National public health campaigns have attempted

WINTER 2005 PREVENTIVE CARDIOLOGY 11 CLINICAL STUDY Knowledge of Cholesterol Levels and Targets in Patients With Coronary Artery Disease Susan Cheng, MD; 1,2 Judith H. Lichtman, MPH, PhD; 3 Joan M. Amatruda, RN; 4 Grace L. Smith, MPH; 1,5 Jennifer A. Mattera, MPH; 1 Sarah A. Roumanis, RN; 1 Harlan M. Krumholz, MD 1,4,6,7 Little is known about the extent to which patients are aware of nationally-recommended cholesterol and lipid subfraction targets. The authors interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their low-density lipoprotein, high-density lipoprotein, and total cholesterol levels as well as corresponding national targets. Only 8%, 8%, and 43% of patients could recall their low-density lipoprotein, high-density lipoprotein, and total cholesterol values, respectively. Only 5%, 2%, and 50% could correctly name targets for these values. Knowledge of cholesterol targets was particularly poor among women, nonwhites, and patients without any college education. Patients with multiple cardiac risk factors and patients with a previous history of cardiovascular disease were no more knowledgeable about their cholesterol targets than those without these conditions. These findings suggest that current cholesterol education efforts appear inadequate, particularly for women, nonwhites, and patients without any college education. (Prev Cardiol. 2005;8:11 17) 2005 Le Jacq Ltd. From the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT; 1 The Johns Hopkins University School of Medicine, Baltimore, MD; 2 Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT; 3 the Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; 4 Department of Medicine, Yale University School of Medicine, New Haven, CT; 5 Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT; 6 and the Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, CT 7 Address for correspondence: Harlan M. Krumholz, MD, Yale University School of Medicine, 333 Cedar Street, Room I-456 SHM (P.O. Box 208088), New Haven, CT 06520-8088 E-mail: harlan.krumholz@yale.edu Manuscript received August 23, 2004; accepted September 14, 2004 www.lejacq.com ID: 3939 National public health campaigns have attempted to increase patient understanding of high blood cholesterol with the aim of decreasing its prevalence. Since its inception by the National Heart, Lung, and Blood Institute (NHLBI) in 1985, the National Cholesterol Education Program (NCEP) has implemented patient-based and population-based approaches to this goal. 1 6 Over the last decade, public health, pharmaceutical, and professional organizations such as the American Heart Association (AHA) have also sponsored initiatives encouraging patients to know their cholesterol levels and achieve target levels. Despite these efforts, early population studies have shown that many individuals remain unaware of their total cholesterol levels 7 11 ; however, the extent to which patients are aware of guideline-based cholesterol targets has never been reported. Although national guidelines emphasize the importance of low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) levels, it is also not known whether many patients know their LDL and HDL levels and recommended targets. Therefore, we evaluated knowledge of LDL, HDL, and total cholesterol levels and targets among patients hospitalized with coronary artery disease (CAD). We also sought to determine whether certain subgroups of CAD patients, defined by demographic or clinical characteristics, were particularly likely to lack knowledge of their cholesterol levels and targets. METHODS Setting and Subjects For this study, we used data from the Reinforcing Education About Cholesterol (REACH) study, a randomized trial of an educational intervention designed to improve compliance with national cholesterol targets in CAD patients. The REACH investigators screened consecutive patients admitted to Yale-New Haven Hospital in New Haven, CT from December 1998 January 2000 for enrollment. Patients aged 30 80 years were evaluated for participation in the REACH study, within 24 hours of admission, for evidence of CAD defined as: current or prior myocardial infarction, current or prior coronary artery bypass graft surgery, current

