Cholesterol Treatment Guidelines Update

Hypercholesterolemia is a major contributor to atherosclerosis and coronary heart disease in our society. The National Cholesterol Education Program of the National Institutes of Health has created a set of guidelines to standardize the clinical evaluation and management of high cholesterol for the practice of doctors and other professionals in the medical community. In May 2001, the National Cholesterol Education Program published its third set of guidelines, which reflects changes in the management of cholesterol from their previous report in 1993. In addition to modifying the current strategies of risk assessment, the new guidelines emphasize the importance of an aggressive therapy in the management of high cholesterol. The main risk factors that modify low-density lipoprotein goals include age, smoking, hypertension, high density lipoprotein, and family history. The concept of "CHD equivalent" is introduced -- conditions that require the same care used in patients with coronary heart disease. Patients with diabetes and those with 10 years of cardiac event risk of 20% or more are considered as equivalent CHD. Once low-density lipoprotein cholesterol is at an acceptable level, doctors are invited to address the metabolic syndrome, and hypertriglyceridemia. (Am Fam Physician 2002; 65:871-80. Copyright © 2002 American Academy of Family Physicians.) A PDF version of this document is available. Download PDF now (104 pages per 10 KB). More information on the use of PDF files. See editorial On page 783. Coronary heart disease (CHD) is the leading cause of morbidity and mortality in the United States, which represents approximately 500,000 deaths per year and morbidity associated annual cost of more than $ 200 billion.1 Over the past three decades, And many clinical epidemiological studies have repeatedly shown that the high level of blood cholesterol is a major modifiable risk factors associated with the development of CHD.2 In particular, these studies have shown that low-density lipoprotein ( LDL) cholesterol is the main mediator lipoprotein atherosclerosis. Other risk factors such as smoking, hypertension, diabetes and low levels of high-density lipoprotein (HDL) cholesterol were also involved in CHD.3 In an effort to address this public health issue, the National Institutes of Health established the National Cholesterol Education Program in 1985. In 1988, the National Cholesterol Education Program, I Adult Treatment Panel (NCEP ATP I) has produced its first set of guidelines, setting out clear objectives for patients with lipid abnormalities. In 1993, the NCEP ATP II revised its initial recommendations and prepared a second set of guidelines; In addition to stressing CHD risk status, the report placed more emphasis on the levels of HDL, weight loss and the physical activity. In May 2001, the NCEP ATP III released its third set of guidelines, which reflects changes in the calculation of coronary risk and in the management of high cholesterol. Under the new guidelines, the number of patients with cholesterol, which can be seen as abnormal has now tripled. The NCEP ATP III guidelines are similar to those contained in the second report to identify LDL, focused on cholesterol-lowering therapy. Stratification of risk continues to determine the goals of LDL and intensity of LDL-lowering therapy. Dietary therapy is the first line of treatment, with drug treatment reserved for the treatment of patients at high risk for coronary heart disease or patients who do not respond to nonpharmacologic therapy. The differences between the third report and the previous report are summarized in Table 14 and discussed in this article. TABLE .

