Lipids
Screening:

Screening should begin with an assessment of the patient's cardiac risk factors. This helps to determine target LDL, and recommended interventions.

With 0-1 risk factors, target LDL is <160. With 2+ risk factors, target LDL is <130. With personal Hx of CAD, target LDL is <100.

Next, total cholesterol should be checked in all patients between 20 and 75 years of age every five years - this can be done without fasting. (>75yo there is no clear relationship between CAD and cholesterol)
Desirable:<200Re-screen in 5 years
Borderline High:200-239, 0-1 risk factorsEducate re: diet, exercise and repeat in 1 year.
High:200-239, 2+ risk factors
or >240
Check lipid panel (fasting), TSH, and fasting blood glucose. Then follow Recommended Interventions, below.
Total Cholesterol/HDL Ratio >4.5Check lipid panel (fasting)
Prior Known HyperlipidemiaCheck lipid panel (fasting)

The fasting lipid panel includes Total Cholesterol, HDL, and Triglycerides. LDL is calculated using the formula: LDL = total chol - HDL - TG/5    If triglycerides are >400, this formula loses accuracy, and a separate LDL needs to be ordered.

Treatment:

 

Recommended Interventions:
Patient's LDL0-1 risk factors2+ risk factorsHx of CAD
100-129Repeat in 5 yearsRepeat in 1 yrDiet
130-159Repeat in 1 yearDietDiet & Drug
160-189DietDiet & DrugDiet & Drug
>190Diet & DrugDiet & DrugDiet & Drug
All interventions should include patient education re: lifestyle, follow-up, risk factors.

 

Diet:

Utilize nutritionists! Reduce calories from fat and saturated fat to <30 and 10%, respectively - roughly 60 grams of fat for average woman, 80 grams of fat for average man. Avoid obviously fatty foods, such as oils, butter (& margarine!), fried foods, etc. Reduce caloric intake overall. Increase exercise (obesity raises lipids!).

 

Drugs:
DrugLDLHDLTGSide EffectsContraindications
NiacinFlushing, GI upset, itchingDM, gout, hepatic dz. Do not give with statins
Binder
(cholestyramine, colestipol)
GI upsetTG>250, constipation
Statins
(HMG-CoA Reductase Inhibitors)
Mild GI upsetpregnancy, hepatic dz. Do not give with gemfib or niacin
GemfibrozilMild GI upsetHepatic dz. Do not give with statins
Hormone Replacement Therapyuterine bleeding, risk breast CADM, gout, hepatic dz