Austrian perspective

Italy’s 30 lipid clinics. The campaign aims to educate both the medical profession and the general public. A survey conducted in 1988 among 35.COO Italian physicians showed that risk factors rated as ‘very impcnant’ for coronary heart disease included hypertension (61%). hypercholesterolaemia (58%). smoking (45%). diabetes (28%). and hypemiglyceridaemia (20%). Most doctors believed that, in adults, dietary therapy should be started at cholesterol levels of ‘240-260 ma/d1 (6.2-6.7 mmol/l1 and that drug treatment sl&ld‘be initiated when diet has failed to reduce the level c 240 mg/dl (6.2 mmoVI). About one-third would reserve drag therapy for levels > 300 mg/dl(7.8 mmov1). Younger doctors set lower cut-off levels for the initiation of therapy; doctors aged 25-34 years believed *hat an acceptable cholesterol level was < 230 mg/dl(5.9 mmolil). The concept of the ‘normal’ or desirable level

Austrian perspective

Cardiovascular diseases are the leading cause of death in Austria (56% in 1986). Death rates because of coronary heart disease are similar to those in Germany i.e.. in the middle to upper range for the industrialized countries. Hypercholestemlaemia is the most prevalent risk factor for coronary heart disease [I]. According to an Austrian atherosclerosis report [2] oublished in 1988 under the ausoices of the Instiiute for Social Medicine, Vienna, the main pope. lation cholesterol level is 225 mddl(5.8 mmol/l); 25% of Austrians have levels of > 250 mgldl(6.5 mmol/l) and 7% of > 300 mg/dl (7.8 mmol/l). The same year saw a national consensus conference and the publication of a consensus document contained in the above report [Z]. The Austrian consensus is similar to the Euro-

of plasma cholesterol is often confused with pop”lation norms, which of course may be unbesirable. ‘Nomxd levels are strongly influenced by the clinical laboratories. A survey in 1987 showed that most laboratories reported a level of 250 ma/d1 (6.5 mmol/l) as normal. and onlv 7% considlred &Xl-209 n&d1 (5.2-5.4 mmol/i) the normal value. A second survey in 1990 following

pean Atherosclerosis Society consensus, except that, like the U.S. National Cholesterol Education Program, it is strictly related to cholesterol and there is no stratification with respect to triglycerides. In the light of more recent information, the omission of triglycerides from the consensw is,

a vigorous campaign of education directed at the laboratories showed that 23% had come to regard

idaemia which causes a depression of high-density lipoprotein-cholesterol [3] should not he discard-

200-209

ed as a risk factor for coronary heart disease [4]. However, in the Austrian consensus, high-density

the

mg/dl (X2-5.4

number

who

mm&l)

regarded

as normal, and 2XL260

mg/dl

perhaps, unfortunate. Recently, an International Commi!tee has pointed out, that hypertriglycer-

(6.5-6.7 mmol/l) as normal had decreased from 50% to 25%. Another component of the cholesterol campaign has been the measurement of cholesterol in schools. So far this has been done in 3000 children aged less than 10 years. and the average chc-

lipoprotein cholesterol of c 35 mg/dl(O.9 mmol/l) constitutes an additional risk factor giving an indirect consideration to-uiglycerides. Special attention is given in the Austrian con-

lesteml value found was 168 t&d1 (4.3 mm&l) - similar to Spanish studies. In 31% of the children, the level was > 180 mg/dl(4.7 mmoVI) and in 11%. it was > 200 mgldl (5.2 mmol/l). An intervention programme based on dietary information given to families, teachers, and school doctors resulted in a 9% fall in mean cholesterol after 9 months, compared to ao increase of 2.5% in a control group.

shouid be < 160 mg/dl (4.1 mmol/l), and lowdensity lipoprotein < 100 mg/dl(2.6 mmol/l). As lipid-lowering drugs, two statins (with a third to be added in 1992). acipimox, chylestyramine. probucol and six fibric acid derivates are available in Austria. Of these, only the tihrates are freely prescribable. Recently, a study of the World Health Organization investigated the prevalence of hypercho-

sensus to young people; in those < 20 years of age it is recommended that total cholesterol

s24

1es:eiolaemiabi :he inert western pan of Austria, bordering Switzerland, Germany and Liechtenstein [51. In this region, level was 224 mg/dl (5.8

