[Lipid therapy in daily routine]. / Lipidtherapie im Alltag.

Patients with increased cardiovascular risk profile are frequently seen in general practice. Comprehensive management of modifiable risk factors, in particular dyslipidemia, is mandatory. Many studies in clinical practice have shown a gap between the recommendations in clinical guidelines and the actual situation. Current data on the management situation of patients with high cardiovascular risk is provided by the prospective registry LIMA. Primary care physicians in 2,387 offices throughout Germany documented 13,924 patients with coronary artery disease (CAD), diabetes mellitus or peripheral arterial disease (PAD). Treatment with simvastatin 40 mg was an inclusion criterion. Physicians documented drug utilization, laboratory values (lipids, blood glucose), blood pressure and clinical events over one year and received feedback about the target value attainment of their patients after data entry. Mean age of the patients was 65.7 years, and 61.6 % were men. CAD was reported in 70.6 %, diabetes mellitus in 58.2 % and PAD in 14.9 %. Most patients (68 %) received simvastatin as monotherapy also after the inclusion visit; 20.6 % of patients received in addition the cholesterol absorption inhibitor (ezetimibe) in the first 6 months, and 23.3 % in the second 6 months. Patients achieved the LDL-cholesterol target value in 31.8 % at entry and 50.0 % after one year. The blood pressure target < 140 /90 mmHg was reached by 65.8 % after one year. Of patients with diabetes mellitus 40.0 % reached an HbA1c value below 6.5 %. Clinical events (death, hospitalization, (cardio-) vascular events, and dialysis) were reported by 11.7 % of patients between entry and Month 6, and by 12.0 % between Month 7 and 12. In daily practice comprehensive management of risk factors in patients at high cardiovascular risk remains a challenge. For normalization of increased LDL cholesterol values addition of ezetimibe to existing statin therapy improves the chances of patients for target level attainment.

Secondary prevention of diabetic patients with coronary artery disease in cardiac rehabilitation: risk factors, treatment and target level attainment.

INTRODUCTION: Diabetic patients who have suffered from an acute coronary syndrome (ACS) or have had coronary artery bypass graft (CABG) surgery are at very high risk of recurrent cardiovascular events. Their prognosis, however, can be improved if the target values for blood pressure (BP < 130/80 mmHg) or low density lipoprotein cholesterol [LDL-C < 2.6 mmol/L (100 mg/dl), optionally < 1.8 mmol/L (70 mg/dl)] are achieved. It is not known what proportion of diabetic patients receives such stringent secondary prevention measures and achieves target level attainment for BP, lipids and glucose in cardiac rehabilitation (CR). METHODS: During 2003 to 2005, 11 973 diabetic (29.7%) and 28 370 non-diabetic patients (70.3%), predominantly after ACS (74 and 80%), were included in a nationwide registry. At entry and at discharge, patient characteristics, pharmacotherapy and blood pressure, lipids and blood glucose were recorded. In a mixed model approach, temporal changes between centres and within centres, respectively, were analysed. RESULTS: At discharge, a lower proportion of diabetic patients achieved normalisation of BP (in 2005: <140/90 mmHg: 78.4 vs. 82.9% in non-diabetic patients, p < 0.001) or <130/80 mmHg (45.5 vs. 49.8%), respectively. LDL-C < 2.6 mmol/L was more frequently attained in diabetic patients (68.2 vs. 66.5%), as was LDL-C < 1.8 mmol/L (28.8 vs. 23.0%). Fasting blood glucose was not changed during the observation period, as at discharge almost a quarter of all diabetic patients exceeded the threshold value of 7.0 mmol/L (126 mg/dl). In 2005 at discharge, statin therapy was administered in 93% in both diabetics and non-diabetics, acetylic salicylic acid in 79% in diabetics vs. 80% in non-diabetic patients (clopidogrel: 41 vs. 45%). CONCLUSION: Generally there is room for improvement in the management of cardiac risk factors for both patients groups. In diabetic patients in CR at high risk for recurrent cardiac events, in recent years an improvement of the lipid profile has been observed. Hypertension and glycaemia are still not optimally addressed.