Measure total cholesterol and high-density lipoprotein (HDL) every 5 years (unless abnormal), starting at age 20 (although this recommendation is not universally accepted). Start, earlier if the patient is obese or has a strong family history. Look for xanthelasma (know what it looks like), corneal arcus (in younger patients), lipemic-looking serum, and obesity as markers of possible familial, hypercholesterolemia. Family members should be tested. Also, look for pancreatitis with no risk factors (e.g., no alcohol, gallstones) as a marker for familial hypertriglyceridemia.

Patient with xanthelasma in all four lids. (From Tasman W, Jaeger EA: The Wills Eye Hospital Atlas of Clinical Ophthalmology, Philadelphia, Lippincott-Raven, 1996, with permission.)

Patient with xanthelasma in all four lids. (From Tasman W, Jaeger EA: The Wills Eye Hospital Atlas of Clinical Ophthalmology, Philadelphia, Lippincott-Raven, 1996, with permission.)




Total dioiesierol 200 Totti choiwterol «. 200

Toui ^»J.êtifex^/^ië.r^ * ïbuJ cholesterol > ¿00.

Remwiu« in 5 years? CoïirtSi'Iing ami recheck to 1-?. yr* ÎV> fasitog Upoprptdrs-aiuiys« (gives JJÛÏ,) Rejnessurc )»■ i yr (patient tmvts goals)

■ Ñott!;. W^ïi: èyii.lifnirëisf C1.-EÉ>, ^wïiich■ íRtití^s ^kjîvA ^iiïry.íÍ}íÍí;ííSíí pCTiphe.ntl vascular disease), use medications when

■ - ÚiiÍpk-HÍ>Í,-<->5 íug/dS, i» which caw you gö alî^tsisà 'âjjtî tîb itfsring bpoprwciiï analysis.

Risk factors for coronary heart disease (LDL and total cholesterol are risk factors for CHD, but do not count them in deciding to treat or not to treat high cholesterol):

■ Age (men > 45, women > .55 or with premature menopause and no estrogen replacement therapy)

« Family history of premature CHD (defined as definite myocardial infarction or sudden death in father/first-degree male relative <55 years old or mother/first-degree female relative <65 years old)

Cigarette smoking (> 10 cigarettes/day)

m Hypertension (> 140/90 mmHg or on antihypertensive medications)

* Diabetes mellitus b Low HDL (< 35 mg/dl) (Note: HDL > 60 mg/dl is considered to be protective and negates one risk factor.)

■ Male sex is also considered a risk factor because men develop coronary heart disease earlier than women (but postmenopausal women quickly catch tip with age-matched men). If you give a patient one risk factor for being male, do not give him a second, risk factor for age (use one or the other in men).

a Obesity is not an independent risk factor for boards purposes. Stress, physical inactivity and type A personality (look for a hard-driving attorney) are controversial (presumed to be risk factors by some clinicians).

a Hypertriglyceridemia alone is not considered a risk factor, but when associated with high cholesterol causes more coronary heart disease than high cholesterol alone,

Note: Lipoprotein analysis involves measuring total cholesterol, HDL and triglycerides. I.DL can then be calculated from the formula LDL = total cholesterol - HDL -- (triglycerides/5).

Note: Always give new patients at least 3 months to try lifestyle modifications (decrease calories, cholesterol, and saturated fat in diet; decrease alcohol and smoking; exercise) before initiating drug therapy.

First-line agents are niacin (poorly tolerated but effective) and bile acid-binding resins (e.g., cholestyramine). LIMG CoA-reductase inhibitors are the most effective drugs and are considered first-line agents by some, but for board purposes, they are used first only if the other two choices are not appropriate or if patient has extremely high cholesterol (> 300 mg/dl, which is a marker for familial hypercholesterolemia).

Note: High HDL is protective against atherosclerosis and is increased by moderate alcohol consumption (1-2 drinks/day) hut not high alcohol intake, exercise and estrogens. HDL is decreased by smoking, androgens, progesterone, and hypertriglyceridemia.

Be aware of secondary causes of hyperlipidemia: uncontrolled diabetes mellitus, hypothyroidism, uremia, nephrotic syndrome, obstructive liver disease, excessive alcohol intake (increases triglycerides), and medications (oral contraceptives, glucocorticoids, thiazides, and beta blockers).

Atherosclerosis is invol ved in about one-half of all deaths in the United States and one-third of deaths between ages 35 and 65. Atherosclerosis is the most important cause of permanent disability and accounts for more hospital days than any other illness (translation: understand atherosclerosis for the boards').

Smoking is the single most significant source of preventable morbidity and premature death in the United States. Whenever you are not sure which risk factor to eliminate, smoking is a safe guess.

Important points:

1. Smoking is the best risk Factor to eliminate to prevent heart disease-related deaths (responsible for 30-45% of deaths due to coronary heart disease deaths). Risk decreases by 50% within 1 year compared with continuing smokers and decreases to the level of pa tients who never smoked in 15 years.

2. Smoking also increases risk for the following cancers: lung (90% of cases), oral cavity, esophagus, larynx, pharynx, bladder (50% of cases), kidney, pancreatic, and cervical cancers. Smoking possibly increases stomach cancer also.

3. Chronic obstructive pulmonary disease is often due to smoking. Emphysema almost always is due to smoking (unless the patient is very young or has no smoking history, in which case you should consider alpha ( antitrypsin deficiency). Although the changes of emphysema are irreversible, risk of death still decreases after smoking cessation.

4. When parents smoke, children at increased risk for asthma and upper respiratory infections, including otitis media.

5. Smoking retards healing of peptic ulcer disease, and cessation .stops Buerger's disease (Raynaud's sympt.oms in a young male smoker).

6. Smoking by pregnant woman increases the risk of low birth weight, premat urity, spontaneous abortion, stillbirth, and infant mortality.

7. Smoking cessation preoperative^ is the best way to decrease risk of postoperative pulmonary complications.

8. Do not give birth control pills to women over 35 who smoke; do give women smokers postmenopausal estrogen therapy

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