Norwegian

mmoV1). Over 70% of men had cholesterol levels > 200 mg/dl (5.2

mm&l). About 21% had elevated triglycerides but very few had high-density lipoprotein levels < 35 mg/dl (0.9 mmoyl). Less than 50% of men had a normal body mass index. Total cholesterol, high-density lipoprotein cbolestero!, triglycerides. fasting blood glucose and systolic blood pressure all tended to deteriorate with increasing body mass iodtx, in both men and women [5]. Three studies, two in the west of Austria, and one in Vienna, have shown that there are very few hypertriglyceridaemias in individuals with plasma cholesterol levels < 200 mg/dl (5.2 mmol/l). Most cases of hypertriglyceridaemia occur in individuals with cholesteml above this reference value (Schuurman B, Kunze M. Personal communication). A number of smaller studies are in progress in Austria, aimed at determining the effects of population strategies on risk factors. In one such study, in a rural community of about 3ooO people, planned to iast about iG years, a change in eating habits in response to education has already been observed 18 months after inception of the intervention [6]. References

I Schwan.B. Kunr.eM, BischofHP et al. Gesamtchoksterinbefunde in iisleneich. Ein Oberblick epidemiologischer Srudien.Wien Klin Wochenschr 1989; 101:405-S 2 Kunre M. Schwan P. Bayer B et al. Athemsk,eroseberich,. lnstitutflir Sozialmedizinder UniversittilWien. OsterreichischeGesellschaftfib Hygiene. Mikmbiologie und Priiventivmedizin.Wien. 19F.S. 3 PatschJR.HDL-interactionswith the metabolismof triglyceride-richparticles.J Drug Dev 1990:3 (SUPP~ I): 81. 4 The InternationalCommitteefor the w~Iu&n of byphiglyceridemiaas B V&FCUIBT risk factor.The hypenriglyceridemias: risk and management.Am J Cardiol 1991; 68 (“r. 3): t A-IZA. 5 ScbwarzB, BiscbafHP, KunzeM. OverweightandCO~UMry risk factors.Resultsfrom a westernAustriansurvey.Soz Priv Med 1991:36: 322-6. 6 Weiss K. KatmnschlagerR, Egen H et al. Risikofaktoren der Atbemsktcmsc: Ergebnisse einesScreeningsin Nirderiisterreicb.Wien Klin Wocbenrchr1991; 10308: 566-70.

perspective

I. Hjwmam and L. Ose

the mean cholesterol In

Norway, the prevalence of coronary heart disease was 11% in 1985. Mortality was low in 1950, but increased among men by 2W250% until 197.5, and has since decreased by 10% among 50-59-year olds and 30% among 40-49-year olds. The most important reasons for the dramatic increaw in coronary heart disease over the last 50 years appear to be an increase in the consumption of sattttated fats and smoking. The distribution of total cholesterol values in the Norwegian pop&tion is shown in Table 1. In 1991. the Norwegian Medical Association publishad a Policy statement [I]. This statement aimed to simplify and update a previous statement (1988). incorporating the conclusions of a 1989 consensus conference. The primary objective ,Jf the Norwegian consensus is to concentrate resources on individuals with an elevated total risk and to give these people optimal treatment, while avoiding the unnecessary use of resources in low-risk groups and the assignment of indi.vi&aIs at !os:~r&k to the ro!e of patients. The Norwegian statement differs from other consensus documents, in that no cut-off points are set for intervention. Instead, it is stated that the aim should be a cholesterol level of 193 mg/dl (5.0 mmoUl). The total risk should be evaluated in every patient in whom treatment is considered, taking into account not only cholesterol, but also smoking, family history, diabetes, and high blood pressure. A scoring system for risk factors is pmTABLE

I

mgldl

(“““o”,) 40 years 65years 4Oyears 65y.w~

< 193 193-232 232-271

(C5.0) 804 (5.c-6.0) ,392 ~6.0-7.0~ ,075

499 I202 12.54

30%348 >348

iS.o-9.Oi 124 09.0) 37

2ot 70

1198 1.527 820 58 19

174 653 1195 5fh5 247