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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oupjournals.org

Defining the prevalence of low HDL-C in a European cohort of dyslipidaemic patients

Eric Bruckert1,*, Raymond Pamphile2, Fran McCoy3 and Philippe André4

1Service d'Endocrinologie Métabolique, Groupe Hospitalier Pitié-Salpêtrière, 47, Boulevard de l'Hôpital, 75651 Paris Cedex 13, France
2Merck KGaA, Darmstadt, Germany
3IMS Health, London, UK
4Inserm U258, Villejuif, France

* Corresponding author. Tel: +331 42 17 78 49; fax: +331 42 17 78 65. E-mail address: eric.bruckert{at}psl.ap-hop-paris.fr


   Abstract
Top
 Abstract
Introduction
 Design of the survey
 Results
 Discussion
 Conclusions
 References
 
Low HDL-cholesterol is increasingly recognized as an independent risk factor for adverse cardiovascular outcomes, irrespective of levels of LDL-cholesterol. Although sporadic reports suggest that the prevalence of low HDL-cholesterol is substantial, we lack detailed data on the true prevalence of this condition among patients receiving treatment for dyslipidaemia. The Pan-European survey on HDL-cholesterol has collected data on levels of HDL-cholesterol, together with other lipid parameters and cardiovascular risk factors, from more than 9000 dyslipidaemic patients by 1350 specialist physicians in 11 European countries. A preliminary analysis of a subset of the participants in the survey suggests a population at markedly elevated cardiovascular risk. The detailed information from this survey, currently under analysis, will define the magnitude of the contribution of low HDL-cholesterol to dyslipidaemia in Europe and will focus on the need to include strategies for correcting low HDL-cholesterol within multiple risk factor intervention programmes.

Key Words: HDL-cholesterol • Prevalence • Atherosclerosis • Cardiovascular risk • Dyslipidaemia


   Introduction
Top
 Abstract
 Introduction
Design of the survey
 Results
 Discussion
 Conclusions
 References
 
Epidemiological surveys and analyses of baseline characteristics of trial populations suggest a high prevalence of low HDL-cholesterol. For example, estimates of the proportions of men with HDL-cholesterol below cut-off points [usually 0.9 mmol/L (35 mg/dL) or 1.0 mmol/L (40 mg/dL)] range from 7 to 9% in France,1,2 15% in Mexico,3 ~15% in Germany,4 15–23% in Holland (depending on age),5 17% in the UK,6 18% in the Rio de Janeiro area of Brazil,7 24% in India, 30% in Canada,8 32% in Iran,9 7–38% in USA,10–14 and an astounding 75% in Thailand.15 Within these overall figures lie variations in the prevalence of low HDL-cholesterol due to ethnicity,16,17 a sharply increased prevalence in patients who have coronary artery disease,4,6,8,18 and different study designs.

These data are sufficient to strongly suggest that low HDL-cholesterol is a clinically significant problem in many areas. However, experience from the large cohort followed up in the PROspective CArdiovascular Münster (PROCAM) Study in Germany illustrates the importance of accurately defining regional differences in risk factor profiles, as these can impact strongly on the design of interventions and, ultimately, the prognosis of patients.19

No data on the epidemiology of low HDL-cholesterol are available from large-scale surveys in Europe and standardized, well-designed observational studies of sufficient size and geographical coverage are needed before we can estimate with confidence the magnitude of the therapeutic challenge posed by low HDL-cholesterol in Europe.

Accordingly, a major survey of levels of HDL-cholesterol in patients receiving treatment for dyslipidaemia has been carried out in a number of European countries. Detailed information on the management of cardiovascular risk, in general, in these patients was also sought in the survey. The survey results are under analysis, and this report focuses on the rationale and design of this study.


   Design of the survey
Top
 Abstract
 Introduction
 Design of the survey
Results
 Discussion
 Conclusions
 References
 
Objectives
The primary objective of this survey was to determine the proportion of individuals with low HDL-cholesterol in a European population of dyslipidaemic patients. Low HDL-cholesterol was defined as a level of <1.0 mmol/L (<40 mg/dL) in men and <1.2 mmol/L (<50 mg/dL) in women. The characterization of co-existing risk factors by multivariate analysis was a secondary objective.

