Repeated Serum Lipid Measurements During the Peri-Hospitalization Period

doi:10.1016/j.amjcard.2006.06.030

The American Journal of Cardiology

Volume 98, Issue 10, 15 November 2006, Pages 1379-1382

https://doi.org/10.1016/j.amjcard.2006.06.030 Get rights and content

The early treatment of hyperlipidemia in hospitalized patients confers potential benefit, yet total cholesterol is known to vary with acute illness, often delaying treatment decisions. A prospective study was conducted of 61 patients (mean age 57 years; 49% women) admitted to an acute care community hospital with various diagnoses with random nonfasting lipid profile measurements at admission, followed by second fasting lipid profile measurements on day 3 of hospitalization or upon discharge (whichever occurred first), and final fasting lipid profile measurements 4 weeks after discharge. All individual values of the lipid profile decreases at discharge, whereas the ratios of total cholesterol to high-density lipoprotein (HDL) and of low-density lipoprotein (LDL) to HDL did not change significantly. The 95% confidence interval around the total cholesterol/HDL ratio for each patient was within the same National Cholesterol Education Program Adult Treatment Panel III treatment recommendation category 42.6% of the time, whereas corresponding intervals for total cholesterol and LDL were within a single treatment category only 6.6% of the time. The total cholesterol/HDL ratio was significantly more consistent with regard to treatment implications than LDL or total cholesterol (p <0.0001). In conclusion, serum lipid values vary significantly during and after a hospital stay, whereas the ratio of total cholesterol to HDL remains relatively stable. This ratio may therefore serve as a more reliable basis for early treatment decisions in dyslipidemia.

Section snippets

Methods and Results

A prospective cohort study was conducted at an acute care community hospital in Derby, Connecticut. The study was approved by the institutional review board at Griffin Hospital, and all participants signed an approved consent form. All patients admitted to Griffin Hospital were assessed for eligibility. Patients were eligible if they (1) were aged 30 to 85 years, (2) remained inpatients for ≥24 hours, (3) were able to consent to participate in the study, and (4) agreed to have blood drawn for

Discussion

Several previous studies have investigated the effect of the acute stress of hospitalization: medical procedures such as coronary arteriography, angioplasty, or coronary bypass surgery, and general surgery on lipid profiles.9, 10, 11 At least 1 previous study¹² demonstrated that total cholesterol also decreases in minor illnesses, such as upper respiratory tract infections. Although many previously published studies support the idea that total cholesterol and LDL decrease <24 to 48 hours after

