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R3i EDITORIAL

1 January 2009

Micro- and macrovascular residual risk: one of the most challenging health problems of the moment

Professor Frank Sacks

Vice-President of the R3i
Professor Frank Sacks Improvements in cardiovascular prevention achieved over the last few decades are now seriously challenged by the impact of global epidemics of obesity, metabolic syndrome, and type 2 diabetes.

Despite achieving targets for LDL-cholesterol, blood pressure and glycemia in accordance with current standards of care, dyslipidemic patients remain at high residual risk of cardiovascular (CV) events. Pooled results of major trials show that statins reduce risk of major coronary events
by 25%. Thus, high-risk patients continue to experience substantial event rates while receiving statin therapy.

Patients with diabetes are particularly affected. Data from the Framingham Heart Study show that the population-attributable risk related to diabetes as CV risk factor has almost doubled between 1952-74 and 1975-98. In addition, intensive multifactorial intervention fails to prevent the development of microvascular complications, including diabetic retinopathy, nephropathy, and peripheral artery disease, in up to 50% of patients with type 2 diabetes.

Atherogenic dyslipidemia, characterized by elevated triglycerides and low levels of HDL-cholesterol, often with elevated apolipoprotein B and non-HDL-cholesterol, is common in patients with established CV disease, type 2 diabetes or metabolic syndrome, and is as a key modifiable factor contributing to both macrovascular and microvascular residual risk. However, atherogenic dyslipidemia is largely under-diagnosed and under-treated in clinical practice.

The Residual Risk Reduction Initiative (R3i) was established to address this highly-relevant clinical issue through its missions of research, communication, and education.

Based on available evidence, the R3i recommends to use lifestyle modification as an important first step to reducing residual vascular risk. To improve the efficacy of current standards of care, clinicians should improve achievement of all lipid targets, including recommended levels of LDL-cholesterol, HDL-cholesterol, and triglycerides. Another key measure to achieve residual risk reduction is to intervene earlier in the disease process with lifestyle modification, combined with drug therapy whenever needed.