12 PREVENTIVE CARDIOLOGY WINTER 2005 or prior percutaneous coronary intervention, or a coronary artery stenosis 70% documented by cardiac catheterization. Patients were excluded if they had contraindications to taking cholesterollowering medication or situations or conditions that would restrict their ability to participate in an interview, benefit from an educational program, or be followed up at the end of the study. The Institutional Review Board of the Yale University School of Medicine approved the study; all participants gave written informed consent. Data Collection As part of the REACH trial, baseline demographic and clinical variables from patients medical records were abstracted, including: cardiac risk factors, history of tests and procedures (cardiac catheterization, coronary artery bypass graft, and percutaneous coronary intervention), and history of cardiovascular (CVD) disease, (myocardial infarction, angina, cerebrovascular accident, and peripheral vascular disease). Upon enrollment, trained research staff interviewed all participants a mean of 3.7±3.4 days after admission to assess their baseline knowledge, attitudes, and behaviors related to CAD, as well as education level and cholesterol-lowering medication usage. Cholesterol Knowledge Measurements For this study, we analyzed baseline REACH data including responses to patient interviews. We defined reported knowledge of personal cholesterol levels as a positive response to the question, Can you tell me what your cholesterol levels are? and the ability to offer at least one numeric value when subsequently asked, What are they? Patients were asked to specify subfraction vs. total values. We considered patients able to recall their LDL, HDL, or total cholesterol level if they could name a numeric value for these measurements, respectively. We defined reported knowledge of cholesterol target levels as a positive response to the question, Can you tell me what your cholesterol levels should be? and the ability to name at least one numeric value when subsequently asked, What should they be? Patients were asked to specify subfraction vs. total values. Since all patients were admitted with CAD, the values they named were compared with the then current NCEP II target levels designated for patients in the highest NCEP risk group: LDL-C 100 mg/dl, HDL-C >35 mg/dl, and total cholesterol <200 mg/dl. 3 We considered patients to have correct knowledge of LDL or total cholesterol targets if they named a value 100 mg/dl or 200 mg/dl, respectively. Correct knowledge of their HDL target was considered if patients named a value 35 mg/dl. We repeated this evaluation using NCEP target levels designated for low, moderate, or high NCEP risk groups as they would have applied to patients before hospitalization. Statistical Analysis Dependent variables in the analysis included: reported knowledge of own levels; ability to recall own LDL-C level; ability to recall own HDL-C level; ability to recall own total cholesterol level; reported knowledge of target levels; ability to name correct LDL-C target; ability to name correct HDL-C target; and ability to name correct total cholesterol target. We used chi-square tests to evaluate bivariate associations between each dependent variable and patient demographic and clinical characteristics. Based on clinical relevance and the results of bivariate analyses, relevant characteristics (female sex, age 65 and older, nonwhite race, less than any college education, two or more NCEP risk factors, previous history of CVD, no cholesterol screening within the last 6 months, and not taking cholesterol-lowering medication) were selected and entered into a logistic regression model. To assess the independent relationship of each characteristic with the different cholesterol knowledge components, a separate model was constructed for each dependent variable. Statistical analyses were conducted with SAS statistical software, version 8.01 (SAS Institute Inc., Cary, NC). RESULTS Of the 2657 patients screened for participation in the REACH trial, 1172 were eligible. Of these patients, 432 were not enrolled due to refusal or discharge before being interviewed by research staff; these patients were similar to study patients with respect to sex, age, race, admission diagnosis, and length of stay. Baseline interviews were missing for two patients. Characteristics of the remaining 738 patients included in our study sample are given in Table I. Knowledge of Personal Cholesterol Levels Of the total sample, 45.3% reported knowing their cholesterol levels, and only 8.4%, 8.1%, and 42.8% of all patients could recall a value for their LDL, HDL, and total cholesterol levels, respectively (Table II). Patients who reported knowledge of and then could recall their personal cholesterol levels were more likely to be male, less than 65 years old, white, and college educated. Patients knowledgeable of their personal cholesterol levels were also more likely to have had their cholesterol screened within the last 6 months and more likely to be taking cholesterol-lowering medication. Having any single NCEP risk factor, any combination of two or more risk factors, or a previous history of CVD was not associated with knowledge of personal cholesterol levels. Patients with a history of diabetes mellitus, however, were less likely than those without diabetes to report knowing their personal cholesterol levels (33.0% vs. 50.7%, p<0.001) or to recall personal levels (LDL 4.5% vs. 10.2%, p<0.01; HDL 4.5% vs. 9.8%, p<0.05; total cholesterol 31.7% vs. 43.7%, p<0.001).

