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:

  1. Age: M ≥ 45: W ≥ 55 or post menopausal
  2. Family history premature: CHD 1° relative ( M ≤ 55/ F ≤ 65)
  3. Smoking: > 1 cigarette/ day
  4. Hypertension: BP ≥ 140/90 ( at least twice) or on Rx
  5. Diabetes: FBG ≥ 7.0 mmol/L or 2 hr PCG ≥11.1 mmol/L.
  6. 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
    • every 5 years


Step 4: Evaluate risk modifiers:

  1. 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.
  2. 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
  3. 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
  4. Homocysteine > 10-15 µmol/L associated with increased risk CVD, CVA and DVT. Measurement not recommended in light of negative trials (HOPE-2,NORVIT)
  5. 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
  6. Measure FPG every 1-3 years > age 50 or younger if obesity or FH type 2 DM. Measure HbA1c if FPG > 6 mmol/L
  7. Genetic Risk:
    • Family history of CAD in CHD 1° relative ( M ≤ 55/ F ≤ 65) raises risk 1.7-2 fold
  8. Ethnicity
    • • South Asian ethnicity living in Western society doubles risk
  9. Post-menopausal status or combined HRT increases CV risk
  10. 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

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  Version 2.0, September 2006
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