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Commentary

Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update

Jacques Genest, Jiri Frohlich, George Fodor and Ruth McPherson
CMAJ October 28, 2003 169 (9) 921-924;
Jacques Genest
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Jiri Frohlich
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George Fodor
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Ruth McPherson
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  • Cardiovascular Prevention and Dyslipidemia Management
    Eddie Vos
    Posted on: 28 November 2003
  • VASCULAR DISEASES IN A THIRD WORLD COUNTRY
    CELIO LEVYMAN,MD,MSc
    Posted on: 04 November 2003
  • Posted on: (28 November 2003)
    Page navigation anchor for Cardiovascular Prevention and Dyslipidemia Management
    Cardiovascular Prevention and Dyslipidemia Management
    • Eddie Vos
    Dear Editor

    This concerns the dyslipidemia management and cardiovascular prevention review by J. Genest et al, as published on the Internet only [CMAJ Oct. 28, 2003; 169 (9)]. The review deals much with the statin issue but since the 3 most recent large studies, PROSPER, ALLHAT and ASCOT failed to show any all-cause mortality benefit from stati...

    Show More
    Dear Editor

    This concerns the dyslipidemia management and cardiovascular prevention review by J. Genest et al, as published on the Internet only [CMAJ Oct. 28, 2003; 169 (9)]. The review deals much with the statin issue but since the 3 most recent large studies, PROSPER, ALLHAT and ASCOT failed to show any all-cause mortality benefit from statins and a 4th, HPS, has not published cumulative mortality data, we shall leave this issue to others after pointing out that the failure to reduce all-cause mortality even in high-risk groups from cholesterol lowering [paraphrase from the ALLHAT website] supports the urgency to explore other routes in secondary and certainly in primary prevention.

    As the authors point out, there is much potential in homocysteine lowering with high-dose multi B-vitamins, an approach supported by many hundreds of studies but that still lacks placebo controlled trials. As proposed, we indeed need trials that treat to the suggested 9 µmol/L target or, one may suggest, to a target near 6 µmol/L. To our knowledge, there are no reported fatalities from no-iron containing over the counter multi-vitamins, the only therapy known to lower homocysteine and an urgent issue in the French Canadian population that appears to have a relatively high incidence of genetic enzyme impediments in metabolizing homocysteine.

    Other than the above, our main concern with the recommendation is the suggestion to "..increase the proportion of mono- and polyunsaturated fats in the diet while decreasing the proportion of saturated fats..".  All common vegetable oils except olive and canola, e.g. soybean, corn, cottonseed, sunflower and safflower, contain over 50% linoleic acid, a potentially pro-inflammatory omega-6 fatty acid that may already provide 2 or 3x over the ISSFAL proposed maximum of 3% of energy intake [adequate: 2%]. Demonstrated as early as 35 years ago in the Veterans Trial, the replacement of saturated fat and cholesterol with high omega-6 oil did not decrease all-cause mortality but there was an about doubled cancer mortality after 8 and 9 years, a cancer problem also suggested by PROSPER's 24 more cancer deaths in a smaller pravastatin group with fewer smokers. The failure of the trials of dietary fat changes, other than those involving omega-3's, was high-lighted in the meta analysis by L. Hooper et al BMJ 2001.

    The recommendation to increase plant-based omega-3 [good sources: canola: 10%, flax oil: 55% and walnut oil: 10%] as well as fish-based omega-3 is clearly well supported, and here we refer to an important omega-3 editorial by A. Leaf in Circ.1999;99:733-735. However, and in summary, the vast majority of store-shelf poly-unsaturates are of the relatively pro-inflammatory omega-6 family of fatty acids and of which an increased consumption is not supported by controlled trial data.

    [all hyperlinks accessed 27-11-2003]

    Eddie Vos (corresponding) www.health-heart.org Sutton (Qc) J0E 2K0 vos@health-heart.org
    Colin Rose, M.D., cardiologist, Montreal (Qc) colin.rose@mcgill.ca

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Posted on: (4 November 2003)
    Page navigation anchor for VASCULAR DISEASES IN A THIRD WORLD COUNTRY
    VASCULAR DISEASES IN A THIRD WORLD COUNTRY
    • CELIO LEVYMAN,MD,MSc

    The prevention of vascular diseases, cardiac and neurological pointed out by this paper, shows the great problem of overweight not only in USA, but in Canada either. Here in Brazil, South America, we have a paradoxes conditions: large areas of poverty and famine, but people also with risk factors to cardiovascular and stroke problems, side by side with the typical Third World problems, as parasitary problems, Chaga’s dise...

    Show More

    The prevention of vascular diseases, cardiac and neurological pointed out by this paper, shows the great problem of overweight not only in USA, but in Canada either. Here in Brazil, South America, we have a paradoxes conditions: large areas of poverty and famine, but people also with risk factors to cardiovascular and stroke problems, side by side with the typical Third World problems, as parasitary problems, Chaga’s disease, etc.The vascular risks don’t pay attention to the economic status of a country.

    The novel and left-winged federal government are making strong fights in regard to social benefits (the “Fome Zero” program), but public health doctors here don’t have special preoccupations about vascular diseases. And the Brazilian people can develop sub nutrition with overweight, with laboratory alterations of C-protein, apolipoprotein, homicystein, etc.

    In our large country we adopt, in the regions where are possible, something like a blind prevention, with aspirin, one statin,folic acid and vitamin E.A lot of physicians of the developed country don’t like this type of prevention for all people, without a look of individual things, like microalbuminuria,gastric problems, and so. A strong debate in regard of this issue were occurred in the British Medical Journal e-letters, after a paper of Wald et al proposal of a kind of “polypill”.However, is comfortable criticism of UK doctors – we use the gold standard and evidence-based guidelines in the great cities and hospitals; and as I pointed before, in a lot of places is better a prevention stratetegy, because we can observe cases of malnutrition with stroke sequels, for instance.

    This Canada report is very important to physicians, like neurologists, to provide material to the health authorities of this country to prevent also the vascular diseases.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
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Canadian Medical Association Journal: 169 (9)
CMAJ
Vol. 169, Issue 9
28 Oct 2003
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Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update
Jacques Genest, Jiri Frohlich, George Fodor, Ruth McPherson
CMAJ Oct 2003, 169 (9) 921-924;

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Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update
Jacques Genest, Jiri Frohlich, George Fodor, Ruth McPherson
CMAJ Oct 2003, 169 (9) 921-924;
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