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Pharmacological rationale for the very early treatment of acute coronary syndrome with monoclonal antibodies anti-PCSK9
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Immediate and aggressive lipid lowering therapies after acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI) are supported by the ESC/EAS dyslipidemia guidelines, recommending the initiation of high-intensity statin therapy within the first 1–4 days of hospitalization. However, whether non statin lipid-lowering agents, added to statin treatment, could produce a further reduction in the risk of major adverse cardiovascular events (MACE) is still unknown. Thus, the efficacy of early treatment post-ACS with monoclonal antibodies (mAbs) anti PCSK9, evolocumab and alirocumab, is under investigation. The rationale to explore the rapid and aggressive pharmacological intervention with PCSK9 mAbs is supported by at least five confirmatory data in ACS: 1) circulating PCSK9 levels are raised during ACS 2) PCSK9 may stimulate platelet reactivity, this last being pivotal in the recurrence of ischemic events; 3) PCSK9 is associated with intraplaque inflammation, macrophage activation and endothelial dysfunction; 4) PCSK9 concentrations are associated with inflammation in the acute phase of ACS; and 5) statins raise PCSK9 levels promptly and, at times, dramatically. In this scenario, appropriate pharmacodynamic characteristics of anti PCSK9 therapies are a prerequisite for an effective response. Monoclonal antibodies act on circulating PCSK9 with a direct and rapid binding by blocking the interaction with the low-density lipoprotein receptor (LDLR). Evolocumab and alirocumab show a very rapid (within 4 h) and effective suppression of circulating unbound PCSK9 (− 95 % ÷ − 97 %). This inhibition results in a significant reduction of LDL-cholesterol (LDL-C) after 48 h (− 35 %) post injection with a full effect after 7–10 days (55–75 %). The complete and swift inhibitory action by evolocumab and alirocumab could have a potential clinical impact in ACS patients, also considering their potential inhibition of PCSK9 within the atherosclerotic plaque. Thus, administration of evolocumab or alirocumab is effective in lowering LDL-C levels in ACS, although the efficacy to prevent further cardiovascular (CV) events is still undetermined. The answer to this question will be provided by the ongoing clinical trials with evolocumab and alirocumab in ACS. In the present review we will discuss the pharmacological and biological rationale supporting the potential use of PCSK9 mAbs in ACS patients and the emerging evidence of evolocumab and alirocumab treatment in this clinical setting.
Cardiometabolic determinants of mortality in a geriatric population: Is there a "reverse metabolic syndrome"?
2009, Diabetes and Metabolism
Diabetes or insulin resistance, overweight, arterial hypertension, and dyslipidaemia are recognized risk factors for cardiovascular (CV) disease. However, their predictive value and hierarchy in elderly subjects remain uncertain.
We investigated the impact of cardiometabolic risk factors on mortality in a prospective cohort study of 331 elderly high-risk subjects (mean age ± SD: 85 ± 7 years).
Two-year total mortality was predicted by age, diabetes, low BMI, low diastolic blood pressure (DBP), low total and HDL cholesterol, and previous CV events. The effect of diabetes was explained by previous CV events. In non-diabetic subjects, mortality was predicted by high insulin sensitivity, determined by HOMA-IR and QUICKI indices. In multivariate analyses, the strongest mortality predictors were low BMI, low HDL cholesterol and previous myocardial infarction. Albumin, a marker of malnutrition, was associated with blood pressure, total and HDL cholesterol, and HOMA-IR. The inflammation marker CRP was associated with low total and HDL cholesterol, and high HOMA-IR.
In very old patients, low BMI, low DBP, low total and HDL cholesterol, and high insulin sensitivity predict total mortality, indicating a “reverse metabolic syndrome” that is probably attributable to malnutrition and/or chronic disorders. These inverse associations limit the relevance of conventional risk factors. Previous CV events and HDL cholesterol remain strong predictors of mortality. Future studies should determine if and when the prevention and treatment of malnutrition in the elderly should be incorporated into conventional CV prevention.
Le diabète, la résistance à l’insuline, le surpoids, l’hypertension artérielle et la dyslipidémie sont des facteurs de risque cardiovasculaires (CV) reconnus chez l’adulte jeune. Leur valeur prédictive et leur hiérarchie restent incertaines chez la personne âgée.
Nous avons étudié l’impact de facteurs de risque cardiométaboliques dans une cohorte de patients âgés à haut risque CV (âge moyen [± SD]: 85 ± 7 ans).
La mortalité globale à deux ans est prédite par l’âge, le diabète, un IMC, une pression artérielle (PA) diastolique, un cholestérol total, un cholestérol-HDL abaissés et les antécédents CV. Chez les personnes non diabétiques, la mortalité est aussi prédite par la sensibilité à l’insuline. En analyse multivariée, les meilleurs facteurs prédictifs sont un indice de masse corporelle (IMC) bas, un cholestérol-HDL bas et les antécédents d’infarctus du myocarde. L’albumine circulante, reflétant une dénutrition, est associée à la PA, au cholestérol total et au cholestérol-HDL et à l’index HOMA-IR. La CRP, marqueur d’inflammation, est associée à un cholestérol total et un cholestérol-HDL abaissés et au HOMA-IR.
Chez les patients très âgés, un IMC, une PA diastolique, un cholestérol total et un cholestérol-HDL abaissés et une sensibilité à l’insuline élevée prédisent la mortalité globale, ce qui suggère l’existence d’un « syndrome métabolique à rebours » expliqué par la dénutrition et les comorbidités. Ces associations paradoxales limitent l’utilisation des facteurs de risque conventionnels dans cette population. Les antécédents CV et le cholestérol-HDL demeurent des facteurs prédictifs importants de la mortalité. L’intégration de la prise en charge de la dénutrition dans la prévention CV reste à étudier chez la personne âgée.
Lipid Levels After Acute Coronary Syndromes
2008, Journal of the American College of Cardiology
Citation Excerpt :
This suggests that the small dip in LDL-C was associated with the day after admission (Day 2 of hospitalization), rather than with the time after onset of ACS symptoms. This observation is similar to the slight decrease in LDL-C levels from admission to Day 3 found in patients hospitalized for a variety of complaints, including infectious, respiratory, and gastrointestinal diseases (13). Therefore, the decrease in LDL-C concentration on Day 2 of hospitalization may reflect causes related to hospitalization, such as altered oral intake or intravenous hydration.
This analysis from the LUNAR (Limiting UNdertreatment of lipids in ACS with Rosuvastatin) study assessed lipid changes 1 to 4 days after onset of acute coronary syndromes (ACS), before initiation of study treatment.
Early studies indicated that cholesterol levels decrease significantly after ACS. However, most studies were small or did not measure low-density lipoprotein cholesterol (LDL-C) directly, and many used nonfasting or retrospective data. More recent studies suggest less pronounced changes in cholesterol levels after ACS.
The LUNAR trial is a prospective, multicenter, randomized, open-label study in adults hospitalized for acute ST-segment elevation myocardial infarction (STEMI), non-STEMI, or unstable angina (UA). Blood samples were taken at median times after onset of ACS symptoms of 26 h (Day 1, fasting or nonfasting sample), 43 h (Day 2, fasting sample), and 84 h (Day 4, fasting sample) for direct measurement of serum lipid levels before study treatments were started.
Of 507 patients available for analysis, 212 were admitted for STEMI, 176 for non-STEMI, and 119 for UA. The LDL-C levels decreased in the 24 h after admission (from 136.2 to 133.5 mg/dl), followed by an increase over the subsequent 2 days (to 141.8 mg/dl). These changes did not seem to be clinically meaningful. Similar changes were observed for total cholesterol and smaller changes for high-density lipoprotein cholesterol; fasting triglyceride levels did not change.
Mean lipid levels vary relatively little in the 4 days after an ACS and can be used to guide selection of lipid-lowering medication. (LUNAR Phase IIIb Study Comparing Rosuvastatin and Atorvastatin in Subjects With Acute Coronary Syndromes; NCT00214630)
Lipid Levels in the Post-Acute Coronary Syndrome Setting. Destabilizing Another Myth?<sup>*</sup>*Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
2008, Journal of the American College of Cardiology
Cardiovascular prevention and cardiac rehabilitation
2008, Revista Espanola de Cardiologia
Differences between repeated lipid profile measurements in a tertiary hospital over a short time period
2024, Lipids in Health and Disease

