Hyperlipidemia
Classification of Cholesterol
LDL Cholesterol				Total Cholesterol				HDL Cholesterol
Optimal		< 100		Desirable		< 200		Low		< 40
Near Optimal		100-129		Borderline High		200-239		High		> 60
Borderline High		130-159		High		> 240
High		160-189
Very High		> 190
			Major Risk Factors
			1. Cigarette smoking
			2. Hypertension (BP > 140/90 or on antihypertensive medication)
			3. Low HDL Cholesterol (< 40 mg/dl)
			4. Family history of premature CHD (CHD in male first degree relative < 55 years or CHD in female first degree relative < 65 years)
			5. Age (Men > 45 years, women > 55 years)
			6. High HDL Cholestesrol (> 60 mg/dl) - negative risk factor
	LDL Cholesterol Goals and Therapy Options Based on Risk Factors
	Risk Category			LDL Goal	LDL level to initiate TLC		LDL Level to initiate drug therapy
	CHD/CHD risk equivalents (10-year risk > 20%)			< 100mg/dl	> 100mg/dl		> 130mg/dl (100-129mg/dl drug optional)
	2+ Risk factors (10-year risk < 20%)			< 130mg/dl	> 130mg/dl		10-year risk 10-20%: > 130mg/dl
							10-year risk <10%: > 160mg/dl
	0-1 Risk factors			< 160mg/dl	> 160mg/dl		> 190mg/dl (160-189mg/dl: LDL lowering drug optional)
	Calculating LDL: LDL = (total cholesterol - HDL) - (triglycerides / 5)
	Calculating LDL goal reduction (in percent): (current LDL - goal LDL / current LDL) X 100
	Therapeutic Lifestyle Changes (TLC)
		1. TLC diet: Saturated fat < 7% of calories, cholesterol < 200mg/day
		2. Consider increasing viscous (soluble) fiber (10-25g/day) & plant stanols/sterols (2g/day)
		3. Weight management
		4. Increased physical activity
Drug Therapy for LDL Lowering
Drug Class		Agents and Daily Doses			Lipid/Lipoprotein Effects		Side Effects		Contraindications
HMG-CoA reductase inhibitors		Lovastatin (20-80mg), Pravastatin (20-40mg), Simvastatin (20-80mg), Fluvastatin (20-80mg), Atorvastatin (10-80mg), Rosuvastatin (10-40mg)			LDL-C  < 18-60%		myopathy, increased liver enzymes		Absolute: active or chronic liver disease
					HDL-C  > 5-15%
					TG       < 7-30%				Relative: Concomitant use of certain drugs*
Bile acid Sequestrants		Cholestyramine (4-16g), Colestipol (5-20g), Colesevelam (2.6-3.8g)			LDL-C  < 15-30%		GI distress, constipation, decrease absorption of other drugs		Absolute: dysbeta-lipoproteinemia; TG > 400mg/dL
					HDL-C  > 3-5%
					TG       no change/slight >
									Relative: TG > 200mg/dl
Nicotinic acid		Immediate release nicotinic acid (1.5-3g), extended release nicotinic acid (Niaspan) (1-2g), sustained release nicotinic acid (1-2g)			LDL-C  < 5-25%		flushing, hyperglycemia, hyperuricemia (or gout), upper GI distress, hepatotoxicity		Absolute: chronic liver disease, severe gout
					HDL-C  > 15-35%
					TG        < 20-50%				Relative: diabetes, hyperuricemia, peptic ulcer disease
Fibric acids		Gemfibrozil (600mg bid), Fenofibrate (200mg), Clofibrate (1000mg bid)			LDL-C  < 5-20%**		dyspepsia, gallstones, myopathy		Absolute: severe renal/hepatic disease
					HDL-C  > 10-20%
					TG        < 20-50%
2-Azetidinone		Ezetimibe (10mg)			LDL-C  < 16-18%		headache		Absolute: severe hepatic disease
					HDL-C  > 1-4%
					TG        < 5-6%				Relative: renal disase, mild hepatic disease
* - Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and nicin should be used w/caution)
** - LDL-C may be increased in patients with high triglycerides
10-Year Risk for Coronary Heart Disease
Males							Females
Age							Age
Age			Points				Age			Points
20-34			-9				20-34			-7
35-39			-4				35-39			-3
40-44			0				40-44			0
45-49			3				45-49			3
50-54			6				50-54			6
55-59			8				55-59			8
60-64			10				60-64			10
65-69			11				65-69			12
70-74			12				70-74			14
75-79			13				75-79			16
Total Cholesterol							Total Cholesterol
Age	< 160	160-199	200-239	240-279	280+		Age	< 160	160-199	200-239	240-279	280+
20-39	0	4	7	9	11		20-39	0	4	8	11	13
40-49	0	3	5	6	8		40-49	0	3	6	8	10
50-59	0	2	3	4	5		50-59	0	2	4	5	7
60-69	0	1	1	2	3		60-69	0	1	2	3	4
70-79	0	0	0	1	1		70-79	0	1	1	2	2
	20-39	40-49	50-59	60-69	70-79			20-39	40-49	50-59	60-69	70-79
Smoker	8	5	3	1	1		Smoker	9	7	4	2	1
Non-smoker	0	0	0	0	0		Non-smoker	0	0	0	0	0
HDL Cholesterol							HDL Cholesterol
HDL			Points				HDL			Points
60+			-1				60+			-1
50-59			0				50-59			0
40-49			1				40-49			1
< 40			2				< 40			2
Systolic Blood Pressure							Systolic Blood Pressure
Systolic Blood Pressure		If Untreated		If Treated			Systolic Blood Pressure		If Untreated		If Treated
< 120		0		0			< 120		0		0
120-129		0		1			120-129		1		3
130-139		1		2			130-139		2		4
140-159		1		2			140-159		3		5
160+		2		3			160+		4		6
10-Year Risk By Point Scores							10-Year Risk By Point Scores
Point Total			10-Year Risk				Point Total			10-Year Risk
< 0			< 1%				< 9			< 1%
0			1%				9			1%
1			1%				10			1%
2			1%				11			1%
3			1%				12			1%
4			1%				13			2%
5			2%				14			2%
6			2%				15			3%
7			3%				16			4%
8			4%				17			5%
9			5%				18			6%
10			6%				19			8%
11			8%				20			11%
12			10%				21			14%
13			12%				22			17%
14			16%				23			22%
15			20%				24			27%
16			25%				25 or more			30%
17 or more			> 30%
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