Inclusion criteria
Subjects were ambulatory males or females aged at least 18. Eligible subjects had also received at least 3 months prior treatment for hypercholesterolaemia and/or hypertriglyceridaemia by diet and exercise in combination with one or more lipid-lowering drugs, or had serum cholesterol ≥200 mg/dL (≥5.3 mmol/L) and/or serum triglycerides ≥180 mg/dL (≥2.0 mmol/L) despite at least 3 months treatment with diet and exercise, or had a secondary dyslipidaemia due to diabetes mellitus or associated with metabolic syndrome. Patients with primary dyslipidaemia, dyslipidaemia (hypercholesterolaemia and/or hypertriglyceridaemia) secondary to other causes than diabetes mellitus, or the metabolic syndrome (e.g. arising from the use of oral contraceptives, corticosteroids, or HIV–protease inhibitors) were not eligible.

Data acquisition
Power calculations, based on published estimates of the prevalence of low HDL-cholesterol, required the recruitment of 7000 subjects to provide a prevalence estimate with a two-sided 95% CI of 2%. Anticipating a lack of HDL-cholesterol values in 30% of the subjects, it was calculated that 9100 subjects should be enrolled.

Subjects were recruited by specialist physicians, who were mainly cardiologists or endocrinologists, and all were experienced in the management of dyslipidaemia. Each specialist contributed data from at least four subjects to the survey (each subject was the first, matching the enrolment criteria seen by the specialist on a given day). Data were gathered using a questionnaire (Table 1). Questionnaires could be returned via courier or the internet. Physicians were provided with information within the questionnaire on how to accurately measure the waist circumference (defined as the smallest horizontal circumference at waist level). No information that could identify a subject, directly or indirectly, was requested in the questionnaire, in line with European data protection requirements.


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  		Table 1 Overview of data gathered by questionnaires
 
Several quality assurance measures were put in place. Participating physicians received several follow-up calls to explain the process and the questionnaire, and to address any questions. In addition, the questionnaire materials contained a checklist to ensure proper completion. It was a requirement of the survey that all biochemical/clinical chemistry data should have been obtained from the same blood sample or from blood samples taken on the same date and at the same time.


   Results
Top
 Abstract
 Introduction
 Design of the survey
 Results
Discussion
 Conclusions
 References
 
At the end of the survey, data on 9317 patients had been acquired from 1350 physicians in 11 European countries (Figure 1). The detailed data will be published separately in 2005. However, a provisional analysis of approximately two-thirds of the study population suggests an elderly population (mean age >60 years), with a majority of males (about two-thirds). This was in general a high-risk population, judging from the spectrum of demographic parameters and cardiovascular risk factors. About one-sixth of this sample of the overall population were current smokers, about one-quarter had a history of myocardial infarction, about half were diabetic, and about two-thirds were sedentary (more than two sessions of physical exercise/week).



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  		Figure 1 Number of subjects by country.

 
More than 80% were receiving treatment with lifestyle intervention and lipid-modifying drugs. Importantly, almost half of this provisional population met the National Cholesterol Education Panel/Adult Treatment Panel III definition of the metabolic syndrome.20


   Discussion
Top
 Abstract
 Introduction
 Design of the survey
 Results
 Discussion
Conclusions
 References
 
We require more information on the true prevalence of low HDL-cholesterol in patients requiring treatment for dyslipidaemia and to know whether therapies to correct low HDL-cholesterol are applied in an optimal way. HypoHDLaemia is indeed frequently unrecognized in hyperlipidaemic patients, despite the well-established role of HDL-cholesterol as an independent risk factor for cardiovascular disease. A recent study conducted in France indicates the magnitude of the problem: HDL-cholesterol was not measured in up to one-third of the hyperlipidaemic patients on statin treatment.21

Therefore, we are eager to have the final analyses of this Pan-European Survey on low HDL-cholesterol, still ongoing, which has gathered data from a substantial population who were, on average, at elevated risk of a cardiovascular event.

These data will be compared with landmark epidemiological analyses, including the Framingham22 study in the USA and the PROspective CArdiovascular Münster (PROCAM) study in Europe,23 which have confirmed the importance of low HDL-cholesterol in driving the progression of atherogenesis and coronary disease.

