Changing patterns of referral to UK lipid clinics - a ten-year perspective.

OBJECTIVE: To review changing attitudes of British physicians to the significance of lipids and associated cardiovascular risks over the last decade. METHODS: Analysis of annual trends in referrals to specialist UK lipid clinics as recorded in the UK lipid clinics programme computerised database, with data on source, clinical and metabolic status of up to 12932 patients referred from 1986-1995. - RESULTS: Over the decade the proportion of referrals from hospital teams rather than GP s, and with clinical vascular disease has increased. The predominantly male patients have been referred at lower initial cholesterol levels but increasing BMI, with less emphasis on rare disorders. Recorded reductions in total cholesterol on treatment have also fallen from some 20% to 13%. Alcohol and smoking habits have been in accord with national trends. CONCLUSIONS: These changes suggest that awarerness of the significance of cholesterol and particularly of the opportunities available in secondary prevention, and awareness that lipid problems are seen to apply to a much wider patient base than the rare genetic disorders have all increased. However the increasing proportion of cases found at first referral to have lipaemia secondary to other undiagnosed metabolic disturbance suggests that appreciation of such wider influences on lipids remains incomplete.

Usual care dietary practice, achievement and implications for medication in the management of hypercholesterolaemia. Data from the U.K. Lipid Clinics Programme.

AIMS: To evaluate long-term responses to cholesterol-lowering diets in usual care and their associations with responses to lipid medication. METHODS: Analysis of paired data from the U.K. Lipid Clinics Programme computerized database for lipid responses, and associations of weight loss with later response to medication, plus analysis of a questionnaire on clinic dietary practice. RESULTS: Cholesterol, predominantly as low density lipoprotein was reduced in 60% of 2508 patients entered, and maintained long-term. Moderate 5-7% average responses incorporated reductions of at least 0.6 mmol x (-1) in 40% of patients, consistent with a 25% fall in the risk of cardiac events if maintained for 2 years. Responses to medication were greater for up to 2194 patients who previously lost weight on diet, an effect not apparent for 291 patients on statins alone. Physicians worked with dieticians in most clinics, and with individually tailored diets but with incomplete appreciation of the differences between available dietary protocols. CONCLUSIONS: Usual care dietary advice can be effective in lipid management, weight loss is important and associates with greater responses to lipid medication although statin monotherapy may not be affected. However, average responses are modest and physicians are not well informed of the dietary principles involved.

Corneal arcus, case finding and definition of individual clinical risk in heterozygous familial hypercholesterolaemia.

Premature corneal arcus may identify individuals with hyperlipidaemia and increased cardiovascular risk. We have attempted to quantitate relationships through determination of graded prevalence of corneal arcus with age for 81 males and 73 females suffering from heterozygous familial hypercholesterolaemia (HFH) at presentation, and for 280 male and 353 female unselected patients (age range 16-76 years) attending a country general practice. Some degree of arcus affected 50% of HFH patients by age 31-35 years, and 50% of practice patients by age 41-45 years. Complete full ring arcus affected 50% of the familial hypercholesterolaemia (FH) group by age 50 years, with only 5% similarly affected in the non-FH group. Arcus grade with age was advanced by some 5 years in males versus females. Premature arcus potentially alerting to HFH can be broadly defined for males and females combined, as heavy full ring by age 50 years, or any degree of arcus by age 30-35 years. Arcus grade was not related to the presence of coronary disease. Accelerated development of corneal arcus with age is an indicator of HFH, but premature arcus is not an additional marker of premature coronary disease for individual cases of HFH.

Lipid screening in an elderly population: difficulty in interpretation and in detection of occult metabolic disease.

AIMS: To determine lipid profiles and associations with other metabolic disease in a representative British elderly population. METHODS: Part of a prevalence survey of dementia in all 75+ year olds conducted from the large general practice serving the town and surrounding area of Melton Mowbray, Leicestershire (the M-old study). Patients (n = 224) aged from 75 to 98 years, and representative of the overall population, also provided pre-prandial blood samples on which various age and nutrition related analytes were determined. These included documented medical history, thyroid stimulating hormone (TSH), glucose, immunoglobulins, and lipid profile in plasma. RESULTS: Cholesterol and lipid variables showed wide scatter, with some negative trends but no significant associations with age for total cholesterol, high density lipoprotein (HDL) cholesterol, the ratio of total to HDL cholesterol or triglycerides. Women had significantly higher concentrations of total and HDL cholesterol at all ages. Serum TSH was above 6.0 mU/1 in 10/205 patients, random glucose was above 11.2 mmol/l in nine of 207 patients, borderline dysglobulinaemia was present in four of 210 patients, all without correlation with cholesterol concentrations. CONCLUSION: This British data is consistent with an inverse correlation between survival and cholesterol, but wide scatter restricts reliance on single result lipid data in individual patient management. Random lipid screening is also unhelpful, inefficient and without added value in revealing other age related and unrecognised occult metabolic disease.