WINTER 2005 PREVENTIVE CARDIOLOGY 13 In logistic regression models testing for the independent effect of patient characteristics on knowledge of personal cholesterol levels, women (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.49 0.97), nonwhites (OR, 0.43; CI, 0.25 0.74), and patients without any college education (OR, 0.54; CI, 0.39 0.74) were less likely to report knowing their cholesterol levels. When specifically asked, patients without any college education were less likely than college-educated patients to recall any of their cholesterol levels (LDL OR, 0.43; CI, 0.24 0.77; HDL OR, 0.44; CI, 0.25 0.80; total OR, 0.69; CI, 0.50 0.95). The same applied to patients without a cholesterol screening within the last 6 months as compared with patients with a recent screening (LDL OR, 0.28; CI, 0.10 0.82; HDL OR, 0.19; CI, 0.06 0.63; total OR, 0.16; CI, 0.09 0.27). Patients aged 65 years (OR, 0.71; CI, 0.51 0.98), nonwhites (OR, 0.40; CI, 0.22 0.74), and patients not taking cholesterol-lowering medication (OR, 0.60; CI, 0.43 0.83) were less likely to recall their total cholesterol levels. Knowledge of Target Cholesterol Levels Of the total sample, 54.9% of patients reported knowing their target cholesterol levels, and only 4.7%, 2.3%, and 49.5% of all patients could correctly name their LDL, HDL, and total cholesterol target levels, respectively (Table III). These rates did not differ when named values were evaluated using target levels defined by patients NCEP risk status before admission. Of all cholesterol target values named by patients, the majority were correct (Figure). Patients who reported knowing their targets and could then correctly name their target levels were more likely to be men, white, and have at least some college education. Patients who demonstrated knowledge of their targets were also more likely to have had a cholesterol screening within the last 6 months and to be taking cholesterol-lowering medication. Having any single NCEP risk factor, any combination of two or more risk factors, or any history of CVD were not associated with a greater knowledge of their targets. Patients with a history of diabetes mellitus were less likely than those without diabetes to report knowing their targets (48.2% vs. 57.6%, p<0.05) and correctly name their total cholesterol target (43.8% vs. 51.7%, p<0.05). Multivariate analysis showed that patients less likely to report knowing their cholesterol targets were aged 65 years (OR, 0.66; CI, 0.47 0.91), nonwhite (OR, 0.46; CI, 0.26 0.83), and without any college education (OR, 0.66; CI, 0.49 0.91). When specifically asked, women were less likely than men to correctly name their LDL-C target (OR, 0.32; CI, 0.11 0.95). Nonwhites (OR, 0.39; CI, 0.22 0.69) and patients without a recent cholesterol screening (OR, 0.52; CI, 0.35 0.77) were less likely to correctly name their total cholesterol target. Patients without any college education were less likely to Table I. Sample Characteristics CHARACTERISTICS N % Total 738 100.0 Women 214 29.0 Age (mean±sd) 63.3±9.7 65 368 49.9 Nonwhite race 71 9.7 < Any college education 359 50.3 NCEP CARDIAC RISK FACTORS Older age (men 45, women 686 93.0 55) History of hypertension 530 72.3 History of diabetes mellitus 224 30.6 Current smoker 140 19.1 HDL-C <35 mg/dl 240 39.7 2 NCEP cardiac risk factors 605 82.0 HISTORY OF CVD Myocardial infarction 341 46.5 Angina 608 83.0 Positive catheterization result 473 64.5 Percutaneous coronary 200 27.3 intervention Coronary artery bypass 108 14.7 Cerebrovascular accident 61 8.3 Peripheral vascular disease 112 15.3 NCEP RISK CATEGORY History of diagnosed CVD 679 92.0 No CVD history and 2 risk 41 5.6 factors No CVD history and <2 risk 18 2.4 factors CHOLESTEROL MANAGEMENT Cholesterol test in last 6 582 81.7 months Taking medication 377 52.7 NCEP=National Cholesterol Education Program; HDL-C=high-density lipoprotein cholesterol; CVD=cardiovascular disease (includes history of myocardial infarction, angina, positive catheterization result, percutaneous coronary intervention, coronary artery bypass, cerebrovascular accident, or peripheral vascular disease) correctly name their HDL (OR, 0.22; CI, 0.06 0.81) or total (OR, 0.64; CI, 0.47 0.87) cholesterol targets. Similarly, patients not taking cholesterol-lowering medication were less likely to correctly name their LDL (OR, 0.16; CI, 0.06 0.44) or total (OR, 0.61; CI, 0.44 0.84) cholesterol targets. DISCUSSION Our study demonstrates that individuals hospitalized with CAD have a poor knowledge of their cholesterol levels and targets. National education programs sponsored by organizations such as the NHLBI and AHA have promoted awareness of personal and target cholesterol levels, particularly among

