|Year : 2019 | Volume
| Issue : 3 | Page : 1117-1122
Tracking lipid profile and atherogenic indices in the prediabetics of Andaman Nicobar Islands: A retrospective hospital-based study
Montosh Chakraborty1, Shivakrishna Gouroju2, Prerna Singh2, Pandurang V Thatkar3, Debajit Bagchi2
1 Department of Biochemistry, AIIMS, Mangalagiri, Guntur, Andhra Pradesh, India
2 Department of Biochemistry, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
3 Department of Community Medicine, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India
|Date of Web Publication||27-Mar-2019|
Dr. Montosh Chakraborty
Department of Biochemistry, AIIMS, Mangalagiri, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Context: Cardio vascular disease (CVD) is the leading cause of mortality and morbidity in diabetes mellitus (DM) contributing to 65% of all deaths with diabetic complications. The most important cause of CVD is atherosclerosis, and dyslipidemia acts as a marker of developing atherosclerosis. The derangement of lipid profile and atherogenic indices start in the prediabetic state, much before the development of DM. Detection of the deranged lipid profile and atherogenic indices in the prediabetic state can help devise the aggressive treatment strategy right from this stage, so as to arrest the development of CVD as a complication of diabetes. Aims: To compare the lipid profile and atherogenic indices of prediabetics with controls and diabetics. Settings and Design: The electronic medical records of 239 subjects were reviewed retrospectively. Materials and Methods: About 187 cases consisting of 137 diabetics and 50 prediabetics were evaluated for serum fasting blood sugar, post prandial blood sugar, HbA1c, total cholesterol (TC), triglycerides (TGs), high-density lipoprotein cholesterol (HDLc), and low-density lipoprotein cholesterol (LDLc). Atherogenic indices [TC/HDLc, LDLc/HDLc, (TC-HDLc)/HDLc, TG/HDLc] were also evaluated in the two groups. Rest 52 age- and sex-matched subjects were taken as controls. Statistical Analysis Used: The comparisons were evaluated using SPSS statistical package version 20. Results: TC, TG, LDLc, and the atherogenic indices were significantly increased in prediabetics as compared with controls. HDLc was significantly decreased in prediabetics. Conclusions: The altered lipid profile and atherogenic indices in prediabetics signify the increased susceptibility of prediabetics to CVD in the long run. Hence, we recommend screening of prediabetics for dyslipidemia to arrest the development of cardiovascular complications.
Keywords: Atherogenic indices, cardiovascular diseases, diabetics, lipid profile, prediabetics
|How to cite this article:|
Chakraborty M, Gouroju S, Singh P, Thatkar PV, Bagchi D. Tracking lipid profile and atherogenic indices in the prediabetics of Andaman Nicobar Islands: A retrospective hospital-based study. J Family Med Prim Care 2019;8:1117-22
|How to cite this URL:|
Chakraborty M, Gouroju S, Singh P, Thatkar PV, Bagchi D. Tracking lipid profile and atherogenic indices in the prediabetics of Andaman Nicobar Islands: A retrospective hospital-based study. J Family Med Prim Care [serial online] 2019 [cited 2020 Feb 26];8:1117-22. Available from: http://www.jfmpc.com/text.asp?2019/8/3/1117/254882
| Introduction|| |
Diabetes mellitus (DM) is considered to be a global pandemic nowadays. The prevalence of diabetes worldwide stands at 8.3% as per the data recorded in 2013 and this magic figure is expected to reach 10.1% by 2035 of which 80% will be in the developing countries. India stands out way ahead as the diabetic capital of the world with 69.1 million diabetics. The prevalence of diabetes in many Indian cities stands in between 9% and 12% with a national average of 7.7% in 2016. It is a slowly developing but progressive condition; and it can take many years to progress from prediabetic to diabetic state without interventions.
The American Diabetes Association (ADA) defines prediabetes as impaired fasting glucose (100–125 mg/dL), impaired glucose tolerance (2-h glucose level of 140–199 mg/dL during an oral glucose tolerance test), or glycated hemoglobin (HbA1c) level of 5.7%–6.4% or both. Many studies have reported that lifestyle modifications in the prediabetic stage can not only delay the development of DM by ≥10 years, but it can also prevent the development of the disease. This increases the quality of life and life expectancy and reduces the economic burden on the society., Prevalence of prediabetes in India stands in between 10% and 14% as against the global prevalence of 8%., Around 70% of the prediabetics eventually develop diabetes if not managed early., The annual turnover rate being 5%–10%.
