Managing borderline levels of risk for coronary heart disease: two illustrative case presentations.

Much has been learned about preventing and treating coronary heart disease (CHD) since publication of the National Cholesterol Education Program (NCEP) Adult Treatment Panel II (ATP II) guidelines in 1993. Even with the recent release of the ATP III guidelines, clinical decision making has become increasingly complex as a result of the tremendous volume of new data, and because many common patient types do not fit precisely into the defined risk categories. The case studies presented here illustrate how data from recent trials and the clinician's judgment should be weighed together in the decision to initiate cholesterol-lowering therapy in patients with borderline risk levels, as part of a strategy for primary and secondary prevention of CHD.

Developing a clinical strategy for cholesterol management in an era of unanswered questions.

Recent clinical trials have supported the use of cholesterol-lowering therapies to reduce cardiovascular events. Despite these results, a number of unanswered questions remain, including the appropriate intensity of lipid-lowering therapy and the role of high-density lipoprotein cholesterol and/or triglycerides in cardiovascular risk assessment and reduction. In addition, the optimal treatment strategies for women, the elderly, and patients with diabetes are more difficult to determine, as these groups have comprised a minority of subjects in prior trials. Studies in progress will provide guidance toward effective treatment of these populations, the appropriate degree of lipid-lowering therapy, and the role of estrogen replacement therapy in postmenopausal women. In the interim, a clinical strategy incorporating the lessons of recent clinical evidence is suggested.

Cholesterol, stroke risk, and stroke prevention.

Serum cholesterol traditionally has been considered a poor predictor of total stroke risk; however, it is associated positively with ischemic stroke risk and associated negatively with hemorrhagic stroke risk. Although studies failed to demonstrate stroke reduction using older cholesterol-lowering medications, recent study of the statin class of medications shows both consistent stroke and other cardiovascular benefits. Ischemic stroke and coronary heart disease share similar underlying mechanisms, likely explaining much of the therapeutic benefit from statins. Current research is directed at further determining groups of patients most likely to benefit from lipid reduction in stroke prevention. In the interim, patients with established atherosclerosis should be treated with a statin to achieve a low-density lipoprotein cholesterol level less than 100 mg/dL.

An evidence-based assessment of the NCEP Adult Treatment Panel II guidelines. National Cholesterol Education Program.

CONTEXT: The Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II) was issued without the benefit of multiple recently published large clinical trials. OBJECTIVE: To analyze the panel's guidelines for treatment of high cholesterol levels in the context of currently available clinical trial results. DATA SOURCES: MEDLINE was searched for all English-language clinical trial data from 1993 through February 1999 relating to the effects of cholesterol treatment on cardiovascular clinical outcomes. STUDY SELECTION: Studies that were selected for detailed review assessed the effects of cholesterol lowering on either coronary events, coronary mortality, stroke, and/or total mortality, preferably by randomized, double-blind, placebo-controlled design. Selection was by consensus of a general internist, a lipid clinic director, and a researcher in atherosclerotic plaque biology. A core of 37 of the 317 initially screened studies were selected and used as the primary means by which to assess the guidelines. DATA EXTRACTION: By consensus of the group, only prespecified end points of trials were included, unless post hoc analysis addressed issues not studied elsewhere. DATA SYNTHESIS: Recent clinical trial data mostly support the Adult Treatment Panel II guidelines for cholesterol management. While existing trials have validated the target low-density lipoprotein cholesterol (LDL-C) goals in the report, studies are lacking that address mortality benefit from reduction below these levels. Few lipid-lowering trials have treated patients with low high-density lipoprotein cholesterol and/or elevated triglyceride levels with LDL-C levels at or below treatment goals. CONCLUSIONS: Lipid-lowering therapy generally should be more aggressively applied to patients with diabetes and/or at the time of coronary heart disease (CHD) diagnosis. The evidence for statin use in secondary CHD prevention in postmenopausal women outweighs current evidence for use of estrogen replacement in this setting. Further studies are needed to address the effects of lipid modification in primary prevention of CHD in populations other than middle-aged men and to study markers of lipid metabolism other than LDL-C.

