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Prevalence and pattern of diabetic dyslipidemia in Indian type 2 diabetic patients
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 10–12
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Original paper
Prevalence and pattern of diabetic dyslipidemia in Indian type 2 diabetic patients Rakesh M. Parikh a,*, Shashank R. Joshi b, Padmavathy S. Menon c, Nalini S. Shah c a
Department of Diabetology, S K Soni Hospital, Jaipur, India Department of Endocrinology, Lilawati Hospital, Mumbai, India c Department of Endocrinology, Seth G S Medical College & K E M Hospital, Mumbai, India b
A R T I C L E I N F O
A B S T R A C T
Keywords: Diabetes mellitus Type 2 Dyslipidemia India
Aim: To study prevalence and pattern of dyslipidemia in Indian type 2 diabetic patients. Materials and methods: Fasting serum lipid profiles of 788 consecutive patients with type 2 diabetes were retrieved from hospital records. Patients having one or more parameters (TG, HDL cholesterol or LDL cholesterol) outside the targets recommended by American Diabetes Association (ADA) were considered to have dyslipidemia. Those with dyslipidemia were further classified into mixed dyslipidemia, combined two parameter dyslipidemia and isolated single parameter dyslipidemia (TG, HDL or LDL). Results: Prevalence of dyslipidemia among diabetic patients at baseline was 85.5% among males and 97.8% among females. Among the males with dyslipidemia the proportion of patients with mixed dyslipidemia, combined dyslipidemia and single parameter dyslipidemia were 14.1%, 44.9% and 41%, respectively. Figures for the same among female patients stood at 24.6%, 47.8% and 27.7%, respectively. Combined dyslipidemia with high LDL and low HDL was the most common pattern among males and females both, contributing to 22.7% and 33% patients of diabetic dyslipidemia, respectively. Second most common pattern among males was isolated high LDL, contributing to 21.3% of males with dyslipidemia. While among females isolated low HDL emerged as the second most common pattern affecting 13.4% dyslipidemic females. Conclusions: Majority of Indian type 2 diabetic patients are dyslipidemic at baseline. The most common pattern of dyslipidemia is high LDL and low HDL among both males and females. The most prevalent problem among males is high LDL while among females low HDL emerged as a bigger threat. ß 2009 Diabetes India. Published by Elsevier Ltd. All rights reserved.
1. Introduction Coronary artery disease (CAD), which is the most common cause of mortality in diabetic patients, is strongly associated with increased levels of serum low-density lipoproteins (LDL) [1]. Numerous studies have shown the reduction in cardiovascular morbidity and mortality with statin therapy, which can be attributed to the lowering of LDL cholesterol in addition to pleotrophic effects of statins. In spite of advancement in our therapeutic armamentarium, there has not been much reduction in cardiovascular mortality in diabetic patients comparable to that in non-diabetic [2]. Diabetic patients are known to have high levels of serum triglyceride (TG) and low levels high-density lipoproteins (HDL). Low levels of serum HDL might be the missing link, which also has shown to have a strong correlation with cardiovascular disease [3,4]. American Diabetes Association (ADA) guidelines
* Corresponding author at: C-56, Ramnagar, Shastrinagar, Jaipur 302016, India. Tel.: +91 9351384427; fax: +91 1412303411. E-mail address: [email protected] (R.M. Parikh).
recommend maintaining serum levels of TG below 150 mg/dl, LDL cholesterol below 100 mg/dl and HDL cholesterol of more than 40 mg/dl in males and 50 mg/dl in females [5]. In our experience we found very few patients with HDL cholesterol of more than 50 mg/dl, provoking us to look at lipid profile pattern among our patients. We did not find any study from Indian subcontinent looking at pattern of dyslipidemia in large number of diabetic patients. Present study was aimed at analyzing lipid profiles of our patients with a special emphasis on role of each parameter separately in causing dyslipidemia. 2. Study design and methodology 2.1. Study design Records of diabetic patients who have visited our clinic during preceding 6 months were considered for retrospective analysis. In descending order of their registration number total of 1086 records were studied. A note was made regarding the type of diabetes, last HbA1C, last lipid profile (TC, TG, HDL, LDL) of the patient, in addition to the pharmacologic treatment (s)he was on. Patients
1871-4021/$ – see front matter ß 2009 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2009.04.005
R.M. Parikh et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 10–12
with a clinical diagnosis other than type 2 DM and those with poor glycemic control (HbA1C > 10%) were excluded from the analysis. The patients of primary dyslipidemia and those with serum TG of more than 400 mg/dl were also excluded. As the study was aimed at analyzing pattern of lipid profile at baseline, those who were on lipid lowering drugs likes statins, ezetimibe, fibrates and niacin were not included in the analysis.
