General Approach to Treatment
NCEP Goals and Targets 

Drug Therapy
Special Considerations

Misc. Current Issues

Selected Studies
Example Exam Question
References
LFT Monitoring

1. In adults >20 yo, a fasting lipid profile should be obtained once every 5 years (if fasting level is not possible get total + HDL-C if T-Cholesterol >200 or HDL-C >40 mg/dL, get fasting profile)

• Determine lipoprotein profile (LDL-C, HDL-C, TG, Total Cholesterol) after a 9-12 hr fast.
• Lipoprotein analysis should ideally be performed when the patient is not in the recovery phase from an acute coronary or other medical event that would lower the usual LDL-C -cholesterol level.
• If the first two LDL-C -cholesterol test results differ by more than 30mg/dL (0.7mmol/L), a third test result should be obtained within 1 to 8 weeks and the average value of the three tests used.
• Current guidelines by Grundy White Paper, should prevail in terms of clinical practice

• Calculated values (Friedwals Equation NEJM 1995, 312:20;1300):
  Friedwals Equation is currently used to "calculate" LDL from measured values of total cholesterol, HDL and triglycerides. This method is not accurate if Trigs exceed 400 mg/dL (erroneous values may be calculated by using it under these circumstances).
  
• (LDL-C  chol.) = (total chol. - HDL-C  chol.) - (triglycerides / 5). 
  
  Not useful if Triglycerides > 400mg/dL.
• LDL-C direct measurement is occasionally performed in research labs if specifically requested.

Total Cholesterol

HDL Cholesterol

Triglycerides (link to Table of Trig Levels)

LDL Cholesterol Goals and Cut-points for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories

¢: Some authorities recommend use of LDL-lowering drugs in this category in an LDL cholesterol level of <100 mg/dL cannot be achieved by therapeutic lifestyle changes.  Others prefer use of drugs that primarily modify triglycerides and HDL, eg. nicotinic acid or fibrate.  Clinical judgment also may call for deferring drug therapy in this subcategory.

»: Almost all people with 0-1 risk factor have a 10 year risk <10%; thus, 10 year risk assessment in people with 0-1 risk factor is not necessary.

^{¥ Overweight and obesity are associated with insulin resistance and the metabolic syndrome.  However, the presence of abdominal obesity is more highly correlated with the metabolic risk factors than is an elevated body mass index (BMI).  Therefore, the simple measure of waist circumference is recommended to identify the body weight component of the metabolic syndrome.
§ Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased, eg, 94-102cm (37-39 in).  Such patients may have a strong genetic contribution to insulin resistance.   They should benefit from changes in life habits, similarly to men with categorical increases in waist circumference.}

Treatment of the metabolic syndrome
   -Treat underlying causes (overweight/obesity and physical inactivity):
     -Intensify weight management
     -Increase physical activity
   -Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies:
     -Treat hypertension
     -Use aspirin for CHD patients to reduce prothrombotic state
     -Treat elevated triglycerides and/or lowe HDL (as shown in Step 9)

Treatment of elevated triglycerides (>150mg/dL)
-Primary aim of therapy is to reach LDL goal
-Intensify weight management
-Increase physical activity
-If triglycerides are >200mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total-HDL) 30mg/dL higher than LDL goal

Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories

If triglycerides 200-400 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal:
-Intensify therapy with LDL-lowering drug, or
-add nicotinic acid or fibrate to further lower VLDL.

If triglycerides >500 mg/dL, first lower triglycerides to prevent pancratitis:
-very low-fat diet (<15% of calories from fat)
-weight management and physical activity
-when triglycerides <500 mg/dL, turn to LDL-lowering therapy

Treatment of low HDL cholesterol (<40 mg/dL)
-First reach LDL goal, then:
-Intensify weight mangement and increase physical activity
-If triglycerides 200-499 mg/dL, achieve non-HDL goal
-If triglycerides <200 mg/dL (isolated low HDL) in CHD or CHD equivalent consider nicotinic acid or fibrate

See PDF Version

 

Modified Recommendations of Treatment Guidelines based on a 1994 White Paper (Circulation. 2004;110:227-239)
Risk Category	LDL Goal (mg/dL)	LDL Initiation Level (mg/dL)	LDL Drug Therapy Consideration Level
High Risk: CHD or CHD risk equivalents (10 year risk > 20%)	<100 With optional goal of < 70	>100	> 100 (consider drug options if LDL-C <100)
Moderately High Risk (2+ Risk factors) (10 year risk 10% to 20%)	<130 with optional goal of < 100	> 130	> 130 (consider drug options if LDL-C is 100 to 129)
Moderate Risk (2+ Risk factors) (10 year risk < 10%)	<130	> 130	>160
Low Risk: <1 Risk factor »	> 160	>160	>160

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Revised: 02/13/2008
Course Director: Robert J. Straka
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