Cardio vascular disease (CVD) is the leading cause of mortality and morbidity in DM and according to some estimates it accounts for approximately 75%–80% of overall deaths with diabetic complications. It has also been found to be significantly associated with prediabetes., Among the causal factors of CVD, atherosclerosis is the foremost. Dyslipidemia, frequently occurring in diabetic patients, plays a critical role in the acceleration of macrovascular atherosclerosis and thus contribute to the excess risk of CVD.
Mere absence of a deranged lipid profile does not exclude the possibility of CVD. In 2008, Glasziou et al. in their study concluded that low-density lipoprotein cholesterol (LDLc)-based therapy leads to either undertreatment or overtreatment of patients with CVD. Therefore, it was assumed that markers other than LDLc such as non-high-density lipoprotein cholesterol (HDLc) and atherogenic indices have higher significance in cardiovascular risk management and identification of individuals at risk.
The fatality of this silent killer/DM lies in the fact that it escapes detection or prewarning in its inceptive stage, and by the time it is detected, it has already started its damaging effects. With such a high prevalence of prediabetes in our country, the role of primary care physicians become very significant. The first level of contact with the physician can lead to the chance diagnosis of prediabetes as the stage is almost bereaved of symptoms. Due to the significant dyslipidemia and the resulting cardiovascular morbidity and mortality in cases of DM, diagnosis of this impending disease at the level of prediabetes and the state of lipid profile and other atherogenic indicators in the prediabetic stage will help devise the aggressive treatment strategy and management of such patients so as to nip the disease in its budding stage.
The aim of this study was to compare the lipid profile along with atherogenic indices (Castelli's risk index I, Atherogenic index, Atherogenic coefficient (AC), Surrogate marker of insulin resistance) of prediabetics with controls and diabetics. There are very few studies in India doing the same and is the first of its kind in the union territory of Andaman and Nicobar Islands.
| Materials and Methods|| |
The retrospective study reviewed the electronic medical records of 187 patients included over a six month period from February 2017 to July 2017 and whose blood samples were sent to the Department of Biochemistry for analysis. Patients with history of renal disorders, hypothyroidism, smokers, alcoholics, those on lipid lowering therapy, and hypoglycemic drugs were excluded from the study. About 187 patients were divided into two study groups: prediabetics and diabetics. The prediabetic group included the following criteria: fasting glucose (100–125 mg/dL), impaired glucose tolerance (2-h glucose level of 140–199 mg/dL after a standardized meal), and glycosylated hemoglobin (HbA1c) level of 5.7%–6.4%.
Diabetic group was selected as per ADA guidelines. Diabetics with history of the disease for ≥1 year and not on any form of treatment or dietary management for the last 1 year are included in the study so as to get a fair picture of the effect of hyperglycemia on the lipid profile indices. Fifty-two age- and sex-matched controls were taken for the study.
Fasting venous blood samples were collected for the photometric estimation of lipid profile in CST 240 clinical chemistry analyser, Snibe diagnostics, China, using homogenous assay kits.,,, Fasting blood sugar (FBS), 2-h postprandial blood glucose (PPBG) after a standardized meal were estimated on venous blood samples, which were analyzed by spectrophotometry using Biolabo kits. Samples for HbA1c were analyzed by immunoturbidimetric assay using Biolabo kits. The Atherogenic ratios were calculated as follows:,,,
Castelli's Risk Index-I (CRI-I) = TC (Total cholesterol)/HDLc
Atherogenic Index (AI) = LDLc/HDLc
Atherogenic Coefficient (AC) = (TC–HDLc)/HDLc
Surrogate marker of Insulin resistance = TG (triglycerides)/HDLc
Westgard's rules were followed for monitoring the internal quality control on the analyzer. During the course of the study, there was no change in the equipment, reagents, calibration standards, and controls.
