Download Cholesterol and Heart Disease Risk

Cholesterol and Heart Disease Risk
Treating to reduce risk, not treat numbers. . .
Who to Screen for Lipid Disorders:
USPSTF
strongly recommend routine screening in men ≥ 35 years old and women ≥ 45 years old (A recommendation)
recommend screening men 20-35 years and women 20-45 years if at inc. risk for CHD (B recommendation)
ACP Guidelines
Screen and treat with known vascular disease – evidence shows decreased mortality and cost-effectiveness
Primary preventive screening is optional, not mandatory, recommend no screening >75 yo, equivocal 65-75
NCEP Guidelines – ATP III Routine cholesterol screening recommended starting at age 20
Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals
Cigarette smoking
Hypertension (BP 140/90 mmHg or on antihypertensive medication)
Low HDL cholesterol (<40 mg/dL)†
Family history of premature CHD
CHD in male first degree relative <55 years, female first degree relative <65 years
Age (men 45 years; women 55 years)
****HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.
Risk Assessment
CHD Risk Equivalents - 10-year risk for hard CHD >20%
Other clinical forms of atherosclerotic disease (PVD, AAA, etc.)
Diabetes
Multiple risk factors producing 10-yr risk >20%
Risk Prediction Calculators
o http://hp2010.nhlbihin.net/atpiii/calculator.asp - Framingham calculator
o https://www.heartdecision.org/chdrisk/v_hd/main
Evaluate for Secondary Causes
Diabetes
Hypothyroidism
Others
Risk Category
LDL Goal
LDL Level at Which to
Initiate Therapeutic Lifestyle
Changes (TLC)
LDL Level at Which to Consider
Drug Therapy
CHD or CHD Risk
Equivalents (10-year risk
>20%)
<100 mg/dL
100 mg/dL
130 mg/dL (100-129 mg/dL: drug
optional)*
2+ Risk Factors
(10-year risk 20%)
<130 mg/dL
130 mg/dL
10-year risk 10-20%: 130 mg/dL
10-year risk <10%: 160 mg/dL
0-1 Risk Factor**
<160 mg/dL
160 mg/dL
190 mg/dL
(160-189 mg/dL: drug optional)
Disorders of lipid metabolism evidence-based nutrition practice guideline:
http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=9533
Dietary Fat Components
Fat intake 25 to 35% of calories, <7% of cal from saturated fat and trans-fatty acids, <200 mg cholesterol per day
Omega-3 Fatty Acids, preferably from both marine and plant sources
two 4-oz servings of fish per week, plant-based foods of 1.5g ALA 1 Tb canola or walnut oil, 0.5 Tb ground flax
seed, <1 tsp flaxseed oil, or supplement 1g of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)
Fiber - 25 to 30 g fiber per day, soluble fiber 7- 13 g; fruits, veg., whole grains, esp. high-fiber cereals, oatmeal, beans, and
prunes
Plant Stanols and Sterols
Frankenfoods: Plant sterol and stanol ester enriched foods bid-tid, 2-3g/d( effect on morbidity and mortality
unknown, may be bad for theoretical reasons)
Real Foods: Naturally in whole grain flours, bran, many vegetables, fruits and berries.
Soy Protein - 26 to 50g of soy protein per day in place of animal protein
Nuts - 5ounces of nuts per week is associated with a reduced risk of CHD
Antioxidants(Vitamin E, Vitamin C, and Beta-Carotene)
Antioxidant-rich fruits, vegetables, and whole grains are associated with reduced disease risk.
Vitamin E, vitamin C, and beta-carotene supplements should not be recommended to reduce the risk of
Physical Activity: Moderate intensity physical activity (e.g., brisk walking, swimming laps, bicycling) at least 30 minutes
most, if not all, days of the week, if not contraindicated.