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The American Journal of Cardiology

Section snippets

Methods and Results

Discussion

References (16)

Usefulness of the total cholesterol to high-density lipoprotein cholesterol ratio in predicting angiographic coronary artery disease in women

Am J Cardiol

Efficacy of lipid profiles in prediction of coronary disease

Am Heart J

Effect of hospitalization on high-density lipoprotein cholesterol in patients undergoing elective coronary angiography

Am J Cardiol

Measurement of plasma lipids in patients admitted with acute myocardial infarction or unstable angina pectoris

Am J Cardiol

Effect of acute myocardial infarction on cholesterol ratios

Chest

Serum lipids four weeks after acute myocardial infarction are a valid basis for lipid lowering intervention in patients receiving thrombolysis

Br Heart J

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

National Cholesterol Education Program

Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II)

Cited by (12)

Pharmacological rationale for the very early treatment of acute coronary syndrome with monoclonal antibodies anti-PCSK9

Cardiometabolic determinants of mortality in a geriatric population: Is there a "reverse metabolic syndrome"?

Lipid Levels After Acute Coronary Syndromes

Lipid Levels in the Post-Acute Coronary Syndrome Setting. Destabilizing Another Myth?<sup></sup>Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.

Cardiovascular prevention and cardiac rehabilitation

Differences between repeated lipid profile measurements in a tertiary hospital over a short time period

Preventive cardiologyRepeated Serum Lipid Measurements During the Peri-Hospitalization Period

Section snippets

Methods and Results

Discussion

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Chest

Serum lipids four weeks after acute myocardial infarction are a valid basis for lipid lowering intervention in patients receiving thrombolysis

Br Heart J

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

National Cholesterol Education Program

Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II)

Preventive cardiology
Repeated Serum Lipid Measurements During the Peri-Hospitalization Period