11
high LDL. Altogether 253 out of 361 (70.1%) males with dyslipidemia had high levels of LDL cholesterol. 3.3. Pattern of dyslipidemia in females
A total of 788 patients, 422 males and 366 females were included in the analysis (Table 1).
Even among females, combined dyslipidemia was more common involving 171 out of 358 (47.8%) dyslipidemic patients. Unlike males the prevalence of mixed dyslipidemia and single parameter dyslipidemia was comparable involving 88 (24.6%) and 99 (27.7%) patients, respectively. Even in female patients, high LDL with low HDL was the most common pattern of combined dyslipidemia involving 118 out of 358 (33%) patients, proportion being higher than that in males (33% vs. 22.7%). 34 (9.5%) patients had high TG with low HDL while only 19 (5.3%) had high TG with high LDL. Unlike the pattern of single parameter dysliplidemia in males, only 5 (1.4%) females had isolated hypertriglyceridemia. 46 (12.9%) patients had isolated high LDL while the most common single parameter dyslipidemia among females was low HDL affecting 48 (13.4%) females. Combined dyslipidemia with high LDL and low HDL was the most common pattern even among females. But unlike males the second most common pattern was isolated low HDL. Overall low HDL stood as the biggest problem affecting 288 out of 358 (80.4%) females with dyslpidemia.
3.1. Prevalence of dyslipidemia
4. Discussion
361 out of 422 males (85.5%) had dyslipidemia, while the prevalence was even higher among females affecting 358 out of 366 (97.8%) patients.
Patients with type 2 DM show characteristic lipid profile of normal or slightly raised LDL cholesterol, with low HDL and mildly elevated TG concentration [6]. Measurements confined to LDL may therefore underestimate the risk associated with the concentration of atherogenic lipoprotein particles in diabetes [7]. Indeed in some cohorts of patients with diabetes, total cholesterol and LDL cholesterol levels did not associate with cardiovascular risk whereas, high TG and low HDL cholesterol concentration were powerful predictors of cardiovascular events [8]. Low HDL in patients with metabolic syndrome can substantially raise TC/HDL ratio, which was found to be the best lipid index for predicting cardiovascular events in prospective studies such as Framingham Heart Study and Quebec Cardiovascular Study [9]. All above mentioned evidences suggest that targeting HDL is at least equally or may even be more important than other components of lipid profiles. 44 out of 422 (10.4%) males and 48 out of 366 (13.1%) females in our cohort had low HDL as the only problem. Such patients who satisfy all other lipid profile targets may be overlooked because of unavailability of potent drug to increase HDL. In such patients HDL should be targeted aggressively by advising exercise, or with drugs like niacin. Targeting HDL becomes even more relevant among females as 288 out of 366 (78.7%) type 2 diabetic females had low HDL at baseline. Average HDL levels in women are approximately 10 mg/dl higher than in men [10]. Low levels of HDL <35 mg/dl in men and <45 mg/dl in women, is associated with a greater risk of coronary artery disease and more progression of angiographically demonstrated disease in women, while increasing HDL has a more cardio protective effect in the female than in the male population. The total cholesterol (TC)/HDL ratio is also more predictive of coronary artery disease in women than in men [10]. With this background, the results of above study become more relevant. Being a cross-sectional retrospective analysis this study has limitations like lack of standardization in measurement of lipid profile. Though patients with poor glycemic control were excluded, exact glycemic status, which has implications on lipid profile, could not be retrieved. But this study probably is the first such data
