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Prevalence and Treatment of Low HDL Cholesterol Among Primary Care Patients With Type 2 Diabetes

An unmet challenge for cardiovascular risk reduction

From the General Medicine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Address correspondence and reprint requests to Richard W. Grant, MD, MPH, 50-9 Staniford St., Boston, MA 02114. E-mail: rgrant{at}partners.org

OBJECTIVE—Patients with diabetes remain at high risk for cardiovascular events despite aggressive blood pressure, LDL cholesterol, and blood glucose control. We identified prevalence and predictors of low HDL cholesterol, characterized current lipid therapy, and estimated the theoretical benefit of more effective HDL cholesterol–raising methods among patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS—We analyzed a primary care–based population of patients with type 2 diabetes (n = 7,692) in 12 eastern Massachusetts outpatient practices. We grouped fibrates, niacins, and n-3 fatty acid preparations as nonstatin HDL cholesterol–raising medicines, and we used published studies to estimate the potential benefit of raising HDL cholesterol levels in this population.

RESULTS—Nearly half (49.5%) of patients had low HDL cholesterol (<40 mg/dl for men, <50 mg/dl for women). Low HDL cholesterol was independently associated with prevalent cardiovascular disease (CVD), younger age, and higher A1C levels. Nearly two-thirds of patients (63.0%) were prescribed a statin (67.6% of patients below the HDL cholesterol goal, 80.5% of patients with CVD). In contrast, only 7.9% of patients were prescribed a nonstatin HDL cholesterol–raising medication, including 16.4% of patients below the HDL cholesterol goal with CVD. Based on published studies, normalizing low HDL cholesterol in this primary care cohort would correspond to an estimated CVD mortality reduction of 42% in women and 23% in men.

CONCLUSIONS—Nearly half of the patients in this large primary care cohort had low HDL cholesterol levels. In contrast to frequent statin use, few patients were prescribed currently available medicines to raise HDL cholesterol. Low HDL cholesterol represents a highly prevalent and potentially modifiable risk factor for CVD prevention in type 2 diabetes.

Abbreviations: CVD, cardiovascular disease • EMR electronic medical record • FIELD, Fenofibrate Intervention and Event Lowering in Diabetes • MI, myocardial infarction • VA-HIT, Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial

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