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Vol. 51. Núm. 5.
Páginas 254-265 (Mayo 2004)
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Vol. 51. Núm. 5.
Páginas 254-265 (Mayo 2004)
Acceso a texto completo
Guías para el tratamiento de las dislipemias en el adulto: Adult Treatment Panel III (ATP-III)
Guidelines for dyslipemias treatment: adult treatment panel iii (atp-iii)
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M.A. Rubio
Autor para correspondencia
marubio@futurnet.es

Correspondencia: Dr. M.A. Rubio. Unidad de Nutrición Clínica y Dietética. Servicio de Endocrinología y Nutrición. Hospital Clínico Universitario San Carlos. Martín Lagos, s/n. 28040 Madrid. España.
, C. Moreno, L. Cabrerizo
Unidad de Nutrición Clínica y Dietética. Servicio de Endocrinología y Nutrición. Hospital Clínico Universitario San Carlos. Madrid. España
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Las guías de tratamiento para disminuir los lípidos y el riesgo de enfermedad coronaria (EC) diseñadas por el National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP-III) contienen una serie de características que las diferencian de las anteriores guías. Estos nuevos aspectos incluyen modificaciones en las concentraciones de lípidos y lipoproteínas; una mayor atención a la prevención primaria a través del empleo de las puntuaciones obtenidas en las tablas de Framingham, para definir el riesgo de aquellas personas con múltiples factores de riesgo lipídicos y no lipídicos; del mismo modo, ha sido objeto de reflexión la asociación del síndrome metabólico con el riesgo de EC. Se introduce la categoría de equivalentes de riesgo coronario, donde se incluye a personas con enfermedad aterosclerótica, diabetes mellitus o aquellas que presentan un riesgo de EC a los 10 años superior al 20%, basado en las proyecciones de Framingham; se les clasifica como pacientes de alto riesgo coronario y susceptibles de un tratamiento intensivo para reducir las concentraciones del colesterol ligado a las lipoproteínas de baja densidad (cLDL). Asimismo, se ha establecido como objetivo terapéutico secundario la mejoría del colesterol ligado a lipoproteínas de alta densidad (cHDL) en pacientes con aumento de las concentraciones de triglicéridos, una vez que se han alcanzado las metas del cLDL. El ATP-III dedica una extensa sección al tratamiento no farmacológico, que se centra en la dieta aterogénica, la obesidad y los hábitos de vida sedentarios, para recomendar un programa activo de cambios en el estilo de vida.

En esta revisión se discuten algunos aspectos relacionados con: a) la evaluación del riesgo para seleccionar a pacientes susceptibles de intervención clínica, considerando los nuevos factores de riesgo emergentes y el síndrome metabólico; b) la evaluación de diversos algoritmos de evaluación del riesgo cardiovascular; c) el manejo clínico de los factores de riesgo cardiovasculares, con futuras perspectivas de objetivos del cLDL; d) atención a las características especiales de una dieta saludable cardiovascular, y e) el tratamiento de ciertas dislipemias específicas, como la elevación de triglicéridos o la dislipemia diabética.

Palabras clave:
Dislipemias
Hipertrigliceridemia
Factores de riesgo cardiovasculares
ATP-III

The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines for lipid-lowering therapy to reduce coronary heart disease (CHD) risk contains a number of features that distinguish them from the previous ATP guidelines. These new features include modifications in lipid/lipoprotein levels; increased focus on primary prevention through use of Framingham risk scoring to define risk in persons with multiple lipidic/nonlipidic risk factors; and increased focus on the association of the metabolic syndrome with CHD risk. The introduction of the category of CHD risk equivalents-including persons with atherosclerotic disease, diabetes mellitus, or 10-year CHD risk lighter than 20% based on Framingham scoringresults, categorized as being at high risk and therefore eligible for more intensive low-density lipoprotein cholesterol (LDL-c)- lowering therapy. Use of the new secondary therapeutic target of non-high-density lipoprotein cholesterol should improve management of lipid risk factors in patients who have elevated triglyceride levels after LDL-c goals have been met. ATP-III has an extensive section on non-pharmacologic therapy, focused on the high-saturated fat atherogenic diet, obesity, and sedentary lifestyle and recommended a program of therapeutic lifestyle change.

This review discusses several issues, including: a) risk assessment for selection of patients for clinical intervention, considering new emerging risk factors and the metabolic syndrome; b) evaluation from differents risk scoring algorithms; c) clinical management of cardiovascular risk factors, with future perspectives on LDL-c goals; d) special features on a healthy cardiovascular diet, and e) management of specific dyslipidemias like elevated serum triglycerides or diabetic dyslipemia.