2.2. Analysis Patients with one or more parameters (TG, HDL Cholesterol or LDL cholesterol) outside the targets recommended by ADA were considered to have dyslipidemia. Patients with dyslipidemia were further subdivided into those with mixed dyslipidemia (all parameters outside the recommended targets), combined dyslipidemia (two parameters outside and one parameter within target range) and those with isolated single parameter dyslipidemia (TG, HDL or LDL). Among the patients with combined dyslipidemia proportion of patients with different patterns (high TG and low HDL; high TG and high LDL; high LDL and low HDL) was obtained. 3. Results
3.2. Pattern of dyslipidemia in males Proportion of patients with combined dyslipidemia was highest affecting 162 (44.9%) out of 361 dyslipidemic males. Isolated single parameter dyslipidemia was seen in 148 (41%) patients, while 51 patients (14.1%) revealed a mixed pattern. Among patients with combined dyslipidemia, 37 (10.3%) patients had high TG with low HDL, 43 (12%) had high TG with high LDL, while high LDL with low HDL was the most common pattern affecting 82 (22.7%) patients. Sub-analysis of males with isolated single parameter dyslipidemia revealed that 27 (7.5%) patients had isolated hypertriglyceridemia, 44 (12.2%) patients had isolated low HDL while isolated high LDL was seen in 77 (21.3%) patients. Overall the most common pattern among males was combined dyslipidemia, with High LDL and low HDL, followed by isolated Table 1 Prevalence and pattern of dyslipidemia in type 2 diabetic males and females at baseline (not on any lipid lowering agent). Males (422)
Females (366)
Mixed dyslipidemia High TG, high LDL and low HDL
51 (12.1%)
88 (24.0%)
Combined dyslipidemia High TG and low HDL High TG and high LDL High LDL and low HDL
37 (8.8%) 43 (10.2%) 82 (19.4%)
34 (9.3%) 19 (5.2%) 118 (32.2%)
Isolated single parameter dyslipidemia High TG High LDL Low HDL
27 (6.4%) 77 (18.2%) 44 (10.4%)
5 (1.4%) 46 (12.6%) 48 (13.1%)
361 (85.5%)
358 (97.8%)
Total
TG, triglyceride; HDL, high-density lipoprotein; LDL, low-density lipoprotein.
12
R.M. Parikh et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 10–12
from Indian subcontinent and might serve as a basis for comparison from other parts of the country. 5. Conclusions Majority of our diabetic patients failed to achieve all standard goals of dyslipidemia management. In a substantial number of patients this was attributable to the fact the HDL target was not met. Hence, the standard of care demands that we ought to pursue HDL goals more aggressively. Conflicts of interest No financial funding was received for the study and there are no conflicts of interest. References [1] Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus (UKPDS 23). Br Med J 1998;316:823–8.
[2] Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. J Am Med Assoc 1999;281:1291–7. [3] Rubins HB, Robins SJ, Collins D, Fye CL, Anderson JW, Elam MB, Faas FH, Linares E, Schaefer EJ, Schectman G, Wilt TJ, Wittes J. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol: Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. New Engl J Med 1999; 341:410–8. [4] Steiner G. Dyslipoproteinaemias in diabetes. Clin Invest Med 1995;18:282–7. [5] Dyslipidemia Management in Adults With Diabetes. Diabetes Care 2004; 27(Suppl. 1):S68–71. [6] Bierman EL. Atherogenesis in diabetes. Arterioscler Thromb Vasc Biol 1992; 12:647–56. [7] Poirier P, Despres JP, Lipid disorders in diabetes. In: Pickup JC, Williams G, eds. Text book of diabetes, 3rd ed. vol. 2. p. 54.5. [8] Torremocha F, Hadjadj S, Carre F, Rosenberg T, Herpin D, Marechaud R. Prediction of major coronary events by coronary risk profile and silent myocardial ischemia: Prospective follow up study of primary prevention in 72 diabetic patients. Diabetes Metab 2001;27:49–57. [9] Lamarche B, Moorjani S, Cantin B, Dagenais GR, Lupien PJ, Despres JP. Associations of HDL2 and HDL3 subfractions with ischemic heart disease in men: prospective results from the Quebec Cardiovascular Study. Arterioscler Thromb Vasc Biol 1997;17(6):1098–105. [10] Legato MJ. Dyslipidemia, gender, and the role of high-density lipoprotein cholesterol: implications for therapy. Am J Cardiol 2000;86(12A): 15L–18L.