LDLc, very low density lipoprotein cholesterol, and CVD risk was calculated using appropriate formulae and continuous variables were expressed as mean ± standard deviation (SD). The normality of data was tested using Kolmogorov–Smirnov test and Shapiro Wilk test. The comparisons were evaluated by Kruskal Wallis test (nonparametric analysis of variance) using SPSS statistical package version 20. Mann–Whitney U-test was applied following statistically significant value to identify pairwise differences. The association between the groups and lipid profile was analyzed using Pearson's correlation analysis. A P value < 0.05 was considered statistically significant.
| Results|| |
In total, 187 cases were included in the study of which 137 (73%) were diabetics and 50 (26.7%) were prediabetics. Fifty-two controls were also evaluated. Of the total cases, 86 (45.9%) were males and 101 (54.0%) were females as shown in [Table 1]. The mean age of diabetics was found to be 52.51 ± 10.73 years and that of prediabetics 52.90 ± 11.71 years. Interpreting it with the help of table IV, we find that there is no statistically significant difference in the age distribution of prediabetics, diabetics, and controls (P value >0.05) in the study population.
[Table 2] shows the mean ± SD of FBS, 2-h PPBG and HbA1c in the study groups. A highly significant difference (P-value <0.01) is observed in the blood sugar indices (FBG, PPBG, HbA1c) when compared between the study groups. [Table 3] summarizes the difference in the means of these parameters and their statistical significance.
|Table 3: Multiple comparisons of glycemic indices (FBS, PPBS, and HbA1c) in the study groups|
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[Table 4] compares the lipid profile parameters along with the atherogenic ratios in the different study groups. [Table 5] depicts the difference in the means of these parameters and their statistical significance. TC, TG, LDLc, and the different atherogenic ratios were significantly raised in the prediabetic group in comparison to the control group (P-value <0.001) except TG/HDLc.
|Table 5: Multiple comparisons of lipid profile and atherogenic indices in the study groups|
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| Discussion|| |
The prediabetics were diagnosed only on the presence of both the criteria as given by ADA for the same so that the lipid profile indices are a true reflection of prediabetic state. Second, we took cut off for normal fasting blood sugar <110 mg/dL, because in India, it is commonly used by the biochemists and clinicians. Diabetics who were not on treatment for the last ≥1 year are included in the study so as to get a fair picture of the effect of hyperglycaemia on the lipid profile indices.
The mean age of prediabetics and diabetics in our study is almost in coherence with the study by Bhatnagar MK et al. Among the cases whose records were reviewed, 54.01% were females. This might be because of the high turnout of females in the OPD as compared with males as most of the females were housewives and could attend the OPD in the office hours.
The mean total cholesterol (TC) as found in our study in the prediabetic group was 223.64 ± 17.20 mg/dL which is significantly higher (P-value <0.01) than the control group (155.25 ± 15.67 mg/dL). Diabetics have serum TC of 287.09 ± 34.72 mg/dL, which, in turn, is significantly higher than both prediabetics and controls. Higher amount of glucose results in increased synthesis of pyruvate and then citrate in the Krebs cycle pathway. Citrate can move out of mitochondria and can form acetyl CoA in the cytosol. This acetyl CoA in case of glucose surplus state can be channeled to cholesterol synthesis. Ford et al. found that TC in prediabetics of 211 mg/dL and 196 mg/dL in a National Health and Nutrition Examination survey (NHANES), USA, in two successive periods (from 1988 to 1991 and 2005 to 2008, respectively) on age adjustment. The diabetics in this study were found to have a better lipid profile than prediabetes. This might be because most of the diabetics were on medications. Kansal et al. in their study found mean TC of 184.75 ± 46.02 mg/dL in the prediabetic study group. The difference in the observed value might be attributed to the stringent criteria of selection of prediabetic cases in our study.
The mean serum TG in prediabetics as found in our study was 151.74 ± 33.14 mg/dL as compared with 107.23 ± 18.89 mg/dL in controls, which is significantly lower (P-value <0.01). The value for the same in case of diabetics stands at 219.77 ± 59.82 mg/dL, which is significantly higher than the prediabetics and controls (P value <0.01). The same value in NHANES study was found to be 137 mg/dL. Similarly, Miyazaki et al. in their study observed raised TG levels in prediabetic subjects. This might be due to the reduced activity of hepatic lipase and lipoprotein lipase, the clearing agent of Tg from the circulation, due to the decrease in activity of insulin. Also there's increased hepatic synthesis of VLDL due to the excess substrates available.
