HDL cholesterol subclasses,

myocardial infarction, and

mortality in secondary
prevention: the lipoprotein
investigators collaborative
Dipresentasikan oleh
Trismi Istiana

Pembimbing:
dr. Nahar Taufik SP.JP (K)
 Background
Coronary heart disease (CHD) remains a leading
cause of death and disability in Europe and the
USA.
HDL may confer cardiovascular protection
include cholesterol efflux from peripheral cells,
reverse cholesterol transport (RCT), anti-
inflammatory, antioxidative, anti-thrombotic,
and pro-endothelial actions..
HDL-C for predicting vascular risk in CHD
patients undergoing elective coronary artery
bypass grafting or cardiovascular mortality in
the setting of stable or unstable CHD.
 Background
HDL2-C : large, buoyant
HDL3-C : small, dense
HDL2-C or HDL3-C are most strongly
associated with lower risk (remains controversial)
prospective cohorts of secondary prevention
(i) the Translational Research Investigating
Underlying disparities in acute Myocardial
Infarction PatientsHealth status (TRIUMPH) study
(ii) the Intermountain Heart Collaborative Study
(IHCS) of patients undergoing coronary
angiography.
 Methods
Study design
Cohort
Unadjusted Kaplan Meier estimates
Adjusted Retricted cubic spline
curves and multivariable-adjusted
Cox proportional hazards regression
 Methods
TRIUMPH IHCS
between 11 April 2005 1 March 1999 - 5
and 1 December 2008 November 2007
24 centres in the USA, within the Intermountain
Healthcare System (LDS
Participants were Hospital: Salt Lake City,
included on the basis UT, USA; Intermountain
of acute myocardial Medical Center, Murray,
infarction (MI) UT, USA; and McKay Dee
Hospital, Ogden, UT, USA).
participants on the basis
of coronary angiography
for MI, unstable or stable
angina.
06/01/17
 Methods :
Definitions of clinical
presentations
TRIUMPH ICHS
MI was defined as MI was defined as
clinical features of clinical features of
ischaemia with cardiac ischaemia with
biomarker elevation cardiac biomarker
70% obstructive elevation additionaly
lesions by coro stable angina and
unstable angina
70% obstructive
lesions by coro
 Methods
Pengukuran kolesterol dan beberapa jenis
lemak lain (HDL-C, LDL-C, IDL-C, VLDL-C,
lipoprotein a (Lp.a), dan subclass ternasuk
subclas HDL2-C dan HDL3-C telah diukur
dengan alat yang sama metode Vertical
Auto Profile (VAP) yaitu Atherotech
Faktor Risiko juga ditampilkan pada kedua
kelompok penelitian
Pada kedua studi, mortalitas dinilai
menggunakan Social Security Death Index
 Methods
Lipid measurements
Cholesterol concentrations of lipoprotein classes [HDL-C, LDL-C,
intermediate-density lipoprotein cholesterol (IDL-C), very-low-
density
lipoprotein cholesterol (VLDL-C), and lipoprotein(a) [Lp(a)] and
subclasses
(including HDL2-C and HDL3-C) were measured in the same
laboratory by the Vertical Auto Profile (VAP) method
(Atherotech) .
Risk factor measurements
Follow-up and outcome adjudication
Result
 Result

06/01/17
Result
06/01/17
Result
 Discussion
this is the largest and most completely
adjusted observational study seeking to
define the independent associations of
HDL-C and its two major subclasses with
clinicalpatients with established CHD.
higher mortality in MI patients and
mortality or MI in patients undergoing
angiography to be strongly associated
with lowerHDL3-C, but not withHDL2-C
levels.
06/01/17
 KESIMPULAN
Worse prognosis is associated with low
HDL3-C

06/01/17
 Step 1: Formulating the
Foreground Question
Foreground Question: Is that true
that HDL-C subclasses can decresed
the mortality CHD so that it can be
applied in my clinical practice?
Patient
Participants has the same characteristic
compared with Indonesian? Nutritional
state? Immunological states?
applicable?
Intervention: What kind of intervention ?

 Step 2 EBM: Type of
Evidence
Source: A Primer, Original article (not
a systematic review or synopsis or
even expert opinion)
It (title and abstract) seems that the
study relevant with the foreground
clinical question:
Step 3: Critically Appraising
Quality of the Study -
Validity
Sampling Technique randomized
(high validity)
Number of subject: large enough
Comparison of subjects relatively
the same subject (paralle design
Generalisability clearly mentioned
with limitation
Step 3: Critically Appraising
Quality of the Study -
Validity
Measuring variables
(indicators/outcome):
Clearly mentioned

Controlling Confounding Factors

Paralled design with stricked
inclusion and exclusion criteria
Step 3: Critically Appraising
Quality of the Study
Importance
Therapeutic information to prevent
mortality
Outcome, patient oriented
decrease of mortality of patient with
CHD
Clinical significance
Step 3: Critically Appraising
Quality of the Study -
NO Applicability
Effectiveness of intervention (MBSR):
Characteristic of the subjects (USA) and
the community (INA) socioeconomic,
nutrition
Study hope versus patient hope same
Safety?
Cost ?
Feasible ? feasible
 Step 4: Applying the
Evidence - PICO
Patient Most article using non-
Indonesian people
Difference in nutritional status (INA
vs USA) is tolerable
Intervention clinically significant,
statistically significant
Comparison same comparison,
benefit, additive intervention.
Outcome patient oriented
 Conclusion
that the procedure can not be
applied in Indonesia.
Matur nuwun