14 PREVENTIVE CARDIOLOGY WINTER 2005 Table II. Knowledge of Personal Cholesterol Levels Compared Among Patient Subgroups RECALLED A VALUE REPORTED KNOWLEDGE LDL-C HDL-C TOTAL CHOLESTEROL CHARACTERISTICS N % N % N % N % Total 334 45.3 62 8.4 60 8.1 316 42.8 Sex Women 81 37.9* 9 4.2* 11 5.1 78 36.5** Men 253 48.3 53 10.1 49 9.4 238 45.4 Age <65 years 185 50.0* 41 11.1* 36 60.0 172 46.5** 65 years 149 40.5 21 5.7 24 40.0 144 39.1 Race White 312 47.1* 56 8.5 55 8.3 297 44.9 Nonwhite 19 26.8 6 8.5 5 7.0 16 22.5 Education < Any college 138 38.4* 16 4.5* 16 4.5* 131 36.5* Any college 188 53.1 44 12.4 42 11.9 177 50.0 Cholesterol management Cholesterol test in last 6 314 54.0 58 10.0 57 9.8* 298 51.2 months No recent cholesterol 17 13.1 4 3.1 3 2.3 15 11.5 test Taking medication 207 54.9 38 10.1 34 9.0 199 52.8 Not taking medication 124 36.6 24 7.1 26 7.7 114 33.6 LDL-C=low-density lipoprotein cholesterol; HDL-C=high-density lipoprotein cholesterol. *p<0.01; **p<0.05; p<0.001 Table III. Knowledge of Cholesterol Targets Compared Among Subgroups NAMED A CORRECT TARGET VALUE REPORTED KNOWLEDGE LDL-C HDL-C TOTAL CHOLESTEROL CHARACTERISTICS N % N % N % N % Total 405 54.9 35 4.5 17 2.3 365 49.5 Sex Women 97 45.3* 4 1.9** 1 0.05** 91 42.5** Men 308 58.8 31 5.9 16 3.1 274 52.3 Age <65 years 213 57.6 21 5.7 11 3.0 194 52.4 65 years 192 52.2 14 3.8 6 1.6 171 46.5 Race White 378 57.1* 312 4.7 15 2.3 342 51.7* Nonwhite 23 32.4 4 5.6 2 2.8 19 26.8 Education < Any college 167 46.5 11 3.1 3 0.8 154 42.9 Any college 230 65.0 24 6.8 14 4.0) 203 57.3 Cholesterol management Cholesterol test in last 6 349 60.0* 33 5.7** 17 2.9** 315 54.1* months No recent cholesterol test 48 36.9 2 1.5 0 0.0 42 32.3 Taking medication 236 62.6* 30 8.0* 12 3.2 216 57.3* Not taking medication 164 48.4 5 1.5 5 1.5 144 42.5 LDL-C=low-density lipoprotein cholesterol; HDL-C=high-density lipoprotein cholesterol. *p<0.001; **p<0.05; p<0.01

WINTER 2005 PREVENTIVE CARDIOLOGY 15 6% Percentage of all patients Percentage of all patients 5% 4% 3% 2% 1% 0% 3% 2% 1% Any value <40 40 59 60 79 80 99 100 101 120 121 140 141 160 >160 Named values for LDL-C target (mg/dl) 0% Any value <15 15 24 25 34 35 36 45 46 55 >55 Named values for HDL-C target (mg/dl) 60% Percentage of all patients 50% 40% 30% 20% 10% 0% Any value <140 140 159 160 179 180 199 200 201 220 221 240 241 260 >260 Named values for total cholesterol target (mg/dl) Figure. Distribution of named values for LDL-C (low-density lipoprotein cholesterol), HDL-C (high-density lipoprotein cholesterol), and total cholesterol targets

16 PREVENTIVE CARDIOLOGY WINTER 2005 individuals with cardiac risk factors or established CVD; however, only 45% of patients in this study reported knowing their cholesterol levels and only 55% reported knowing their targets. While similarly low rates of personal cholesterol awareness, ranging from 33% 60%, have been found in individuals with and without CAD, 7 9,12 14 the present study extends previous work by specifically investigating knowledge of nationally recommended targets in a CAD patient sample. Our findings suggest there remains much room for improving education of patients about their overall cholesterol status, including their target as well as personal cholesterol levels. Opportunities to improve cholesterol education efforts exist among high-risk patients in particular. In this study, a prior diagnosis of CVD did not enhance patients knowledge of their cholesterol levels or targets, nor did any single NCEP risk factor or any combination of two or more risk factors. Furthermore, we found that patients with diabetes were less likely to have knowledge of their personal or target cholesterol levels. Previous studies have reported similar findings concerning knowledge of personal cholesterol levels, 8,12,13 and these data together suggest that high-risk patients are not currently benefiting from cholesterol counseling and education any more than low-risk patients. Despite the importance of LDL-C and HDL-C, awareness of these cholesterol subfractions has never been reported. Our study found that <10% of patients with CAD could demonstrate a knowledge of their LDL and HDL levels or targets. These patients amounted to less than one fifth of those who knew their total cholesterol levels or targets. Greater knowledge of total cholesterol may be related to its recommended usage as an initial screening for hypercholesterolemia as well as an overall marker of cholesterol status in patients on cholesterol-lowering therapy. 