In our study, the mean total LDLc in prediabetics was significantly higher than the controls (152.19 ± 16.91 vs 87.11 ± 15.77 mg/dL). Diabetics have a higher LDLc than the prediabetics and controls (P value <0.05). Shin et al. also found LDLc to be significantly higher in prediabetic subjects (150.5 ± 38 mg/dL) than nondiabetic controls (134 ± 34.6 mg/dL). They also proved that there was a correlation between raised blood glucose level and LDLc. The same was found to be 138 and 118 mg/dL in the two successive periods in NHANES study. The increase in glycemia causes glycation of apoprotein B lysine residues, thus making it unable to be recognized by LDL receptor and hence decreased catabolism of LDLc.
The prediabetic population in our study was found to have significantly lower serum HDLc than the controls (41.10 ± 3.07 vs 46.69 ± 4.80 mg/dL). In the same line, the mean HDLc in diabetics is still significantly lower than the other two study groups. Shin et al. also found significantly lower HDLc in prediabetic subjects (49.9 ± 11.6 mg/dL) as compared with nondiabetic controls (54.7 ± 13.3 mg/dL). Increased VLDL as mentioned above is acted upon by cholesterol ester transfer protein to form small HDLc, which is easily cleared from the circulation. This leads to decrease in the serum level of HDLc and apoA1. Hence, increase in production of VLDL-TG ends in atherogenic reduction of HDL, intravascular remodeling, and reduced reverse cholesterol transport from peripheral tissues, hepatocytes and macrophages to liver, further aggravating atherosclerosis.
It is considered a surrogate marker of insulin resistance and hence an indicator of the cardio metabolic profile. McLaughlin et al. in their study concluded that TG/HDL ratio >3.5 predicts insulin resistance. We found a mean value of 3.71 ± 0.88 in prediabetics and 9.15 ± 3.89 in diabetics. Nayak et al. in their study on 83 prediabetic cases found the corresponding mean value to be 3.9. Ozder et al. in their study found a value of 7.98 ± 3.8 mg/dL in the diabetic group.
Atherogenic coefficient (TC-HDLc)/HDLc
Atherogenic coefficient is a measure of all lipoproteins that are considered to be atherogenic (VLDL, LDL, IDL, Lpa) with respect to good cholesterol or HDLc. It reflects the atherogenic potential of the entire spectrum of lipoprotein fractions. Non-HDLc has been considered as the second target of therapy after LDLc as per National Cholesterol Education Program Adult Treatment Panel III guidelines especially in individuals with hypertriglyceridemia. It enjoys the same status as Apo-B in assessing atherogenic cholesterol and lipoprotein burden. Prediabetic group in our study recorded a mean value of >4.0, which is significantly higher than controls. Mahat et al. in their study on the prediabetic cases in the city of Gwalior, India, found the value to be 4.87 ± 0.87 vs 3.23 ± 0.50 in controls. Ranjit et al. in their study, however, found a mean value of 4.62 ± 0.19 in coronary artery disease (CAD)-positive diabetic subjects.
Castelli's risk index-I (TC/HDLc)
CRI-I has been considered as a secondary goal of therapy by the Canadian working group for the treatment of dyslipidemia, particularly in individuals with TG >300 mg/dL. It is a more sensitive and specific index of cardiovascular risk than the routine lipid profile parameters and hence a marker of atherogenic dyslipidemia. The value was found to be >5 in prediabetics, which is significantly higher than the controls. The same was found to be 5.87 ± 0.57 in the prediabetic cases by Mahat et al. Ranjit et al. found the value to be >5.6 in the CAD-positive diabetic dyslipidemic subjects.