Key words:
Dyslipemias
Elevated triglycerides
Cardiovascular risk factors
ATP-III
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Bibliografía
[1.]
F. Villar, J.R. Banegas, J.M. Donado, F. Rodríguez-Artalejo.
Las enfermedades cardiovasculares y sus factores de riesgo en España: hechos y cifras. Informe SEA 2003.
[2.]
J. Marrugat, R. Elosua, H. Martí.
Epidemiología de la cardiopatía isquémica en España: estimación del número de casos y las tendencias entre 1997 y 2005.
Rev Esp Cardiol, 55 (2002), pp. 337-346
[3.]
Executive Summary of the third report of the Nacional Colesterol Education Program (NCEP).
Expert Panel on Detection, Evaluation, and Treatment of High Blood Colesterol in Adults (Adult Treatment Panel III).
JAMA, 285 (2001), pp. 2486-2497
[4.]
Executive Summary of the third report of the Nacional Colesterol Education Program (NCEP).
Expert Panel on Detection, Evaluation, and Treatment of High Blood Colesterol in Adults (Adult Treatment Panel III): final report. US Department of Health and Human Services; Public Health Service; National Institutes of Health; National Heart, Lung, Blood Institute.
Circulation, 106 (2002),
[5.]
International Atherosclerosis Society y Sociedad Española de Arteriosclerosis.
Guías clínicas armonizadas para la prevención de la enfermedad vascular aterosclerótica.
[6.]
N.D. Ernst, J.I. Cleeman.
National cholesterol education program keeps a priority on lifestyle modification to decrease cardiovascular disease risk.
Curr Opin Lipidol, 13 (2002), pp. 69-73
[7.]
M.A. Austin, J.E. Hokanson, K.L. Edwards.
Hypertriglyceridemia as a cardiovascular risk factor.
Am J Cardiol, 81 (1998), pp. 7B-12B
[8.]
G. Assman, H. Schulte, H. Funke, A. Von Eckardstein.
The emergence of triglycerides as a significant independent risk factor in coronary artery disease.
Eur Heart J, 19 (1998), pp. 8-14
[9.]
R.M. Krauss.
Atherogenicity of triglyceride-rich lipoproteins.
Am J Cardiol, 81 (1998), pp. 13B-17B
[10.]
L.J. Seman, C. DeLuca, J.L. Jenner, L.A. Cupples, J.R. McNamara, P.W. Wilson, et al.
Lipoprotein(a)-cholesterol and coronary heart disease in the Framingham Heart Study.
Clin Chem, 45 (1999), pp. 1039-1046
[11.]
J. Danesh, R. Collins, R. Peto.
Lipoprotein(a) and coronary heart disease. Meta-analysis of prospective studies.
Circulation, 102 (2000), pp. 1082-1085
[12.]
D.J. Moliterno, E.V. Jokinen, A.R. Miserez, R.A. Lange, J.E. Willard, E. Boerwinkle, et al.
No association between plasma lipoprotein(a) concentrations and the presence or absence of coronary atherosclerosis in African-Americans.
Arterioscler Thromb Vasc Biol, 15 (1995), pp. 850-855
[13.]
P. Tornvall, P. Bavenholm, C. Landou, U. De Faire, A. Hamsten.
Relation of plasma levels and composition of apolipoprotein Bcontaining lipoproteins to angiographically defined coronary artery disease in young patients with myocardial infarction.
Circulation, 88 (1993), pp. 2180-2189
[14.]
G. Montalescot, J.P. Collet, R. Choussat, D. Thomas.
Fibrinogen as a risk factor for coronary heart disease.
Eur Heart J, 19 (1998), pp. 11-17
[15.]
B. Wiman, T. Andersson, J. Hallqvist, C. Reuterwall, A. Ahlbom, U. De Faire.
Plasma levels of tissue plasminogen activator/plasminogen activator inhibitor-1 complex and von Willebrand factor are significant risk markers for recurrent myocardial infarction in the Stockholm Heart Epidemiology Program (SHEP) study.
Arterioscler Thromb Vasc Biol, 20 (2000), pp. 2019-2023
[16.]
A.J. Moss, R.E. Goldstein, V.J. Marder, C.E. Sparks, D. Oakes, H. Greenberg, et al.
Thrombogenic factors and recurrent coronary events.
Circulation, 99 (1999), pp. 2517-2522
[17.]
D.G. Hackman, S.S. Anand.
Emerging risk factors for atherosclerotic vascular disease. A critical review of evidence.
