesartan 300/25 mg daily, aspirin 81

mg daily, metoprolol 100 mg BID, atorvastatin10 mg daily, metformin 1000 mg BID

Vitals: BP: 120/74 mm Hg, HR 60 beats/minwt = 165#, ht = 64”, waist circ: 40”

Labs: TC = 175 mg/dL, HDL- C = 35 mg/dLLDL- C = 94 mg/dL, TGs = 230 mg/dLS.creat = 1.0 mg/dL, A1C = 6.5 mg/dLall other labs, within normal limits

CASE #3: Clinical Considerations• Very high risk – CHD, type 2 diabetes, and

metabolic syndrome

• Receiving “standard dose” statin therapy

• LDL - C goal should be which of the following:< 100 mg/dL and now target

Non - HDL <130 mg/dLor

< 70 mg/dL (therapeutic option)

Very High Risk• Factors that favor the therapeutic option

LDL- C goal < 70 mg/dL:– Established atherosclerotic vascular disease

plus one of the following:1. Multiple major risk factors (esp. diabetes)2. Severe and poorly controlled risk factors (esp.

cigarette smoking)3. Multiple risk factors of the metabolic syndrome4. Acute coronary syndrome

Circulation 2004;110:227-239.

Treat to New Targets (TNT) Trial

ARR = 2.2%NNT = 45

N Engl J Med. 2005;352:1425-1435.

HR=0.78 (0.69–0.89)

p<0.001

0

2

4

6

8

10

12

0 1 2 3 4 5 6Time (years)

Firs

t maj

or C

V ev

ent (

%)

10 mg atorvastatin

Mean LDL = 101 mg/dL

80 mg atorvastatin

Mean LDL = 77 mg/dL

• 10,001 patients with CHD and LDL- C <130mg/dL randomized to atorvastatin 10 mg or 80 mg daily for 5 yrs


o non - H D L reduction– Higher potency

statin regimen– Add a nicotinic acid– Add a fibrate

o LDL -C reduction– Higher potency

statin regimen– Add ezetimibe– Add a bile acid

sequestrant– Add nicotinic acid

• Potential regimen modifications:

N Engl J Med 1999;341;410-418.

Veterans Affairs HDL Intervention Trial (VA-HIT)

• 2531 men with CHD randomized to placebo or gemfibrozil 1200 mg/day x 5.1 yrs

• Lipid differences placebo vs. gemfibrozil:– HDL: 32 vs. 34– LDL: 113 vs. 113– TG: 166 vs. 115

Time (years)

CV

Dea

th a

nd N

onfa

tal M

I (%

)

0

5

10

15

20

25

0 1 2 3 4 5 6

Placebo

Gemfibrozil

p=0.006

ARR = 4.4%NNT = 23

• 3,339 case reports of rhabdomyolysis with statinsfrom 1990 - 2 002; 38% were associated with concurrent fibrate therapy

• Statin/Fibrate:– Controlled clinical trials (n=600): 1% incidence of

CK > 3 x ULN, with no cases of rhabdomyolysis– Low to moderate dose statin with fibrate has a low risk

of myopathy– Interaction most problematic with gemfibrozil

• Statin/Niacin:– Lower risk for myopathy than statin/fibrate

JAMA 2003;289:1681-1690.J Am Col Cardiol 2002;40(3):568-579.

Risks of Statin Combination Therapy

Statin/Fibrate Interaction• Facts about gemfibrozil:

– Known to ↑ risk of rhabdomyolysis with statins– Inhibits hepatic glucuronidation of certain statins– Reduced maximum statin dose in combination:

• Lovastatin 20 mg daily• Rosuvastatin 10 mg daily• Simvastatin 10 mg daily

• Fenofibrate does not inhibit glucuronidation

JAMA 2003;289:1681-1690.


o non - HDL reduction– Higher potency

statin regimen– Add a nicotinic acid– Add a fibrate

o LDL - C reduction– Higher potency

statin regimen– Add ezetimibe– Add a bile acid

sequestrant– Add nicotinic acid

• Potential regimen modifications:

1

Questions and Discussion• We welcome your questions.

• Staff will collect all written question cards.

• Please approach the standing microphones in the aisle.

• Please complete the program evaluation and hand to staff as you exit.

• Thank you for your attention.

• Join us again for CE in the Mornings.


R E F E R E N C E S

Carroll MD, Lacher DA, Sorlie PD et al. Trends in serum lipids and lipoproteins of adults, 1960-2002. JAMA. 2005;294(14):1773-81. Grundy SM, Cleeman JI, Merz CN et al. National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-39. Becker RC. Heart Attack and Stroke Prevention in Women. Circulation 2005 112: e273 - e275. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001; 285:2486-97. Grundy SM. Metabolic syndrome scientific statement by the American Heart Association and the National Heart, Lung, and Blood Institute. Arterioscler Thromb Vasc Biol. 2005;11:2243-4. Sackett DL, Haynes RB. The architecture of diagnostic research. BMJ. 2002;324(7336):539-41. Ballantyne CM. Low-density lipoproteins and risk for coronary artery disease. Am J Cardiol. 1998;82(9A):3Q-12Q. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360(9326):7-22. Baigent C, Keech A, Kearney PM et al. Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet. 2005;366(9493):1267-78. Epub 2005 Sep 27. Erratum in: Lancet. 2005;366(9494):1358. Sever PS, Dahlof B, Poulter NR et al. 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 randomised controlled trial. Lancet. 2003;361(9364):1149-58. Jones PH, Davidson MH, Stein EA et al. STELLAR Study Group. Comparison of the efficacy and safety of rosuvastatin versus atorvastatin, simvastatin, and pravastatin across doses (STELLAR Trial). Am J Cardiol. 2003;92(2):152-60. Gagne C, Bays HE, Weiss SR et al. Ezetimibe Study Group. Efficacy and safety of ezetimibe added to ongoing statin therapy for treatment of patients with primary hypercholesterolemia. Am J Cardiol. 2002;90(10):1084-91.


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Faculty Disclosure Statements ASHP Advantage requires that faculty members disclose any relationships (e.g., shareholder, recipient of research grant, consultant or member of an advisory committee) that the faculty may have with commercial companies whose products or services may be mentioned in their presentations. The existence of these relationships is provided for the information of attendees and should not be assumed to have an adverse impact on faculty presentations. The faculty reports the following relationships: Joseph Saseen, Pharm.D., BCPS, FCCP Dr. Saseen reports that he serves on the speakers’ bureau for Sankyo Pharma and AstraZeneca. Mark J. Cziraky, Pharm.D., FAHA Dr. Cziraky reports that he does not have any relationships to disclose.

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Case Studies in Dyslipidemia: Implementing Evidence … Studies in Dyslipidemia: Implementing Evidence-based Strategies to Manage Patients Joseph Saseen, Pharm.D., BCPS, FCCP Associate