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Original paper
Prevalence and pattern of diabetic dyslipidemia in Indian type 2 diabetic patients Rakesh M. Parikh a,*, Shashank R. Joshi b, Padmavathy S. Menon c, Nalini S. Shah c a
Department of Diabetology, S K Soni Hospital, Jaipur, India Department of Endocrinology, Lilawati Hospital, Mumbai, India c Department of Endocrinology, Seth G S Medical College & K E M Hospital, Mumbai, India b
A R T I C L E I N F O
A B S T R A C T
Keywords: Diabetes mellitus Type 2 Dyslipidemia India
Aim: To study prevalence and pattern of dyslipidemia in Indian type 2 diabetic patients. Materials and methods: Fasting serum lipid profiles of 788 consecutive patients with type 2 diabetes were retrieved from hospital records. Patients having one or more parameters (TG, HDL cholesterol or LDL cholesterol) outside the targets recommended by American Diabetes Association (ADA) were considered to have dyslipidemia. Those with dyslipidemia were further classified into mixed dyslipidemia, combined two parameter dyslipidemia and isolated single parameter dyslipidemia (TG, HDL or LDL). Results: Prevalence of dyslipidemia among diabetic patients at baseline was 85.5% among males and 97.8% among females. Among the males with dyslipidemia the proportion of patients with mixed dyslipidemia, combined dyslipidemia and single parameter dyslipidemia were 14.1%, 44.9% and 41%, respectively. Figures for the same among female patients stood at 24.6%, 47.8% and 27.7%, respectively. Combined dyslipidemia with high LDL and low HDL was the most common pattern among males and females both, contributing to 22.7% and 33% patients of diabetic dyslipidemia, respectively. Second most common pattern among males was isolated high LDL, contributing to 21.3% of males with dyslipidemia. While among females isolated low HDL emerged as the second most common pattern affecting 13.4% dyslipidemic females. Conclusions: Majority of Indian type 2 diabetic patients are dyslipidemic at baseline. The most common pattern of dyslipidemia is high LDL and low HDL among both males and females. The most prevalent problem among males is high LDL while among females low HDL emerged as a bigger threat. ß 2009 Diabetes India. Published by Elsevier Ltd. All rights reserved.
1. Introduction Coronary artery disease (CAD), which is the most common cause of mortality in diabetic patients, is strongly associated with increased levels of serum low-density lipoproteins (LDL) [1]. Numerous studies have shown the reduction in cardiovascular morbidity and mortality with statin therapy, which can be attributed to the lowering of LDL cholesterol in addition to pleotrophic effects of statins. In spite of advancement in our therapeutic armamentarium, there has not been much reduction in cardiovascular mortality in diabetic patients comparable to that in non-diabetic [2]. Diabetic patients are known to have high levels of serum triglyceride (TG) and low levels high-density lipoproteins (HDL). Low levels of serum HDL might be the missing link, which also has shown to have a strong correlation with cardiovascular disease [3,4]. American Diabetes Association (ADA) guidelines
* Corresponding author at: C-56, Ramnagar, Shastrinagar, Jaipur 302016, India. Tel.: +91 9351384427; fax: +91 1412303411. E-mail address: [email protected] (R.M. Parikh).
recommend maintaining serum levels of TG below 150 mg/dl, LDL cholesterol below 100 mg/dl and HDL cholesterol of more than 40 mg/dl in males and 50 mg/dl in females [5]. In our experience we found very few patients with HDL cholesterol of more than 50 mg/dl, provoking us to look at lipid profile pattern among our patients. We did not find any study from Indian subcontinent looking at pattern of dyslipidemia in large number of diabetic patients. Present study was aimed at analyzing lipid profiles of our patients with a special emphasis on role of each parameter separately in causing dyslipidemia. 2. Study design and methodology 2.1. Study design Records of diabetic patients who have visited our clinic during preceding 6 months were considered for retrospective analysis. In descending order of their registration number total of 1086 records were studied. A note was made regarding the type of diabetes, last HbA1C, last lipid profile (TC, TG, HDL, LDL) of the patient, in addition to the pharmacologic treatment (s)he was on. Patients
1871-4021/$ – see front matter ß 2009 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2009.04.005
R.M. Parikh et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 10–12
with a clinical diagnosis other than type 2 DM and those with poor glycemic control (HbA1C > 10%) were excluded from the analysis. The patients of primary dyslipidemia and those with serum TG of more than 400 mg/dl were also excluded. As the study was aimed at analyzing pattern of lipid profile at baseline, those who were on lipid lowering drugs likes statins, ezetimibe, fibrates and niacin were not included in the analysis.