JAMA, 290 (2003), pp. 932-940
[18.]
C. Heeschen, S. Dimmeler, C.W. Hamm, M.J. Van den Brand, E. Boersma, A.M. Zeiher, et al.
Soluble CD40 ligand in acute coronary syndromes.
N Engl J Med, 348 (2003), pp. 1104-1111
[19.]
N. Varo, J.A. De Lemos, P. Libby, D.A. Morrow, S.A. Murphy, R. Nuzzo, et al.
Soluble CD40L. Risk prediction after acute coronary syndromes.
Circulation, 108 (2003), pp. 1049-1052
[20.]
P.M. Ridker, C.H. Hennekens, J.E. Buring, N. Rifai.
C-reactive protein and other markers of inflammation in the prediction of cardiovascular disease in women.
N Engl J Med, 342 (2000), pp. 836-843
[21.]
W. Koenig, M. Sund, M. Frohlich, H.G. Fischer, H. Lowel, A. Doring, et al.
C-reactive protein, a sensitive marker of inflammation, predicts furture risk of coronary heart disease in initially healthy middle-aged men: results from the MONICA (monitoring trends and determinants in cardiovascular disease) Augsburg cohort study, 1984 to 1992.
Circulation, 99 (1999), pp. 237-242
[22.]
S.M. Grundy, M.A. Denke.
Dietary influences on serum lipids and lipoproteins.
J Lipid Res, 31 (1990), pp. 1149-1172
[23.]
R.P. Mensink, M.B. Katan.
Effects of dietary fatty acids on serum lipids and lipoproteins: a meta-analysis of 27 trials.
Arterioescler Thromb, 12 (1991), pp. 911-919
[24.]
P.M. Kris-Etherton, S. Yu.
Individual fatty acids effects on plasma lipids and lipoproteins: human studies.
Am J Clin Nutr, 65 (1997), pp. 1628S-1644S
[25.]
E. Ros.
El colesterol de la dieta y su escasa influencia sobre la colesterolemia y el riesgo cardiovascular.
Clin Invest Arterioscler, 12 (2000), pp. 20-26
[26.]
A.H. Lichtenstein, L.M. Ausman, S.M. Jalbert, E.J. Schaefer.
Effects of different forms of dietary hydrogenated fats on serum lipoprotein cholesterol levels.
N Engl J Med, 340 (1999), pp. 1933-1940
[27.]
A. Ascherio, M.B. Katan, P.L. Zock, M.J. Stampfer, W.C. Willet.
Trans fatty acid and coronary heart disease.
N Engl J Med, 340 (1999), pp. 1994-1998
[28.]
E. Feldman.
Assorted monounsaturated fatty acids promote healthy hearts.
Am J Clin Nutr, 70 (1999), pp. 953-954
[29.]
A. Ascherio, E.B. Rimm, M.J. Stampfer, E.l. Giovanucci, W.C. Willet.
Dietary intake of marine n-3 fatty acids, fish intake, and the risk of coronary disease among men.
N Engl J Med, 332 (1995), pp. 977-982
[30.]
G.E. Fraser.
Nut consumption, lipids and risk of a coronary event.
Clin Cardiol, 22 (1999), pp. 11-15
[31.]
M. De Lorgeril, S. Renaud, N. Mamelle, P. Salen, J.L. Martin, I. Monjaud, et al.
Mediterranean alpha-linoleic acid-rich diet in secondary prevention of coronary heart disease.
Lancet, 343 (1994), pp. 1454-1459
[32.]
D.P. Vivekananthan, M.S. Penn, S.K. Sapp, A. Hsu, E.J. Topol.
Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomised trials.
Lancet, 361 (2003), pp. 2017-2023
[33.]
C.D. Morris, S. Carson.
Routine vitamin supplementation to prevent cardiovascular disease: a summary of the evidence for the US. preventive services Task Force.
Ann Intern Med, 139 (2003), pp. 56-70
[34.]
B.J. Venn, J.I. Mann, S.M. Williams, L.J. Riddell, A. Chisholm, M.J. Harper, et al.
Dietary counseling to increase natural folate intake: a randomized, placebo-controlled trial in free-living subjects to assess effects on serum folate and plasma total homocysteine.
Am J Clin Nutr, 76 (2002), pp. 758-765
[35.]
D.S. Wald, M. Law, J.K. Morris.
Homocysteine and cardiovascular disease: evidence on causality from a meta–analysis.
BMJ, 325 (2002), pp. 1202-1208
[36.]
National Institutes of Health.
Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults –the evidence report.
Obes Res, 6 (1998), pp. 51-209
[37.]
