Cholesterol
Lipid Management in the Prevention
and Treatment of Cardiovascular Diseases 1
Step 1: Lifestyle/hygienic measures:
- Optimize diet: See DIET FOR HIGH CHOLESTEROL
- Physical activity:-60 min light or 30-60 min moderate or 20-30 min vigorous activity 4 to 7 days a week
- Maintain ideal body weight/reduce visceral adipose tissue: BMI < 27 kg/m2 minimum goal and optimally < 25 kg/m2
- Smoking cessation
- Alcohol in moderation
Step 2: Assess Cardiovascular Risk-Estimate 10 year risk of hard CHD endpoints using Framingham
tables or European
SCORECARD,alternate RISK ENGINES or estimate risk (M 40-70/ F 50-70) based on following categorical risks:
- Age: M ≥ 45: W ≥ 55 or post menopausal
- Family history premature: CHD 1° relative ( M ≤ 55/ F ≤ 65)
- Smoking: > 1 cigarette/ day
- Hypertension: BP ≥ 140/90 ( at least twice) or on Rx
- Diabetes: FBG ≥ 7.0 mmol/L or 2 hr PCG ≥11.1 mmol/L.
- LVH
Step 3: Who/When/What to Screen (TC, TG, LDL–C, HDL-C)
- Routinely screen men above age 40 and women who are post menopausal or over age 50 every 1-3 years
- History of CAD, TIA, CVA, PVD, bruits, CKD (chronic kidney disease), or DM > 30 years old are at highest (2° prevention) category
- Screen at any age those with risk factors such as:
- Hypertension
- Smoking
- Abdominal obesity: Waist circumference > 102 cm (M), > 88 cm (W) (lower cutoffs for South and East Asians)
- Strong family history of premature atherosclerosis, monogenic lipid disorder or chylomicronemia
- Stigmata of hyperlipidemia (arcus cornea, xanthelasma or xanthoma)
- Evidence of symptomatic or asymptomatic atherosclerosis
- Symptoms: exertional chest discomfort, dyspnea or erectile dysfunction
- Assess full fasting lipid profile
- Patients with CAD, TIA, CVA, PVD, bruits, CKD (chronic kidney disease) or DM > 30 years old annually to age 75
- As above on hypolipidemic therapy semi-annually with ALT & CK
- Patients with family history early CHD, or genetic hyperlipidemia, xanthomata
- one time during youth
- repeat age 30
- if normal repeat every 5 year > age 40 M / > age 50 F
- Adult diabetics
- Repeat every 1-3 years as indicated
- Men ages 40 - 70 / Women ages 50 - 70
Step 4: Evaluate risk modifiers:
- Presence of metabolic syndrome (abdominal obesity, insulin resistance, elevated triglycerides, low HDL-C and hypertension) elevates CV risk by 1.6-2.6 fold. The greater risk elevation occurs in patient with T2DM or elevated hs-CRP.
- Apolipoprotein B > 1.2 g/L
- Associated with small dense LDL
- Optimal targets: high risk < 1.2 g/L, intermediate risk < 1.05 g/L < 0.85 g/L, high risk < 0.85 g/L
- Lipoprotein (a) > 30 mg/dl/300 mg/L ( consider measurement intermediate risk category if family history of premature CAD)
- Increases risk 4X if 2 other risk factors or TC/HDL > 5.5
- Homocysteine > 10-15 µmol/L associated with increased risk CVD, CVA and DVT. Measurement not recommended in light of negative trials (HOPE-2,NORVIT)
- High-sensitivity CRP: elevated CRP (upper quartile ) raises CV risk 3-4 fold
- Low risk CRP < 1 mg/L/Intermediate risk CRP 1.0-3.0 mg/L/High risk CRP > 3.0 mg/L
- Measure FPG every 1-3 years > age 50 or younger if obesity or FH type 2 DM. Measure HbA1c if FPG > 6 mmol/L
- Genetic Risk:
- Family history of CAD in CHD 1° relative ( M ≤ 55/ F ≤ 65) raises risk 1.7-2 fold
- Ethnicity
- • South Asian ethnicity living in Western society doubles risk
- Post-menopausal status or combined HRT increases CV risk
- Non-invasive assessment of occult atherosclerosis
- Don’t forget to auscultate for bruits. If present presume atherosclerosis. • Assessment of exercise capacity
- Ankle-brachial index < 0.9 sensitivity 90%/specificity 98% for detecting > 50% stenosis.
- Carotid imaging: fivefold increase in CAD risk if carotid intimal medial thickness (IMT) > 1 mm
- Coronary computed tomography
- CT angiography
*
See % reduction tables
Feedback
results to patient to improve compliance.
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