Consistent with these aforementioned published observations, intervention with regimens including a HDL-cholesterol raiser, nicotinic acid24–26 being the most potent one available, has been associated with clinically and statistically significant improvements in clinical outcomes. Accordingly, interventions to correct low HDL-cholesterol, in addition to reducing LDL-cholesterol, will become increasingly important in the management of dyslipidaemia in the future.27

It is our opinion that the data from this large-scale European survey will not only help in the design of treatment strategies for the management of dyslipidaemia today, but will also contribute importantly to tomorrow's management algorithms for the control of cardiovascular risk. For example, current guidelines for the management of dyslipidaemia identify low HDL-cholesterol as a marker of risk and are yet to recognize this condition as a risk factor in its own right. Expert groups, including the European Consensus Panel on HDL-cholesterol among others, have called for greater emphasis on the management of low HDL-cholesterol in management guidelines for dyslipidaemia.28,29 Accurately defining the incidence of low HDL-cholesterol will help to focus attention on this important risk factor and will support the recognition of the importance of correcting low HDL-cholesterol in optimizing prognosis in patients at elevated risk of a cardiovascular event.


   Conclusions
Top
 Abstract
 Introduction
 Design of the survey
 Results
 Discussion
 Conclusions
References
 
The Pan-European Survey on HDL-cholesterol has gathered data on the prevalence of low HDL-cholesterol and on other aspects of cardiovascular care, from a population of more than 9000 dyslipidaemic patients in 11 European countries. These data, currently undergoing detailed analysis, will help to define the scale of the problem of low HDL-cholesterol in routine cardiovascular care and will contribute to the design of optimized management strategies for reducing cardiovascular risk in the future.


   References
Top
 Abstract
 Introduction
 Design of the survey
 Results
 Discussion
 Conclusions
 References
 

