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Macrovascular Residual Risk THROUGH LANDMARK STUDY

12 February 2016
Atherogenic dyslipidaemia is more common in statin-treated than untreated patients in primary care

In this large Canadian study, one in every 5 patients has mixed dyslipidaemia.

Asghari S, Aref-Eshghi E, Godwin M et al. Single and mixed dyslipidaemia in Canadian primary care settings: findings from the Canadian Primary Care Sentinel Surveillance Network database. BMJ open 2015; 5:e007954.
Comments & References
Objective: To investigate the prevalence and types of dyslipidaemia in patients in a primary care setting in Canada
Study design: Cross-sectional study, using the Canadian Primary Care Sentinel Surveillance Network
Study population: 134,074 adults (mean 59.2 years, 55.8% women) were identified, of whom 111,726 had measurements for low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-)C and triglycerides. Pregnancy was an exclusion criterion.
Primary variable: Dyslipidaemia, as defined by Canadian guidelines, i.e.
Total cholesterol ≥5.2 mmol/L
LDL-C ≥ 3.4 mmol/L
HDL-C ≤1.0 mmol/L in men and ≤1.3 mmol/L in women
Triglycerides ≥1.7 mmol/L
Ratio of total cholesterol:HDL-C ≥5
Methods: Data were summarised descriptively. Multivariate multinomial logistic regression modelling was used to investigate dyslipidaemia among individuals using lipid-lowering treatment and untreated individuals. Untreated individuals were defined as those with no record of lipid lowering treatment within 3 months before the date of a blood test.

Overall, 36%, 17% and 3% of individuals had lipid abnormalities in 1, 2 or 3 lipid parameters; 43.7% of individuals did not have dyslipidaemia (see Figure 1).

Figure 1. Prevalence of dyslipidaemia in the study population


Overall, 16,036 (12%) patients received statin monotherapy. While the prevalence of overall dyslipidaemia was similar in statin-treated and non-treated patients (21% vs 20%), the pattern of dyslipidaemia differed.  Comparing statin-treated and non-treated patients:

·       The prevalence of elevated triglycerides was higher (single dyslipidaemia, 12% versus 7%)

·       The prevalence of atherogenic dyslipidaemia (elevated triglycerides and low HDL-C) was almost 2-fold higher than in non-statin treated individuals (16% versus 9%)


Authors’ conclusion: One of every five patients in primary care settings in Canada is suffering from mixed dyslipidaemia. The overall prevalence of dyslipidaemia remains the same between treated and untreated groups, although the type of abnormal lipid component is considerably different.


Last month’s Landmark study highlighted the high prevalence of atherogenic dyslipidaemia and in particular, elevated triglycerides, among a secondary prevention cohort, evident in 11% and 30% of patients, respectively, consistent with a previous report from EUROASPIRE III.1,2 The current report adds to this, and shows that atherogenic dyslipidaemia is also prevalent in the primary prevention setting, evident in 13% of patients overall. Atherogenic dyslipidaemia and elevated triglycerides were also more prevalent among patients treated with statins than among untreated patients.

These data highlight an important need for education to increase the awareness of atherogenic dyslipidaemia, as well as targeted therapeutic intervention. While LDL-C remains the primary priority of guidelines, the increase in the prevalence of atherogenic dyslipidaemia in line with increasing metabolic syndrome, obesity and type 2 diabetes, emphasises the need to consider intervention targeted to this dyslipidaemic profile, Indeed, the American Diabetes Association has recently reaffirmed that elevated triglycerides should be considered as an important secondary target in individuals with type 2 diabetes.3

The Residual Risk Reduction Initiative (R3i) has focused on atherogenic dyslipidaemia, and more recently elevated triglyceride-rich lipoproteins and their remnants (for which elevated triglycerides are a marker), as a key contributor to lipid-related residual cardiovascular risk.4 The resurgence of interest in elevated triglycerides, with the accumulation of epidemiologic and genetic data supporting this dyslipidaemia as a cardiovascular risk factor, has also been a driver for novel therapeutic approaches.5,6 This study adds to the evidence-base showing that management of atherogenic dyslipidaemia, even in the primary care setting, lags behind. Urgent action is needed to address this issue.


1. de la Sierra A, Gorostidi M, Aranda P et al. Prevalence of atherogenic dyslipidemia in Spanish hypertensive patients and its relationship with blood pressure control and silent organ damage.  Rev Esp Cardiol (Engl Ed) 2015;68:592-8.

2. Reiner Z, De Bacquer D, Kotseva K et al. Treatment potential for dyslipidaemia management in patients with coronary heart disease across Europe: findings from the EUROASPIRE III survey. Atherosclerosis 2013;231:300-7.

3. Fox CS, Golden SH, Anderson C et al. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association. Diabetes Care 2015;38:1777-803.

4. Fruchart JC, Davignon J, Hermans MP et al. Residual macrovascular risk in 2013: what have we learned?  Cardiovasc Diabetol 2014;13:26.

5. Varbo A, Benn M, Smith GD et al. Remnant cholesterol, low-density lipoprotein cholesterol, and blood pressure as mediators from obesity to ischemic heart disease. Circ Res 2015;116:665-73.

6. Varbo A, Nordestgaard BG. Remnant cholesterol and ischemic heart disease. Curr Opin Lipidol 2014;25:266-73.

Key words lipid-related residual cardiovascular risk; atherogenic dyslipidaemia; triglycerides; prevalence; primary prevention