The lipoprotein profile can be interpreted without knowledge of risk factors of the patient. Risk factor counting remains an important part of the guidelines (Table 2) .4 In ATP III, diabetes is more about this risk factor, but the list is now included in a new category called "CHD risk equivalent." Optimal cholesterol screening now includes a lipoprotein profile (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides), preferably with blood while the patient is in a state of fasting. As stated in the ATP III, an additional step in determining CHD risk involves calculating the risk score Framingham (FRS) for people with two or more risk factors. Adding this step, and the identification of the main risk factors, allows doctors to recognize patients who are at greater risk for cardiovascular diseases. Risk Factors Since 1993, other proof of age, sex, and HDL significance has emerged, reinforcing the need to address these factors. The NCEP position on smoking, high blood pressure and family history remained unchanged. Age and sex Recent studies have shown that identification and treatment of dyslipidemia in patients 65 years and older can reduce the risk of first and recurrent coronary events. [Evidence level A, randomized controlled trials (ECR) / meta-analysis] The Scandinavian Simvastatin Survival Study (4S), cholesterol and Recurrent Events (CARE) study, and the Air Force / Texas Coronary Atherosclerosis Prevention Study (AFCAPS / TexCAPS) were further analyzed in the population over 65 years. In each treatment group, morbidity and mortality from cardiovascular disease has dropped by at least 29 percent.5-7 Although the data are limited for patients aged over 85 years, seniors are candidates for 'cholesterol-lowering therapy. Initiation of therapy should be carefully considered in the context of comorbidities and the increased use of drugs within this population. TABLE 2 The main risk factors that modify LDL goals -------------------------------------------------- ------------------------------ Positive risk factors Age (men> = 45 years; The women> = 55 years) Low HDL cholesterol (<40> 140/90 mm Hg or taking antihypertensive medication) Family history of premature coronary heart disease (CHD in male first-degree <55> 60 mg / dL [1.55 mmol per L]); Presence of this risk factor to remove a risk factor for the total count -------------------------------------------------- ------------------------------ LDL = low-density lipoprotein; = HDL high-density lipoprotein; CVD = coronary artery disease. Adapted with permission from Synthesis of Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285:2487. Primary and secondary education, the reduction of cardiovascular risk is also important for women. Cardiovascular diseases are the leading cause of death among American women, far exceeding the rate of all cancers combined.1 Women's mortality following myocardial infarction is three times higher than for men, 8 suggesting that women did may not be active participants in strategies for reducing cardiovascular risk. By demonstrating cardiovascular event reduction through the use of statins, 4S, CARE, and AFCAPS / TexCAPS trial support cholesterol in the therapy of women. [A level of evidence, RCTs / meta-analysis] The recent Heart and Estrogen / Progestin Replacement Study (HERS) has cast doubt on the use of hormone replacement therapy (HRT) in the secondary prevention of CHD risk postmenopausal women.9 Although several studies of primary prevention supports the use of HRT to prevent heart disease, studies that support the use of statins for the prevention of heart disease among women is much greater. Consequently, ATP III prefers the first use of a cholesterol-lowering agent HRT for reducing the risk of coronary heart disease in postmenopausal women. Although women have, on average, higher than men of HDL, ATP III guidelines make no distinction between the sexes with regard to the choice of a threshold of HDL. FIGURE 2. Framingham points system for estimating 10-year risk of coronary heart disease in women. (CHD = ischemic heart disease; BP = blood pressure; = HDL high-density lipoprotein; FRS = Framingham risk score) NOTE: The risk assessment for the determination of 10-year risk of developing coronary heart disease is performed using scoring Framingham risk. The first step is to calculate the number of points for each potential risk factor of the table. For the first assessment, the values of total cholesterol and HDL cholesterol are needed. Total cholesterol and HDL cholesterol values must be the average of at least two measurements obtained from the analysis of lipoproteins. The designation means smoking cigarettes in the past month. Blood pressure value is the one obtained at the time of assessment, regardless of whether the person is taking antihypertensive agents. Adapted with permission from Synthesis of Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in adults (Adult Treatment Panel III). JAMA 2001; 285:2486-97. Framingham risk score The FRS is a risk assessment tool that has been compiled from data collected in the Framingham Heart Study.11 As mentioned previously, the new NCEP guidelines recommend that patients with two or more risk factors have calculated FRS. [Evidence Level B, the retrospective analysis of data] The FRS is composed of points that are awarded for the different levels of risk associated with the following five categories: age, the level of total cholesterol, HDL cholesterol, smoking status, and hypertension (and if the latter condition is treated) . The summation of these items results in a percentage risk of having