Atherogenic index (LDLc/HDLc)
In the PROCAM study, it was observed that subjects with LDL-c/HDL-c (CRI-II) >5 showed six times higher rate of coronary events. AI >4.1 is considered as a risk factor for the development of CAD, whereas it indicates a protective effect when the value <4.1. In our study, the corresponding value for prediabetics was found to be 3.73 ± 0.54, which was significantly higher than the controls. It was found to be >9 in diabetics. However, in a study by Miyazeki et al., no statistically significant difference in AI was observed between prediabetics and controls.
| Conclusion|| |
TC, LDLc, TG, and VLDLc were significantly raised in prediabetics as compared with normal healthy subjects, whereas HDLc was decreased significantly in prediabetics. The raised atherogenic indices as discussed in the study point toward their increased susceptibility for cardiovascular complications. Hence, we recommend screening of prediabetics for dyslipidemia to arrest the development of early cardiovascular complications.
Limitations of the study
Patients with H/O hemoglobinopathies could not be ruled out due to the unavailability of the investigation in the hospital during the period.
I am thankful to the technicians, Department of Biochemistry and Medical Records Department, ANIIMS, Port Blair for furnishing the requisite information for the paper.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tandon N, Anjana RM, Mohan V, Kaur T, Afshin A. The increasing burden of diabetes and variations among the states of India: The Global Burden of Disease Study 1990–2016. Lancet Global Health 2018. Published online September 12, 2018. doi: 10.1016/S2214-109X (18) 30387-5.
Lindström J, Peltonen M, Eriksson J, Ilanne-Parikka P, Aunola S, Keinänen-Kiukaanniemi S, et al
. Improved lifestyle and decreased diabetes risk over 13 years: Long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia 2013;56:284-93.
Inzucchi SE. Diagnosis of diabetes. N Engl J Med 2012;367:542-50.
American Diabetes Association Economic costs of diabetes in the US in 2012. Diabetes Care 2013;36:1033-4.
Zhang Y, Dall TM, Chen Y, Baldwin A, Yang W, Mann S, et al
. Medical cost associated with prediabetes. Popul Health Manag 2009;12:157-63
Anjana RM, Pradeepa R, Deepa M. ICMR– INDIAB Collaborative Study Group. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research-INdiaDIABetes (ICMRINDIAB) study. Diabetologia 2011;54:3022-7.
Anjana RM, Deepa M, Pradeepa R, Mahanta J, Narain K, Das HK, et al
. Prevalence of diabetes and prediabetes in 15 states of India: Results from the ICMR–INDIAB population-based cross-sectional study. Lancet Diabetes Endocrinol 2017;5:585-96.
Tabak AG, Herder C, Rathmann W, Brunner EJ, Kivimaki M. Prediabetes: A high-risk state for developing diabetes. Lancet 2012;379:2279-90.
The Diabetes Prevention Program (DPP) Research Group. The diabetes prevention program (DPP): Description of lifestyle intervention. Diabetes Care 2002;25:2165-71.
Animaw W, Seyoum Y. Increasing prevalence of diabetes mellitus in a developing country and its related factors. PLoS One 2017;12:e0187670.
Huang Y, Cai X, Mai W, Li M, Hu Y. Association between prediabetes and risk of cardiovascular disease and all cause mortality: Systemic review and meta-analysis. BMJ 2016;355:i5953.
Bhowmik B, Siddiquee T, Mujumder A, Afsana F, Ahmed T, Mdala IA, et al
. Serum lipid profile and its association with diabetes and prediabetes in a rural Bangladeshi population. Int J Environ Res Public Health 2018;15:1944.
Glasziou PP, Irwig L, Heritier S, Simes RJ, Tonkin A. Monitoring cholesterol levels: Measurement error or true change? Ann Intern Med 2008;148:656-61.
Allain CC, Poon LS, Chan CS, Richmond W, Fu PC. Enzymatic determination of total serum cholesterol. Clin Chem 1974;20:470-5.
Fossati P, Principe L. Serum triglycerides determined colorimetrically with an enzyme that produces hydrogen peroxide. Clin Chem 1982;28:2077-80.
Trinder P. Estimation of Serum Triglyceride. Ann Clin Biochem 1969;6:27-9.
Tietz NW. Clinical Guide to Laboratory Test. 4th
ed. 2006. p. 564-9.
Farrance I. Plasma glucose methods, a review. Clin Biochem Rev 1987;8:55-68.