R.H. Eckel, R.M. Krauss.
American Heart Association call to action: obesity as a major risk factor for coronary heart disease. AHA Nutrition Committee.
Circulation, 97 (1998), pp. 2099-2100
[38.]
M.W. Rajala, P.E. Scherer.
The adipocyte at the cossroads of energy homoestasis, inflammation, and atherosclerosis.
Endocrinology, 144 (2003), pp. 3765-3773
[39.]
C.J. Lyon, R.E. Law, W.A. Hsueh.
Adiposity, inflammation and atherogenesis.
Endocrinology, 144 (2003), pp. 2195-2200
[40.]
A.G. Pittas, N.A. Joseph, A.S. Greenberg.
Adipocytokines and insulin resistance.
J Clin Endocrinol Metabol, 89 (2004), pp. 447-452
[41.]
G.F. Fletcher, G. Balady, S.N. Blair, J. Blumenthal, C. Caspersen, B. Chaitman, et al.
Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association.
Circulation, 94 (1996), pp. 857-862
[42.]
D.A. Thompson, D. Buchner, I.L. Piña, G.J. Balady, M.A. Williams, B.H. Marcus, et al.
Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. A statement from the Council on Clinical Cardiology (subcommittee on exercise, rehabilitation, and prevention) and the Council on Nutrition, Physical Activity, and Metabolism (subcommittee on physical activity).
Circulation, 10703 (2003), pp. 109-116
[43.]
S.M. Grundy, B. Brewer, J.I. Cleeman, S.C. Smith, C. Lenfant.
Definition of metabolic syndrome. Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on scientific issues related to definition.
Circulation, 109 (2004), pp. 433-438
[44.]
American Diabetes Association.
Position statement. Implications of the diabetes control and complications trial.
Diabetes Care, 25 (2002), pp. S25-S27
[45.]
UK Prospective Diabetes Study (UDPDS) Group.
intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Lancet, 352 (1998), pp. 837-853
[46.]
S.M. Haffner, S. Lehto, T. Ronnemaa, K. Pyorala, M. Laakso.
Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction.
N Engl J Med, 339 (1998), pp. 229-234
[47.]
G.C. Leng, F.G. Fowkes, A.J. Lee, J. Dunbar, E. Housley, C.V. Ruckley.
Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study.
BMJ, 313 (1996), pp. 1440-1444
[48.]
M. McKenna, S. Wolfson, L. Kuller.
The ratio of ankle and arm arterial pressure as an independent predictor of mortality.
Atherosclerosis, 87 (1991), pp. 119-128
[49.]
Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.
endarterectomy for asymptomatic carotid artery stenosis.
JAMA, 273 (1995), pp. 1421-1428
[50.]
P.W.F. Wilson, R.B. D'Agostino, D. Levy, A.M. Belanger, H. Silbershatz, W.B. Kannel.
Prediction of coronary heart disease using risk factor categories.
Circulation, 97 (1998), pp. 1837-1847
[51.]
G. Assmann, P. Cullen, H. Schulte.
Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular Munster (PROCAM) study.
Circulation, 105 (2002), pp. 310-315
[52.]
D. Word, G. De Backer, O. Faergeman, I. Graham, G. Mancia.
Pyörälä K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention.
Atherosclerosis, 140 (1998), pp. 199-270
[53.]
J. Marrugat, P. Solanas, R. D'Agostino, L. Sullivan, J. Ordovás, F. Cordón, et al.
Estimación del riesgo coronario en España mediante la ecuación de Framingham calibrada.
Rev Esp Cardiol, 56 (2003), pp. 253-261
[54.]
R.M. Conroy, K. Pyörölä, S. Fitzgerald, C. Sans, A. Menotti, G. De Backer, et al.
Estimation of ten-year risk of fatal cardiovascular disease in Europe: the Score project.
Eur Heart J, 24 (2003), pp. 987-1003
[55.]
L. Masana Martín.
Del Panel III en adelante. ¿Debemos basarnos en la evidencia científica o en la observación epidemiológica?.
Clin Invest Arterioscl, 15 (2003), pp. 54-61
[56.]
Heart Protection Study Collaborative Group.
MRC/BHF heart protection study. Randomised placebo-controlled trial of cholesterol-lowering with simvastatin in 20,536 high-risk individuals.
[57.]
Scandinavian Simvastatin Survival Study.
Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S).
Lancet, 344 (1994), pp. 1383-1389
[58.]
F.M. Sacks, M.A. Pfeffer, L.A. Moye, J.L. Rouleau, J.D. Rutherford, T.G. Cole, et al.
The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels.