4 NCEP guidelines, however, have repeatedly emphasized the importance of LDL-C in CAD risk reduction, 15 and HDL-C has been increasingly recognized as an important component of cholesterol management. 16 18 Our findings suggest that CAD patients remain focused on knowing their total cholesterol levels and targets to the extent that they are aware of lipid levels at all. Therefore, existing education and counseling strategies directed at high-risk patients need to further emphasize the importance of LDL-C and HDL-C. Prior work has indicated that knowledge of personal cholesterol levels is highest among males, whites, and individuals with a higher education level 7 10,12,13,19,20 ; our results demonstrate that knowledge of target cholesterol levels is also highest in these patient groups. Women, nonwhites, and patients without any college education in our study were less likely than their counterparts to report knowing their cholesterol levels or targets, and they were less likely to recall their cholesterol levels or correctly name targets when further questioned. More targeted cholesterol education efforts may be needed to reach these subgroups in particular. Whereas previous studies of patients without CAD have found older adults more likely to know their personal cholesterol levels than younger adults, 8,10,21 our data showed no significant difference in personal cholesterol knowledge between age groups after adjustment for sex, education, presence of multiple risk factors, history of CVD, recent cholesterol screening, and cholesterol-lowering medication status. In fact, adjusted analysis showed patients aged 65 years to be less likely than younger patients to report knowing their cholesterol targets. Age-related differences in knowledge of targets may also be due to inequalities in access to information, access to health care, or other factors not controlled for in this study. Our assessment of personal cholesterol knowledge was based on patients ability to recall values for their LDL, HDL, or total cholesterol. We used this conservative method for evaluating personal cholesterol knowledge since patients measurements before hospitalization were unavailable, and patients cholesterol levels measured during admission were not considered to be representative of their out-ofhospital measurements. 22 Previous assessments of personal cholesterol knowledge in non-hospitalized patients, however, have shown a correlation between self-reported cholesterol levels and corresponding outpatient laboratory measurements. 7,8,23 Our findings were limited to CAD patients admitted to the hospital with acute disease, which could have affected their ability to demonstrate knowledge of their health. While there exist no other data about patient knowledge of cholesterol targets or lipid subfractions for direct comparison, prior studies have found similarly low rates of personal cholesterol and blood pressure knowledge among non-hospitalized patients. 7,9,12,13,23 These studies also suggest that our findings, while limited to a single center, are likely to be supported by further investigations of cholesterol knowledge. Our sample did not include patients who were unable to provide informed consent or be interviewed and patients deemed unable to participate in or benefit from an educational program. Including such patients, however, would likely have resulted in even lower knowledge rates, further supporting the overall findings of this study. In conclusion, patients hospitalized with CAD have remarkably poor knowledge of their cholesterol levels and targets, particularly regarding lipid subfractions. Low rates of cholesterol knowledge are especially prevalent among women, nonwhites, and individuals without any college education. Increased patient-oriented counseling and more targeted education efforts may lead to an improved cholesterol knowledge among individuals at high risk for coronary events and, in turn, more effective patient-provider partnerships in the management of high blood cholesterol as a major modifiable risk factor.