Visual tracking behavior in low functioning head-injured adults.

OBJECTIVE: To analyze visual tracking patterns of low functioning head-injured adults as follow-up to finding that visual tracking performance predicts rehabilitation-ready (RR) status. DESIGN: Case series of patients in a 4-year study of predictors of early cognitive improvement. SETTING: Private subacute care facility providing sensory stimulation and slowly paced rehabilitation. PATIENTS: Convenience sample of 76 subjects: 45 achieved RR status; 31 did not (NRR). Men = 54; Women = 22. Age at injury: 12 to 73 years (median [Md] = 27). Time postinjury at initial assessment: 25 to 365 days (Md = 57). Cognitive status at initial assessment: Western Neuro Sensory Stimulation Profile (WNSSP) Score below 47. INTERVENTION: Subjects assessed by WNSSP Visual Tracking subscale (VISTRACK) at admission and every 2 weeks thereafter for 2 to 48 months postinjury. MAIN OUTCOME MEASURES: VISTRACK scores for Direction (horizontal vs vertical) and Stimulus (mirror, individual, picture, object) analyzed quantitatively and qualitatively at admission and longitudinally. RESULTS: RR subjects showed significantly higher scores at admission when tracking face in mirror versus other stimuli. No differences were observed for NRR subjects. No statistical differences seen for direction of tracking for either group, but 48% of subjects showed preference for tracking in one direction versus the other at initial assessment. CONCLUSIONS: Visual tracking not a unitary phenomenon but dependent on stimulus and direction. RR subjects' ability to track their own face in mirror seems to be critical variable in predictive value of VISTRACK subscale. Potency of human face as stimulus relates to developmental and neurophysiological factors. Awareness of effects of stimulus and direction on tracking function warrants comprehensive visual tracking assessment.

Slow-to-recover brain-injured patients: rationale for treatment.

Approximately 10-20% of head injury survivors sustain extensive neurological damage and remain minimally or inconsistently responsive to stimuli for 3-6 months postinjury. These patients, designated as slow to recover (STR), may be candidates for sensory stimulation programs rather than traditional rehabilitation. Medical and insurance personnel have resisted referral and payment for treatment because of the lack of objective measures of progress, a theoretical basis for treatment, and evidence of treatment efficacy. A valid, reliable assessment tool has recently been developed (Western Neuro Sensory Stimulation Profile) that assesses low-level cognitive/communicative function and documents improvement in STR patients. This article addresses the theoretical rationale for treatment. Evidence from four areas--sensory deprivation, enriched environments, nervous system plasticity, and sensitive periods of neurodevelopment--suggests that sensory stimulation programs are potentially beneficial for STR patients. Speech-language pathologists are encouraged to study the recovery patterns of STR patients and to determine the efficacy of treatment strategies.

The Western Neuro Sensory Stimulation Profile: a tool for assessing slow-to-recover head-injured patients.

The Western Neuro Sensory Stimulation Profile (WNSSP) was developed to assess cognitive function in severely impaired head-injured adults (Rancho levels II-V) and to monitor and predict change in slow-to-recover patients. Slow-to-recover patients are those who remain at Rancho levels II and III for extended periods of time and are candidates for sensory stimulation programs. Although sensory stimulation is considered beneficial, its utility has not been documented, partly because of the absence of formal measurement tools. The WNSSP consists of 32 items which assess patients' arousal/attention, expressive communication, and response to auditory, visual, tactile, and olfactory stimulation. It was administered to 57 patients with a mean age of 29 years at a mean time of eight months after injury. Statistical analyses indicate the WNSSP to be a reliable, valid measure of cognitive function. WNSSP means differ at each Rancho level, and ranges of scores at each level are sufficiently broad to demonstrate improvement within as well as across cognitive levels. Subjects who later improved performed significantly better on initial testing than did those who did not improve, suggesting prognostic ability of the WNSSP. Our data support other investigations which emphasize that some slow-to-recover patients experience significant improvement. The WNSSP can be a useful tool for studying the recovery process and evaluating treatment programs for slow-to-recover patients.