Drug Therapy
HMG CoA Reductase Inhibitors (Statins) - ↓major coronary events, ↓ CHD mortality, ↓ total mortality
Statin
Dose Range
Lovastatin
20–80 mg (40)
Pravastatin
20–40 mg (40)
Simvastatin
20–80 mg (20)
Atorvastatin
10–80 mg (10)
Cerivastatin
0.4–0.8 mg
Rosuvastatin
(5 mg)
(dose in parentheses produces 30-35% lowering of LDL)
S,A,L go through P450 and have more potential drug interactions as a result
S,L have a particularly bad interaction with gemfibrozil
Titration of Statins – NOT clearly beneficial; in ACCORD, intensive therapy caused NS trend to decreased primary endpoint,
BUT Increased total mortality
Side Effects of Statins – myopathy, liver enzymes, others (increased with fibrates)
CoQ10 may decrease side effects
Bile Acid Sequestrants: ↓major coronary events, ↓ CHD mortality
Drug
Dose Range
Cholestyramine
4–16 g
Colestipol
5–20 g
Colesevelam
2.6–3.8g
Niacin
Lowers atherosclerotic complications and total mortality in trials Curr Cardiol Rep. 2003 Nov;5(6):470-6
Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity
Contraindications: liver disease, severe gout, peptic ulcer
Drug Form
Dose Range
Immediate release
1.5–3 g
*Extended release
1–2 g
*Sustained release
1–2 g
*more hepatotoxic
Fibric Acids
Drug
Dose
Gemfibrozil
600 mg BID
Fenofibrate
200 mg QD
Clofibrate
1000 mg BID
Fibrates
Gemfibrozil - ↓long-term CHD mortality, esp. if overweight with hyperTG (no change in overall mort.) Helsinki Heart Study
Clofibrate ↓ coronary events but increased total mortality
Tricor – ↓ angiographic progression of CAD; no data available on effect on coronary morbidity or mortality
Natural Substances for Lowering Cholesterol
**Fiber – psyllium before meals can decrease LDL, help with weight loss and glycemic control and BP
Plant Sterols (Phytosterols)
**Red Yeast Rice Extract - Cholestene, Chole-sterin, and Healthy America, ~2400 mg/d
**Garlic (Allium Sativum) - 1 clove per day or 4000 mg fresh garlic or 10 mg alliin or 4000 mcg total allicin potential; note
blood thinning effects
Probably not worth using: policosanol, guggulipid
But if you really want your patients to live longer:
Mediterranean diet
Fish 2x per week
Aim towards vegetarian And if you still want to treat the numbers. . . . Fleming (Stop Inflammation Now)
Specific Dyslipidemias:
Elevated Triglycerides
Causes of Elevated Triglycerides:
Obesity and overweight
Physical inactivity
Cigarette smoking
Excess alcohol intake
*High carbohydrate diets (>60% of energy intake)
Several diseases (type 2 diabetes, chronic renal failure, nephrotic syndrome)
Certain drugs (corticosteroids, estrogens, retinoids, higher doses of beta-blockers)
Various genetic dyslipidemias
*think of this when deciding on diet for tx
o
If triglycerides 500 mg/dL, first lower triglycerides to prevent pancreatitis:
o very low-fat diet (15% of calories from fat)
o Lower CHO, eliminate alcohol
o weight management and physical activity
o fibrate or nicotinic acid
o when triglycerides <500 mg/dL, turn to LDL-lowering therapy.
if TG 200 – 499 when LDL at goal, consider intensifying to meet non-HDL goals:
Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories
Risk Category
LDL Goal
(mg/dL)
Non-HDL Goal (mg/dL)
CHD and CHD Risk Equivalent (10-year risk for CHD >20%)
<100
<130
Multiple (2+) Risk Factors and 10-year risk 20%
<130
<160
0-1 Risk Factor
<160
<190
Low HDL Cholesterol
Causes of Low HDL Cholesterol (<40 mg/dL)
Elevated triglycerides
Overweight and obesity
Physical inactivity
Type 2 diabetes
Cigarette smoking
Very high carbohydrate intakes (>60% energy)
Certain drugs (beta-blockers, anabolic steroids, progestational agents)
Management of Low HDL Cholesterol
Weight reduction
*Increased physical activity
Limit refined carbs
Increased MUFAs in the diet
*Fish oil
Can consider niacin, fibrates, but benefit unclear
*these decrease overall mortality as well