Burtis CA, Ashwood ER, Saunders WB, Tietz NW. Textbook of Clinical Chemistry. 3rd
ed. 1999. p. 798-800.
Ridker PM, Stampfer MJ, Rifai N. Novel risk factors for systemic atherosclerosis: A comparison of C-reactive protein, fibrinogen, homocysteine, lipoprotein(a), and standard cholesterol screening as predictors of peripheral arterial disease. JAMA 2001;285:2481-5.
Bo MS, Cheah WL, Lwin S, New TM, Win TT, Aung M. Understanding the relationship between atherogenic index of plasma and cardiovascular disease risk factors among staff of an University in Malaysia. J Nutr Metab 2018;2018. doi: 10.1155/2018/7027624.
Kazemi T, Hajihosseini M, Moossavi M, Hemmati M, Ziaee M. Cardiovascular risk factors and atherogenic indices in an Iranian population: Birjand East of Iran. Clin Med Insights Cardiol 2018;12:1-6.
Brehm A, Pfeiler G, Pacini G, Vierhapper H, Roden M, Relationship between serum lipoprotein ratios and insulin resistance in obesity. Clin Chem 2004;50:2316-22.
Bhatnagar MK, Goel A, Jagdish RK, Sud R. Pattern of dyslipidemia in prediabetes and diabetes- A pilot study. Asia Pac J Res 2016;I: 76-80.
Ford ES, Li C, Sniderman A. Temporal changes in concentrations of lipids and apolipoprotein B among adults with diagnosed and undiagnosed diabetes, prediabetes, and normoglycemia: Findings from the National Health and Nutrition Examination Survey 1988-1991 to 2005-2008. Cardiovasc Diabetol 2013;12:26.
Kansal S, Kamble TK. Lipid profile in prediabetes. JAPI 2016;64:18-21.
Miyazaki Y, Furugen M, Akasaka H, Saitoh S, Miura T. Atherogenic lipids profile relates to postprandial hyperglycemia and hyperinsulinemia due to whole body insulin resistance in prediabetic subjects. J Diabetes Mellitus 2012;2:272-8.
Goldberg IJ. Lipoprotein lipase and lipolysis: Central roles in lipoprotein metabolism and atherogenesis. J Lipid Res 1996;37:693-707.
Shin JY, Lee HR, Lee DC. Increased arterial stiffness in healthy subjects with high normal glucose levels and in subjects with prediabetes. Cardiovasc Diabetol 2011;10:30.
Kim-Dorner SJ, Deuster PA, Zeno SA, Remaley AT, Poth M. Should triglycerides and the triglycerides to high-density lipoprotein cholesterol ratio be used as surrogates for insulin resistance? Metabolism 2010;59:299-304.
McLaughlin T, Reaven G, Abbasi F, Lamendola C, Saad M, Waters D, et al
. Is there a simple way to identify insulin resistant individuals at increased risk of cardiovascular disease? Am J Cardiol 2005;96:399-404.
Ozder A. Lipid profile abnormalities seen in T2DM patients in primary healthcare in Turkey: A cross-sectional study. Lipids Health Dis 2014;13:183.
Nayak VKR, Raghurama Nayak K, Vidyasagar S, Kamath A. Body composition analysis, anthropometric indices and lipid profile markers as predictors for prediabetes. PLoS One 2018;13:e0200775.
Subia J, Afshan S. Comparison of CVD risk associated with the long term use of contraceptives in young females. J App Pharm Sci 2012;2:62-6.
Mahat R, Singh N, Rathore V, Gupta A, Shah R. Relationship between atherogenic indices and carotid intima-media thickness in prediabetes: A cross-sectional study from Central India. Med Sci 2018;6. doi: 10.3390/medsci6030055.
Ranjit PM, Guntuku GS, Pothineni RB. Comparison of lipid profile and new atherogenic indices among the coronary artery disease (CAD)-negative and -positive diabetic dyslipidemia subjects. Int J Med Sci Public Health 2015;4:1574-9.
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002;106:3143-421.
Assmann G, Cullen P, Schulte H. The Munster Heart Study (PROCAM). Results of follow-up at 8 years. Eur Heart J 1998;19(Suppl A):A2-11.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]