© 2000 American Heart Association, Inc.
Atherosclerosis and Lipoproteins |
LDL Cholesterol as a Strong Predictor of Coronary Heart Disease in Diabetic Individuals With Insulin Resistance and Low LDL
The Strong Heart Study
From MedStar Research Institute and Washington Hospital Center (B.V.H., D.C.R., W.J.H.), Washington, DC; the Center for American Indian Health Research (E.T.L., O.T.G.), University of Oklahoma Health Sciences Center, Oklahoma City; the Department of Biostatistics and Epidemiology (L.D.C.), University of Oklahoma, Oklahoma City; Cornell University (R.B.D.), College of Medicine, Ithaca, NY; West Lothian NHS Trust (R.S.G.), St. John’s Hospital at Howden, Scotland, UK; the Native Elder Research Center (D.R.), University of Colorado Health Sciences Center, Denver; the Aberdeen Area Tribal Chairmen’s Health Board (T.K.W.), Rapid City, SD; and the National Institutes of Health (M.L.S.), Phoenix, Ariz.
Correspondence to Barbara V. Howard, PhD, MedStar Research Institute, 108 Irving St, NW, Washington, DC 20010. E-mail bvh1{at}mhg.edu
Abstract—Diabetes has been shown to increase the risk of coronary heart disease in all populations studied. However, there is a lack of information on the relative importance of diabetes-associated risk factors for cardiovascular disease (CVD), especially the role of lipid levels, because low density lipoprotein (LDL) cholesterol often is not elevated in diabetic individuals. The objective of this analysis was to evaluate CVD risk factors in a large cohort of diabetic individuals and to compare the importance of dyslipidemia (ie, elevated triglycerides and low levels of high density lipoprotein [HDL] cholesterol) and LDL cholesterol in determining CVD risk in diabetic individuals. The Strong Heart Study assesses coronary heart disease and its risk factors in American Indians in Arizona, Oklahoma, and South/North Dakota. The baseline clinical examinations (July 1989 to January 1992) consisted of a personal interview, physical examination, and drawing of blood samples for 4549 study participants (2034 with diabetes), 45 to 74 years of age. Follow-up averaged 4.8 years. Fatal and nonfatal CVD events were confirmed by standardized record review. Participants with diabetes, compared with those with normal glucose tolerance, had lower LDL cholesterol levels but significantly elevated triglyceride levels, lower HDL cholesterol levels, and smaller LDL particle size. Significant independent predictors of CVD in those with diabetes included age, albuminuria, LDL cholesterol, HDL cholesterol (inverse), fibrinogen, and percent body fat (inverse). A 10-mg/dL increase in LDL cholesterol was associated with a 12% increase in CVD risk. Thus, even at concentrations well below the National Cholesterol Education Program target of 130 mg/dL, LDL cholesterol is a strong independent predictor of coronary heart disease in individuals with diabetes, even when components of diabetic dyslipidemia are present. These results support recent recommendations for aggressive control of LDL cholesterol in diabetic individuals, with a target level of <100 mg/dL.
Key Words: low density lipoprotein cholesterol • coronary heart disease • diabetes mellitus • insulin resistance • Indians, North American
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