a cardiac event within the next 10 years. Figures 1 and 2 outline FRS assessment for both men and women, respectively.4 Equivalents CHD In the ATP II guidelines, risk categories have been developed to separate the patients with coronary heart disease (or its equivalent, such as aneurysm of the abdominal aorta, intermittent claudication, symptomatic carotid artery disease, etc.) for those who lack of cardiovascular disease. This distinction was made primarily to delineate the creation of new target LDL levels for patients with coronary artery disease and to provide appropriate therapy for these patients in terms of increased cardiovascular risk. The ATP III guidelines, the target level of LDL for patients with established coronary heart disease even 100 mg dL is, by less. Patients with diabetes and patients with an FRS of 20% or more are considered as equivalent CHD. Because patients with diabetes and patients with an FRS of 20% or more are in the same risk category as CHD patients, they are also recommended to maintain an LDL of 100 mg per dL level. [Evidence level C, consensus / expert opinion] Interventions to achieve the goal LDL in patients with diabetes or an FRS of 20% or more are the same as those in patients with cardiovascular disease. The creation of diabetes as a CHD risk equivalent reflects the prevalence of heart disease as a cause of death among diabetic population. Three quarters of patients with diabetes die of heart disease-related illnesses compared to half the population in general. Poor glycemic control has been repeatedly demonstrated to be associated with a high risk of cardiovascular events. According to the 2000 American Diabetes Association Guidelines, the main objective of hyperlipidemia in patients with type 2 diabetes (with or without vascular disease) is to reduce LDL cholesterol levels below 100 mg per dL.12 [C level proof, consensus / expert advice The events in this patient population The distribution of fat allowance has been amended to recognize the value of monounsaturated and polyunsaturated fatty acids. By replacing saturated fat (cheese, whole milk, red meat), with monounsaturated fats (olive, canola oil) and polyunsaturated fats (corn oil, peanut), LDL is reduced. Although replacing saturated fats with a high-carbohydrate diet reduced levels of LDL, it has the adverse effect of higher triglyceride levels and lowering HDL. Saturated and trans fatty acids should be avoided. ATP III proposes adding plant stanols (hydrogenated phytosterols) to the patient's diet when initial attempts to change the system have not been successful in achieving the goal LDL. [Evidence level C, consensus / expert opinion] Plant stanols interfere with the absorption of the small intestine and intestinal biliary cholesterol. Although they lower LDL levels, they have no significant effect on the HDL or triglycerides levels.14 Phytosterols can be found in many products, including margarine spreads. Other sources of phytosterols include sesame seeds and peanuts; Soybeans are a natural source of phytosterols. Where this results in weight loss, it contributes to the reduction of LDL. The weight loss also improves insulin sensitivity and serum glucose uptake, which reduces the risk of diabetes. Smoking is a risk factor for cardiovascular. Patients who stop smoking can expect an increase of up to 30% in their HDL levels.16 Drug Therapy As indicated by the ATP III, the failure of TLC to change the LDL cholesterol levels or the presence of high levels of risk of coronary heart disease warrants the use of drugs. Despite its use, particular attention to TLC should always be maintained and strengthened by the doctor. Several drugs have an effect on the metabolism of lipoproteins. Table 5 lists the current classes of drugs and their associated lipid change effects.17 Arabic to English BETAChinese to English BETAChinese (Simplified to Traditional) BETAChinese (Traditional to Simplified) BETAEnglish to Arabic BETAEnglish to Chinese (Simplified) BETAEnglish to Chinese (Traditional) BETAEnglish to FrenchEnglish to GermanEnglish to ItalianEnglish to Japanese BETAEnglish to Korean BETAEnglish to PortugueseEnglish to Russian BETAEnglish to SpanishFrench to EnglishFrench to GermanGerman to EnglishGerman to FrenchItalian to EnglishJapanese to English BETAKorean to English BETAPortuguese to EnglishRussian to English BETASpanish to English

What is Cholesterol?

Before you start chomping on those cheese fries or greasy hamburger, you may want to take a closer look if you get too much cholesterol. Cholesterol, a waxy substance produced by the liver and found in some foods, is needed to make vitamin D and certain hormones, building cell walls, and create bile salts that help you digest fat. In fact, your body produces enough cholesterol so that if you have never touched another cheese fry, you would be OK. But it is difficult to avoid entirely cholesterol because many foods contain. Too much cholesterol in the body can cause serious problems, such as heart disease. Many factors can contribute to high cholesterol, but the good news is there are things you can do to control them. Look at taking a Cholesterol Lipids are fats that are found throughout the body. Cholesterol, a type of fat is found in foods of animal origin. This means that eggs, meat and whole-fat dairy products (including milk, cheese, and ice cream) are responsible for cholesterol and vegetables, fruits and grains contain any. The liver produces about 1,000 milligrams of cholesterol per day, and you probably consume about 150 to 250 milligrams in the food you eat. Because cholesterol may