Patrick Couture,MD, FRCP(C), PhD, Lipid Research Center, Laval University Medical Center, Laval,QC.
Nancy Gilbert, RN, Lipid Research Center, Laval University Medical Center, Laval,QC.

Several lines of evidence suggest that triglyceride-rich lipoproteins contribute significantly to the development of atherosclerosis. However, the relationship between cardiovascular disease and plasma levels of triglyceride remains complex due to the presence of two major confounders: (1) the inverse relationship between plasma triglyceride levels and highdensity lipoprotein-cholesterol and (2) the heterogeneity in triglyceriderich lipoprotein size, number, and composition between individuals. Plasma apo-B measurement is recommended for patients with high triglyceride levels to identify their risk category.The goals of lipidmodifying therapy for these patients are to reduce the atherogenic lipoprotein number and to increase HDL particle number.
Keywords: triglyceride, lipoprotein, atherosclerosis, coronary heart disease, cholesterol.

D. Larry Sparks, PhD, Senior Scientist and Head, Roberts Laboratory for Neurodegenerative Disease Research, Sun Health Research Institute, Sun City, AZ, USA.

The primary care physician is often pressed with first-line treatment of Alzheimer’s disease (AD). A number of FDA-approved therapies are available. Emerging data indicate that circulating cholesterol levels may influence progression of the dementing disorder. A recent pilot, proof-of-concept, placebo-controlled clinical trial suggests that the cholesterol-lowering medication atorva-statin provides benefit in treating mild-to-moderate AD. Although not approved for the treatment of AD, statin therapy might be considered in the setting of elevated cholesterol levels--even when LDL/HDL ratios are acceptable.
Key words: Alzheimer’s disease, cholesterol, statins, dementia, atorvastatin.

Fatim Ajwani, BSc RD, ARAMARK Canada Ltd at the Toronto Rehabilitation Institute, Toronto, ON.
Maria Ricupero, BA, RD, CDE, ARAMARK Canada Ltd at the Toronto Rehabilitation Institute, Toronto, ON.

Dietary trans fatty acids (TFA) have been implicated in contributing to cardiovascular disease (CVD). Higher intakes of industrial TFA negatively impact cholesterol and inflammation levels, endothelial function, and LDL particle size. Dietary TFA are also associated with myocardial infarction and death. Due to the negative impact of TFA on cardiovascular health, the current recommendation is to keep total TFA intake to less than 2 grams/day. New labeling legislation has made it easier to achieve this goal. However, nutrition claims can be misleading. Despite positive new changes, patient counseling will still be required for accurate and careful interpretation of nutrition information.
Key words: trans fatty acids, diet, cholesterol, cardiovascular disease, conjugated linoleic acid.

David Fitchett, MD, FRCP(C), Cardiologist, St. Michael’s Hospital; Associate Professor of Medicine, University of Toronto, Toronto, ON.

Coronary and cerebrovascular disease is the leading cause of death and disability in the older population. Control of vascular risk factors such as blood pressure, lipids, and glucose is important in higher risk patients to reduce the impact of stroke and myocardial infarction, whatever their age. Although total and LDL cholesterol levels are less predictive of coronary heart disease in the older patient, clinical trials demonstrate an important benefit from statin therapy in high-risk individuals over a wide age range with either established cardiovascular disease or diabetes. Older patients with multiple risk factors for vascular disease, yet without coronary, cerebrovascular, or peripheral vascular disease, should also be considered for statin treatment.
Key words: cholesterol, lipid management, statin, cardiovascular disease.

Raymond Fung, MD, BSc, Fellow, Division of Endocrinology, University of Toronto, Toronto, ON.

Lorraine L. Lipscombe, MD, FRCPC, Clinical Associate, Research Fellow, Division of Endocrinology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

The prevalence of diabetes has been increasing significantly in the last several years, especially in the older population. Cardiovascular disease (CVD) represents the most important complication of diabetes in this age group, as up to 80% of persons with diabetes die from CVD. The treatment of dyslipidemia and hypertension are both key in ameliorating CVD risk. Recent randomized controlled trials have included older persons with diabetes and have demonstrated that both statin therapy for dyslipidemia and antihypertensive agents are highly effective and safe in preventing CVD in this population. This review will examine the evidence for treatment in both areas, outlining the special considerations in the aged.

Key words: diabetes mellitus, cardiovascular disease, statins, hypertension, cholesterol.

James Shepherd, MD, PhD, Institute of Biochemistry, Royal Infirmary, Glasgow, Scotland, UK.

In the last two decades the prevalence of stroke, diabetes mellitus, and heart disease has increased significantly as a tangible index of aging in the population. All these diseases are increasing the strain on community health care and social services. Policy-makers need to understand and monitor these trends in order to make informed and cogent decisions about the management of this growing problem. This review highlights some of the key health issues facing older adults in regard to vascular disease and statin therapy in the hope that enlightened debate will inform decision makers in resource allocation for this important and growing segment of society.

Key words: statins, PROSPER, vascular risk reduction, economic evaluations, cholesterol.

Milita Crisby, MD, PhD, Neurotec Department, Division of Geriatric Medicine, Stockholm, Sweden.

The interaction of genetic and multiple environmental factors contributes to the development of Alzheimer disease (AD). Hypertension and hypercholesterolemia have been identified as risk factors for ischemic heart disease (IHD). Recent epidemiological data also have revealed an association between hypercholesterolemia and AD. Experimental models of AD and in vitro studies have shown that cholesterol modulates the amyloidogenic pathway in favour of production and deposition of amyloid in the brain. Dysregulation of the lipid metabolism in the brain due to apolipoprotein E4 or 24-hydroxylase polymorphisms has been observed in patients with AD and related dementias. Furthermore, observational studies have revealed that statin use could have a potential role in the prevention of AD.
Key words: cholesterol, statins, lipid-lowering, Alzheimer disease, neurodegeneration.

Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Department of Medicine, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY.

Serum High-Density Lipoprotein Cholesterol
A low serum, high-density lipoprotein (HDL) cholesterol is a risk factor for the development of new coronary events in older men and women.^1-6 In the Framingham Heart Study,¹ in the Established Population for Epidemiologic Studies of the Elderly Study,⁴ and in 2,152 older men and women,³ a low serum HDL cholesterol was a more powerful predictor of new coronary events than was serum total cholesterol. In 1,793 older men and women, mean age 81 years, a decrease of 10 mg/dL (0.26 mmol/L) of serum HDL cholesterol significantly increased by 2.56 times, the probability of having coronary artery disease after controlling for other prognostic variables.² At 48-month follow-up of 1,488 older women, mean age 82 years, and at 40-month follow-up of 664 older men, mean age 80 years, a decrease of 10 mg/dL (0.26 mmol/L) of serum HDL cholesterol significantly increased the relative risk of developing new coronary events by 1.95 times in women and by 1.7 times in men, after controlling for other prognostic variables.