NCEP: Comments from the Field

SELA approaches lipid management as a professional multidisciplinary team where physicians of different specialties, primary care providers, nurses and nurse practitioners, dietitians, pharmacists and others play a key role in dialogue about approaches that are required to lower cardiovascular risk. Nowhere has it been more obvious than in the new Guidelines that managing lipids is inclusive of lifestyle change and incorporating many other biological and environmental factors.

SELA sought opinions from our membership about the new Guidelines. From Dr. Brown's broad picture of the regional and national role played by SELA and how this is concordant with the mission of the ATP Guidelines, to Ms. Tempest's clear view as a dietitian of the TLC, these comments offer a microcosm of the dialogue in the practice world. We thank our commencers for sharing their thoughts.

W. Virgil Brown, MD
Emory University
Chief, Medicine and Primary Care
Atlanta VA Medical Center

"One of the most important aspects of the new Guidelines is the opportunity it offers all of us to become part of a future where prevention is a meaningful part of both patient care and public health approaches. It has been only a few short years since cholesterol was important to the clinician only because it provided for steroid hormone synthesis and caused gall stones. The world has changed dramatically and now the various lipoproteins are household words. Controlling lipoprotein levels is part of every primary care practice and is important in many specialties. As a group, drugs to lower LDL cholesterol have become among the largest markets for the pharmaceutical industry. The scientific effort to improve our knowledge about lipoprotein metabolism is growing and the development of new pharmacological tools to alter this metabolism is a major program in many companies.

"With scientifically documented data and new effective treatments, we find ourselves at the center of the major health issue of all human kind, the prevention of progressing arterial disease. Arteriosclerosis is the number one cause of death in the world today and will grow in importance over the next several decades. Our only hope for relief is that medical and public health efforts are markedly improved. The health professional must play a central role in this effort. A successful effort must include a variety of health professionals that are working together with common purpose since this disease is insidious, multifaceted and influenced by many factors.

"SELA has evolved because we have realized that health professionals need interaction and communication at a personal level to develop the full potential necessary for an effective role in this effort. We should be very proud of the success to date. We have established a tradition of annual meetings that provide growth in fundamental knowledge, improvement in day to day skills and development of valuable personal relationships with our peers.

"Furthermore, programs that will provide the resources for continuing professional development are now available and others are planning stage. Our growth approaching 400 active members is proof that SELA has addressed a real need. Additionally, how we have addressed that need has built the base for continuing growth. We are inclusive of all health professionals who wish to have a role in the prevention of arteriosclerosis and to grow their professional capabilities. We are a truly professional organization that recognizes the need to work in a market economy with sound principals of management.

"Each of us wants to deliver truly valuable services and to be justly compensated for them. If we continue valuing that objective, we will experience enduring success. I believe that what we have done in the Southeastern United States may be applicable to the rest of the nation. Accordingly, a group of leaders in the development of clinical lipidology will come to the annual scientific meeting as observers, with the possibility of developing similar organizations in other regions of the country. SELA will make every effort to nurture such efforts by sharing our experiences and offering any counsel that may be needed. Having other regional lipid associations can only help us achieve our fundamental goal. The new Guidelines provide us with a call to arms, an opportunity to serve our mission well. We welcome the advancement in lipid management and the capacity it affords each of us to meet the goal of reducing the epidemic of cardiovascular disease in the US."

John R. Crouse, III, MD
Professor or Medicine and Public Health Science
Wake Forest University
School of Medicine

"Although only mentioned briefly, I believe one of the most important 'clinical pitfalls' is highlighted in three sentences on page 2,494 of the guidelines: "In rare cases in which triglycerides are very high (> 500 mg/dl), the initial aim of therapy is to prevent acute pancreatitis through triglyceride lowering. This approach requires very low-fat diets ---, weight reduction, increased physical activity, and usually a triglyceride-lowering drug - italics added - (fibrate or nicotinic acid). Only after triglyceride levels have been lowered to < 500 mg/dl should attention turn to LDL lowering to reduce risk for CHD.

"The most common mistake I see in patients referred to me for consultation is treatment of markedly hypertriglyceridemic patients with statins because their total cholesterol is often in excess of 300 mg/dl. But, this high total cholesterol is only a reflection of the elevated triglycerides, and LDL in such patients may actually be normal. The first cut in pharmacologic management of lipids is a triglyceride cut; LDL comes next. Admittedly there are only a few patients who fall out of initial LDL management by this approach, and the use of statins is very tempting, but statins are contraindicated as initial therapy for marked hypertriglyceridemia."

Connie F. Tempest, MPH, RD, LDN
Clinical Research Coordinator II
Duke University Medical Center

"In great part, the new ATP III guidelines arm health care providers involved in primary and secondary prevention of heart disease with a sound preventative message.

"Therapeutic Lifestyle Changes (TLC) is the multifaceted lifestyle approach to reduce risk for coronary heart disease emphasized in the new ATP III guidelines. The nutrition component of TLC is intensified, emphasizing that saturated fats comprise less than 7% of total calories, and total fat is allowed to range from 25%-35%. Included in the total fat allowance is avoidance of trans fatty acids (TFA). TFA are the partially hydrogenated form of polyunsaturated fats that elevate LDL-cholesterol and may possibly lower HDL-cholesterol. TFAs also occur naturally in foods produced from ruminant animals. The increased total fat percentage assists in reducing triglycerides and raising HDL-cholesterol in individuals with metabolic syndrome.

"This nutrition message translates into eating less fried foods, stick margarine, and processed food made with saturated and/or partially hydrogenated fats. Instead, one should eat healthy oils and foods containing healthy fats. As an example, use canola oil, olive oil, and nuts and seeds in one's meal plan to add flavor, assist with satiety, while boasting a healthy profile of both monounsaturated fatty acids and polyunsaturated fatty acids. So go ahead. Drizzle the olive oil on your salad with fresh lemon, grab a handful of walnuts for a snack and know that food truly can be the best medicine!"

Maria Lopes-Virella, MD, PhD
Professor of Medicine and Pathology
Medical University of South Carolina
Staff Physician at Ralph H. Johnson Medical Center

"The new NECP guidelines will have a great impact in the treatment of lipid disorders. They recognize not only LDL but also non-HDL cholesterol as targets for therapy. They set up a new set of normal levels for HDL cholesterol and for triglycerides. Above all, the new guidelines set up the conditions for more aggressive lipid-lowering therapy in patients with multiple risk factors and CHD equivalents and define clearly how to recognize patients who are CHD equivalents. For the first time, emphasis has been placed on the metabolic syndrome and in the need to make lifestyle changes, including exercise. Furthermore combined therapy is being recognized as an option for the treatment of patients with mixed hyperlipidemia and that may decrease the fear most physicians have of using combined drug therapy when treating patients with mixed hyperlipidemias. The number of subjects requiring lifestyle changes and lipid-lowering therapy is staggering. Our expertise in many areas (diagnosis, diet management, exercise, behavorial modification and drug management) is going to be required.

"SELA members are uniquely placed to play a crucial role in the implementation of the new guidelines. Each of us has a major and extremely rewarding task to perform. SELA will position itself to help its members to fulfill this considerable task."