N Engl J Med, 335 (1996), pp. 1001-1009
[59.]
Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group.
Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels.
N Engl J Med, 339 (1998), pp. 1349-1357
[60.]
S.E. Nissen, E.M. Tuzcu, P. Schoenhagen, B.G. Brown, P. Ganz, R.A. Vogel, et al.
Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial.
JAMA, 291 (2004), pp. 1071-1080
[61.]
C.P. Cannon, E. Braunwald, C.H. McCabe, D.J. Rader, J.L. Rouleau, R. Belder, et al.
Comparison of intensive and moderate lipid lowering with statins following acute coronary syndrome.
N Engl J Med, 350 (2004), pp. 1495-1504
[62.]
US Public Health Service.
A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service report. The tobacco use and dependence clinical practice guideline panel, staff, and consortium representatives.
JAMA, 283 (2000), pp. 3244-3254
[63.]
Joint National Committee.
The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure.
Arch Intern Med, 157 (1997), pp. 2413-2446
[64.]
World Health Organization.
1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee.
J Hypertens, 17 (1999), pp. 151-183
[65.]
S.C. Smith Jr, S.N. Blair, R.O. Bonow, L.M. Brass, M.D. Cerqueira, K. Dracup, et al.
AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update. A statement for healthcare professionals from the American Heart Association and the American College of Cardiology.
J Am Coll Cardiol, 38 (2001), pp. 1581-1583
[66.]
Gómez Gerique JA y grupo DRECE.
Impacto farmacoeconómico de las directrices del ATP-III.
Clin Invest Arterioscl, 15 (2003), pp. 17-33
[67.]
National Institutes of Health: National Cholesterol Education Program.
Second report of the Expert Panel on Detection, Evaluation, and Treatment of high blood cholesterol (Adult Treatment Panel II).
Circulation, 89 (1994), pp. 1333-1445
[68.]
J. Plat, D. Kerckhoffs, R.P. Mensink.
Therapeutical potential of plant sterols and stanols.
Curr Opin Lipidol, 11 (2000), pp. 571-576
[69.]
M. Law.
Plant sterol and stanol margarines and health.
BMJ, 320 (2000), pp. 861-864
[70.]
L. Brown, B. Rosner, W.W. Willett, F.M. Sacks.
Cholesterol-lowering effects of dietary fiber: a meta-analysis.
Am J Clin Nutr, 69 (1999), pp. 30-42
[71.]
R.M. Krauss, R.H. Eckel, B. Howard, L.J. Appel, S.R. Daniels, R.J. Deckelbaum, et al.
AHA dietary guidelines: revision 2000: a statement for healthcare professionals from the Nutrition Committee of the American Heart Association.
Circulation, 102 (2000), pp. 2284-2299
[72.]
L.A. Bazzano, J. He, L.G. Ogden, C.M. Loria, S. Vupputuri, L. Myers, et al.
Fruit and vegetable intake and risk of cardiovascular disease in US adults: the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study.
Am J Clin Nutr, 76 (2002), pp. 93-99
[73.]
M. De Lorgeril, P. Salen, J.L. Martin, I. Monjaud, J. Delaye, N. Mamelle.
Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study.
Circulation, 99 (1999), pp. 779-785
[74.]
P.M. Kris-Etherton, W.S. Harris, L.J. Appel.
for the Nutrition Committee Fish Consumption, Fish Oil Omega-3 Fatty Acids, and Cardiovascular Disease.
Arterioscler Thromb Vasc Biol, 23 (2003), pp. e20-e31
[75.]
E. Guallar, A. Aro, F.J. Jiménez, J.M. Martín-Moreno, I. Salminen, P. Van't Veer, et al.
Omega-3 fatty acids in adipose tissue and risk of myocardial infarction. The EURAMIC study.
Arterioscler Thromb Vasc Biol, 19 (1999), pp. 1111-1118
[76.]
C.M. Albert, C.H. Hennekens, C.J. O'Donnell, U.A. Ajani, V.J. Carey, W.C. Willet, et al.
Fish consumptionn and risk of sudden cardiac death.
JAMA, 279 (1998), pp. 23-28
[77.]
A. Geelen, I.A. Brouwer, P.L. Zock, M.B. Katan.
Antiarrhythmic effects of n-3 fatty acids: evidence from human studies.
Curr Opin Lipidol, 15 (2004), pp. 25-30
[78.]
K.J. Mukamal, K.M. Conigrave, M.A. Mittleman, C.A. Camargo, M.J. Stampfer, W.C. Willett, et al.
Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men.
N Engl J Med, 348 (2003), pp. 109-118
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