  1. Balkau B, Vernay M, Mhamdi L et al.; D.E.S.I.R. Study Group. The incidence and persistence of the NCEP (National Cholesterol Education Program) metabolic syndrome. The French D.E.S.I.R. study. Diabetes Metab 2003;29:526–532.[Web of Science][Medline]
  2. Marques-Vidal P, Mazoyer E, Bongard V et al. Prevalence of insulin resistance syndrome in southwestern France and its relationship with inflammatory and hemostatic markers. Diabetes Care 2002;25:1371–1377.[Abstract/Free Full Text]
  3. Aguilar-Salinas CA, Olaiz G, Valles V et al. High prevalence of low HDL cholesterol concentrations and mixed hyperlipidemia in a Mexican nationwide survey. J Lipid Res 2001;42:1298–1307.[Abstract/Free Full Text]
  4. Assmann G, Schulte H, von Eckardstein A et al. High-density lipoprotein cholesterol as a predictor of coronary heart disease risk. The PROCAM experience and pathophysiological implications for reverse cholesterol transport. Atherosclerosis 1996;124(Suppl.):S11–S20.
  5. Verschuren WM, Boerma GJ, Kromhout D. Total and HDL-cholesterol in The Netherlands: 1987–1992. Levels and changes over time in relation to age, gender and educational level. Int J Epidemiol 1994;23:948–956.[Abstract/Free Full Text]
  6. Primatesta P. Relationship of CVD to risk factors and socio-demographic factors. Health Survey for England. Chapter 4, 1998. http://www.archive.official-documents.co.uk/document/doh/survey98/hse98.htm (1 February 2005).
  7. de Souza LJ, Souto Filho JT, de Souza TF et al. Prevalence of dyslipidemia and risk factors in Campos dos Goytacazes, in the Brazilian state of Rio de Janeiro. Arq Bras Cardiol 2003;81:249–264.[Medline]
  8. Lamarche B, Despres JP, Moorjani S et al. Triglycerides and HDL-cholesterol as risk factors for ischemic heart disease. Results from the Quebec cardiovascular study. Atherosclerosis 1996;119:235–245.[CrossRef][Web of Science][Medline]
  9. Azizi F, Rahmani M, Emami H et al. Cardiovascular risk factors in an Iranian urban population: Tehran lipid and glucose study (phase 1). Soz Praventivmed 2002;47:408–426.[Web of Science][Medline]
  10. Schaefer EJ, Lamon-Fava S, Ordovas JM et al. Factors associated with low and elevated plasma high density lipoprotein cholesterol and apolipoprotein A-I levels in the Framingham Offspring Study. J Lipid Res 1994;35:871–882.[Abstract]
  11. Rubins HB, Robins SJ, Collins D et al. Distribution of lipids in 8,500 men with coronary artery disease. Department of Veterans Affairs HDL Intervention Trial Study Group. Am J Cardiol 1995;75:1196–1201.[CrossRef][Web of Science][Medline]
  12. Asztalos BF, Cupples LA, Demissie S et al. High-density lipoprotein subpopulation profile and coronary heart disease prevalence in male participants of the Framingham Offspring Study. Arterioscler Thromb Vasc Biol 2004;24:2181–2187.[Abstract/Free Full Text]
  13. Bates HM. Prevalence of hyperlipidemia in a large sample population. J Cardiovasc Pharmacol 1982;4(Suppl. 2):S196–S200.
  14. Meigs JB, Wilson PW, Nathan DM et al. Prevalence and characteristics of the metabolic syndrome in the San Antonio Heart and Framingham Offspring Studies. Diabetes 2003;52:2160–2167.[Abstract/Free Full Text]
  15. Bhuripanyo K, Tatsanavivat P, Matrakool B et al. A prevalence survey of lipids abnormalities of rural area in Amphoe Phon, Khon Kaen. J Med Assoc Thai 1993;76:101–108.[Medline]
  16. France MW, Kwok S, McElduff P et al. Ethnic trends in lipid tests in general practice. Q J Med 2003;96:919–923.
  17. Gidding SS, Liu K, Bild DE et al. Prevalence and identification of abnormal lipoprotein levels in a biracial population aged 23 to 35 years (the CARDIA Study). The Coronary Artery Risk Development in Young Adults Study. Am J Cardiol 1996;78:304–308.[CrossRef][Web of Science][Medline]
  18. Genest J Jr, McNamara JR, Ordovas JM et al. Lipoprotein cholesterol, apolipoprotein A-I and B and lipoprotein (a) abnormalities in men with premature coronary artery disease. J Am Coll Cardiol 1992;19:792–802.[Abstract]
  19. Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular Munster (PROCAM) study. Circulation 2002;105:310–315.[Abstract/Free Full Text]
  20. ATP III Guidelines At-A-Glance Quick Desk Reference. Step 8. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Publication No. 01-3305, May 2001.
  21. Chevalier C, Giral P, Chinaud F et al. Application of medical guidelines for the prescription of statins. Rev Epidemiol Santé Publique 2002;50:463–473.[Web of Science][Medline]
  22. Gordon DJ, Probstfield JL, Garrison RJ et al. High-density lipoprotein cholesterol and cardiovascular disease. Four prospective American studies. Circulation 1989;79:8–15.[Abstract/Free Full Text]
  23. Assmann G, Schulte H. Relation of high-density lipoprotein cholesterol and triglycerides to incidence of atherosclerotic coronary artery disease (the PROCAM experience). Prospective Cardiovascular Munster study. Am J Cardiol 1992;70:733–737.[CrossRef][Web of Science][Medline]
  24. Coronary Drug Project Research Group. Clofibrate and niacin in coronary heart disease. JAMA 1975;231:360–381.[Abstract/Free Full Text]
  25. Canner PL, Berge KG, Wenger NK et al. Fifteen-year mortality in coronary drug project patients: long-term benefit with niacin. J Am Coll Cardiol 1986;8:1245–1255.[Abstract]
  26. Brown BG, Zhao XQ, Chait A et al. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. N Engl J Med 2001;345:1583–1592.[Abstract/Free Full Text]
  27. Bruckert E. New lipid-modifying therapies. Expert Opin Investig Drugs 2003;12:325–335.[CrossRef][Web of Science][Medline]
  28. Chapman MJ, Assmann G, Fruchart JC et al. Raising high-density lipoprotein cholesterol with reduction of cardiovascular risk: the role of nicotinic acid—a position paper developed by the European Consensus Panel on HDL-C. Curr Med Res Opin 2004;20:1253–1268.[CrossRef][Web of Science][Medline]
  29. Gotto AM, Brinton EA. Assessing low levels of high-density lipoprotein cholesterol as a risk factor in coronary heart disease. J Am Coll Cardiol 2004;43:717–724.[Abstract/Free Full Text]

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Epidemiology of low HDL-cholesterol: results of studies and surveys
Eur. Heart J. Suppl., October 1, 2006; 8(suppl_F): F17 - F22.
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