not travel in the blood, it must be combined with certain proteins. These proteins act as trucks, pick-up and transport of cholesterol in different parts of the body. When this happens, cholesterol and protein form a lipoprotein. The two main types of lipoproteins are the high-density lipoproteins (HDL) and low density lipoprotein (LDL). You may have heard people call LDL "bad cholesterol" HDL cholesterol and "good cholesterol" because of their very different effects on the body. Most cholesterol is LDL cholesterol, and it is the kind that is most likely to become clogged blood vessels, keeping the blood from flowing through the body as it should. About one third to one fourth of total cholesterol to HDL cholesterol. HDL Cholesterol transports cholesterol to the liver, where it can be processed and sent out of the body. Why do people worry about high cholesterol? When you have too much cholesterol, it can be dangerous for your health. When LDL cholesterol is high cholesterol deposited on artery walls and form a hard substance called plaque. Over time, plaque causes the arteries to become narrower, reducing blood flow and cause a disease called atherosclerosis (pronounced: ha-thuh-ro skluh roll-on/roll-off sis), or hardening of the arteries. When atherosclerosis affects the coronary arteries (the blood vessels supplying the heart muscle), the condition is called coronary artery disease, which puts a person at risk of a heart attack. When atherosclerosis affects the blood vessels that feed the brain, the condition is called cerebral vascular disease, which puts a person at risk of having a stroke. Atherosclerosis can also block blood flow to other vital organs, including the kidneys and intestines. That's why it is so important to begin to pay attention to cholesterol levels as a teenager-you can delay or prevent serious health problems in the future. What causes LDL cholesterol high? Some of the factors that can lead to high cholesterol are: Overweight-overweight has been linked to high cholesterol. Heredity - If cholesterol problems and heart disease run in your family, you are at a higher risk of having problems. Remember that the diet said "you are what you eat"? Avoid foods high in cholesterol, saturated fat and trans fats, which all high cholesterol and the risk of developing heart disease. - Exercise of physical activity tends to increase levels of HDL, which reduces your chances of developing heart disease. Age - The risk of high cholesterol increases as you get older. What can I do to lower my cholesterol? Some people who have high cholesterol should be medicines as part of their treatment has fallen. Although most teens are not required to take medication to lower their cholesterol, it is always important to keep cholesterol in check. To see if you have high cholesterol, talk to your doctor, who can test your cholesterol by drawing a sample of your blood. You can not change your genes, but there are things you can do now to reduce the risk of heart disease later. Try eating less saturated fat, limit the amount of trans fat, and to limit cholesterol (check food labels if you do not know how many of these foods contain particular). The American Heart Association recommends that cholesterol intake should be less than 300 milligrams per day, total fat should be 30% or less of total calories, saturated fat and should be 10% or less in the number total calories you consume daily. Also, maintain a healthy weight and get moving. Aerobic exercise regularly-things like cycling, walking, swimming, and strengthens the heart, lowers cholesterol and helps you lose excess weight. For people who smoke, abandonment can help reduce the risk of heart disease. Here are some useful tips to try: Eat a diet that contains many of cholesterol foods: fruits, vegetables, whole grains (breads and cereals), legumes (beans), and fish. Eat a diet that is low in saturated fats and trans. Replace saturated and trans fats with unsaturated fats, for example, to cook with olive oil or other heart-friendly instead of using oil butter or stick margarine. If you eat meat, try using lean meat like chicken skin. Make sure you trim off all fat notables before cooking and drain fat from the pan after browning meat. Instead of frying, try boiling, broiling, baking, roasting, poaching, steaming or sautéing. Instead of whole milk, use low-fat or nonfat milk, which contains all the nutrients without all the fat. Also, try low-fat or nonfat yogurt and cheese or cottage cheese. You can also replace the low-fat buttermilk or yogurt in a recipe that calls for cream cheese or sour cream. Use without trans fat margarine. Instead of meat, try beans, peas, lentils or tofu. Instead of eggs, try just egg whites, or cholesterol-free egg substitutes trade. Use vegetable oil or liquid tub margarine instead of butter, shortening or margarine sticks. Stay away from products that contain hydrogenated vegetable oils. Pass on trade in prepared baked goods, which are often made with hydrogenated oils or trans fats. Looking snacks that are low in fat and cholesterol? Try fruit, raw vegetables and low-fat dips, low-fat cookies and crackers, plain unsalted popcorn or pretzels, gelatin, yogurt or low fat. If you are concerned about cholesterol and heart disease, talk to your doctor. Visit the American Heart Association's Web site, which contains a lot of information as well as low cholesterol recipes for you to try at home. Although all the factors that contribute to heart disease and high cholesterol can be controlled, many possible. Start taking care of your body now, and she thanks you in the future.