Lipids

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

• Male >45 yo
• Female >55 yo (or premature menopause without estrogen Tx)
• Family Hx of CAD - this is defined as a first degree male relative <55yo or female relative <65yo with CAD (or evidence thereof, such as MI or stroke)
• Smoker (current or within 10 years)
• Hypertension (>140/90 or taking antihypertensive Rx)
• Diabetes Mellitus
• HDL <35 mg/dl (HDL >60 allows you to subtract one other risk factor)

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:	<200	Re-screen in 5 years
Borderline High:	200-239, 0-1 risk factors	Educate 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 >4.5		Check lipid panel (fasting)
Prior Known Hyperlipidemia		Check 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.

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!).

Drug	LDL	HDL	TG	Side Effects	Contraindications
Niacin				Flushing, GI upset, itching	DM, gout, hepatic dz. Do not give with statins
Binder (cholestyramine, colestipol)				GI upset	TG>250, constipation
Statins (HMG-CoA Reductase Inhibitors)				Mild GI upset	pregnancy, hepatic dz. Do not give with gemfib or niacin
Gemfibrozil				Mild GI upset	Hepatic dz. Do not give with statins
Hormone Replacement Therapy				uterine bleeding, risk breast CA	DM, gout, hepatic dz