11
high LDL. Altogether 253 out of 361 (70.1%) males with dyslipidemia had high levels of LDL cholesterol. 3.3. Pattern of dyslipidemia in females
A total of 788 patients, 422 males and 366 females were included in the analysis (Table 1).
Even among females, combined dyslipidemia was more common involving 171 out of 358 (47.8%) dyslipidemic patients. Unlike males the prevalence of mixed dyslipidemia and single parameter dyslipidemia was comparable involving 88 (24.6%) and 99 (27.7%) patients, respectively. Even in female patients, high LDL with low HDL was the most common pattern of combined dyslipidemia involving 118 out of 358 (33%) patients, proportion being higher than that in males (33% vs. 22.7%). 34 (9.5%) patients had high TG with low HDL while only 19 (5.3%) had high TG with high LDL. Unlike the pattern of single parameter dysliplidemia in males, only 5 (1.4%) females had isolated hypertriglyceridemia. 46 (12.9%) patients had isolated high LDL while the most common single parameter dyslipidemia among females was low HDL affecting 48 (13.4%) females. Combined dyslipidemia with high LDL and low HDL was the most common pattern even among females. But unlike males the second most common pattern was isolated low HDL. Overall low HDL stood as the biggest problem affecting 288 out of 358 (80.4%) females with dyslpidemia.
3.1. Prevalence of dyslipidemia
4. Discussion
361 out of 422 males (85.5%) had dyslipidemia, while the prevalence was even higher among females affecting 358 out of 366 (97.8%) patients.
Patients with type 2 DM show characteristic lipid profile of normal or slightly raised LDL cholesterol, with low HDL and mildly elevated TG concentration [6]. Measurements confined to LDL may therefore underestimate the risk associated with the concentration of atherogenic lipoprotein particles in diabetes [7]. Indeed in some cohorts of patients with diabetes, total cholesterol and LDL cholesterol levels did not associate with cardiovascular risk whereas, high TG and low HDL cholesterol concentration were powerful predictors of cardiovascular events [8]. Low HDL in patients with metabolic syndrome can substantially raise TC/HDL ratio, which was found to be the best lipid index for predicting cardiovascular events in prospective studies such as Framingham Heart Study and Quebec Cardiovascular Study [9]. All above mentioned evidences suggest that targeting HDL is at least equally or may even be more important than other components of lipid profiles. 44 out of 422 (10.4%) males and 48 out of 366 (13.1%) females in our cohort had low HDL as the only problem. Such patients who satisfy all other lipid profile targets may be overlooked because of unavailability of potent drug to increase HDL. In such patients HDL should be targeted aggressively by advising exercise, or with drugs like niacin. Targeting HDL becomes even more relevant among females as 288 out of 366 (78.7%) type 2 diabetic females had low HDL at baseline. Average HDL levels in women are approximately 10 mg/dl higher than in men [10]. Low levels of HDL <35 mg/dl in men and <45 mg/dl in women, is associated with a greater risk of coronary artery disease and more progression of angiographically demonstrated disease in women, while increasing HDL has a more cardio protective effect in the female than in the male population. The total cholesterol (TC)/HDL ratio is also more predictive of coronary artery disease in women than in men [10]. With this background, the results of above study become more relevant. Being a cross-sectional retrospective analysis this study has limitations like lack of standardization in measurement of lipid profile. Though patients with poor glycemic control were excluded, exact glycemic status, which has implications on lipid profile, could not be retrieved. But this study probably is the first such data