WINTER 2005 PREVENTIVE CARDIOLOGY 17 Acknowledgments. This study was supported by a grant from Pfizer. Dr. Lichtman is a Goddess Fund Career Development Scholar. REFERENCES 1 Cleeman JI, Lenfant C. The National Cholesterol Education Program: progress and prospects. JAMA. 1998;280:2099 2104. 2 Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. The Expert Panel. Arch Intern Med. 1988;148:36 69. 3 Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA. 1993;269:3015 3023. 4 National Cholesterol Education Program. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Circulation. 1994;89:1333 1445. 5 Executive Summary of the 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). JAMA. 2001;285:2486 2497. 6 Bellicha T, McGrath J. Mass media approaches to reducing cardiovascular disease risk. Public Health Rep. 1990;105:245 252. 7 Pieper RM, Arnett DK, McGovern PG, et al. Trends in cholesterol knowledge and screening and hypercholesterolemia awareness and treatment, 1980 1992. The Minnesota Heart Survey. Arch Intern Med. 1997;157:2326 2332. 8 Murdoch M, Wilt TJ. Cholesterol awareness after case-finding: do patients really know their cholesterol numbers? Am J Prev Med. 1997;13:284 289. 9 Nieto FJ, Alonso J, Chambless LE, et al. Population awareness and control of hypertension and hypercholesterolemia. The Atherosclerosis Risk in Communities study. Arch Intern Med. 1995;155:677 684. 10 Cholesterol screening and awareness behavioral risk factor surveillance system, 1990. Morb Mortal Wkly Rep. 1992;41:675 678. 11 Luepker RV. Current status of cholesterol treatment in the community: the Minnesota Heart Survey. Am J Med. 1997;102:37 42. 12 Ayanian JZ, Landon BE, Landrum MB, et al. Use of cholesterol-lowering therapy and related beliefs among middleaged adults after myocardial infarction. J Gen Intern Med. 2002;17:95 102. 13 Ayanian JZ, Landrum MB, McNeil BJ. Use of cholesterollowering therapy by elderly adults after myocardial infarction. Arch Intern Med. 2002;162:1013 1019. 14 Frank E, Winkleby MA, Fortmann SP, et al. Improved cholesterol-related knowledge and behavior and plasma cholesterol levels in adults during the 1980s. JAMA. 1992;268:1566 1572. 15 Ballantyne CM. Low-density lipoproteins and risk for coronary artery disease. Am J Cardiol. 1998;82:3Q 12Q. 16 Boden WE. High-density lipoprotein cholesterol as an independent risk factor in cardiovascular disease: assessing the data from Framingham to the Veterans Affairs High-density Lipoprotein Intervention Trial. Am J Cardiol. 2000;86:19L 22L. 17 Rubins HB, Robins SJ, Collins D, et al. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med. 1999;341:410 418. 18 Downs JR, Clearfield M, Weis S, et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. JAMA. 1998;279:1615 1622. 19 Polednak AP. Awareness and use of blood cholesterol tests in 40 74-year-olds by educational level. Public Health Rep. 1992;107:345 351. 20 Sprafka JM, Burke GL, Folsom AR, et al. Hypercholesterolemia prevalence, awareness, and treatment in blacks and whites: the Minnesota Heart Survey. Prev Med. 1989;18:423 432. 21 Blount BW, Brown JB. Retiree awareness of levels of blood pressure and cholesterol. Mil Med. 1996;161:683 686. 22 Rosenson RS. Myocardial injury: the acute phase response and lipoprotein metabolism. J Am Coll Cardiol. 1993;22:933 940. 23 Bairey Merz CN, Felando MN, Klein J. Cholesterol awareness and treatment in patients with coronary artery disease participating in cardiac rehabilitation. J Cardiopulm Rehabil. 1996;16:117 122.