2.2. Analysis Patients with one or more parameters (TG, HDL Cholesterol or LDL cholesterol) outside the targets recommended by ADA were considered to have dyslipidemia. Patients with dyslipidemia were further subdivided into those with mixed dyslipidemia (all parameters outside the recommended targets), combined dyslipidemia (two parameters outside and one parameter within target range) and those with isolated single parameter dyslipidemia (TG, HDL or LDL). Among the patients with combined dyslipidemia proportion of patients with different patterns (high TG and low HDL; high TG and high LDL; high LDL and low HDL) was obtained. 3. Results
3.2. Pattern of dyslipidemia in males Proportion of patients with combined dyslipidemia was highest affecting 162 (44.9%) out of 361 dyslipidemic males. Isolated single parameter dyslipidemia was seen in 148 (41%) patients, while 51 patients (14.1%) revealed a mixed pattern. Among patients with combined dyslipidemia, 37 (10.3%) patients had high TG with low HDL, 43 (12%) had high TG with high LDL, while high LDL with low HDL was the most common pattern affecting 82 (22.7%) patients. Sub-analysis of males with isolated single parameter dyslipidemia revealed that 27 (7.5%) patients had isolated hypertriglyceridemia, 44 (12.2%) patients had isolated low HDL while isolated high LDL was seen in 77 (21.3%) patients. Overall the most common pattern among males was combined dyslipidemia, with High LDL and low HDL, followed by isolated Table 1 Prevalence and pattern of dyslipidemia in type 2 diabetic males and females at baseline (not on any lipid lowering agent). Males (422)
Females (366)
Mixed dyslipidemia High TG, high LDL and low HDL
51 (12.1%)
88 (24.0%)
Combined dyslipidemia High TG and low HDL High TG and high LDL High LDL and low HDL
37 (8.8%) 43 (10.2%) 82 (19.4%)
34 (9.3%) 19 (5.2%) 118 (32.2%)
Isolated single parameter dyslipidemia High TG High LDL Low HDL
27 (6.4%) 77 (18.2%) 44 (10.4%)
5 (1.4%) 46 (12.6%) 48 (13.1%)
361 (85.5%)
358 (97.8%)
Total
TG, triglyceride; HDL, high-density lipoprotein; LDL, low-density lipoprotein.
12
R.M. Parikh et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 10–12
from Indian subcontinent and might serve as a basis for comparison from other parts of the country. 5. Conclusions Majority of our diabetic patients failed to achieve all standard goals of dyslipidemia management. In a substantial number of patients this was attributable to the fact the HDL target was not met. Hence, the standard of care demands that we ought to pursue HDL goals more aggressively. Conflicts of interest No financial funding was received for the study and there are no conflicts of interest. References [1] Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus (UKPDS 23). Br Med J 1998;316:823–8.
[2] Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. J Am Med Assoc 1999;281:1291–7. [3] Rubins HB, Robins SJ, Collins D, Fye CL, Anderson JW, Elam MB, Faas FH, Linares E, Schaefer EJ, Schectman G, Wilt TJ, Wittes J. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol: Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. New Engl J Med 1999; 341:410–8. [4] Steiner G. Dyslipoproteinaemias in diabetes. Clin Invest Med 1995;18:282–7. [5] Dyslipidemia Management in Adults With Diabetes. Diabetes Care 2004; 27(Suppl. 1):S68–71. [6] Bierman EL. Atherogenesis in diabetes. Arterioscler Thromb Vasc Biol 1992; 12:647–56. [7] Poirier P, Despres JP, Lipid disorders in diabetes. In: Pickup JC, Williams G, eds. Text book of diabetes, 3rd ed. vol. 2. p. 54.5. [8] Torremocha F, Hadjadj S, Carre F, Rosenberg T, Herpin D, Marechaud R. Prediction of major coronary events by coronary risk profile and silent myocardial ischemia: Prospective follow up study of primary prevention in 72 diabetic patients. Diabetes Metab 2001;27:49–57. [9] Lamarche B, Moorjani S, Cantin B, Dagenais GR, Lupien PJ, Despres JP. Associations of HDL2 and HDL3 subfractions with ischemic heart disease in men: prospective results from the Quebec Cardiovascular Study. Arterioscler Thromb Vasc Biol 1997;17(6):1098–105. [10] Legato MJ. Dyslipidemia, gender, and the role of high-density lipoprotein cholesterol: implications for therapy. Am J Cardiol 2000;86(12A): 15L–18L.