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Adult Treatment Panel III _ATP I

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									Interpreting Your Blood Lipid
           Results


   DR. STEPHEN R. HOLT, MD, MPH
      Senior Director, Health Fitness
                  NDU

  Adapted From: MARK A. KOENIGER
         Lt Col, USAF, MC, SFS
IT’S ALL ABOUT
      RISK
          Lipids In A Nutshell
• Cholesterol -- fat-like substance produced in the
  liver and absorbed from diet
• Low Density Lipoprotein (LDL) – bad
  cholesterol; carries and deposits cholesterol in
  arteries
• High Density Lipoprotein (HDL) – good
  cholesterol; cleans up cholesterol from arteries
• Triglycerides – milder risk factor; type of fat;
  high levels felt to be a precursor to diabetes
           CHOLESTEROL
      WHAT’S ACCEPTABLE?

                      Desirable    Borderline-   High
                                   High Risk     Risk
Total Cholesterol      <200         200-239      >240

LDL                    <130         130-159      >160
                    <100 optimal

HDL                     >60          40-60       <40

Triglycerides          <150         150-199      >199
           HOWEVER


Chol  HDL + LDL + Triglycerides
                         5
        EXAMPLES
Chol   HDL   LDL   Trigly   Overall

220    80    110    150     Good

210    75    100    170     Good

195    35    165    25      V. Bad
       Cholesterol vs HDL


Ratio - Total Cholesterol / HDL
<4.5 Desirable
4.5 High
    Why Determine Risk Level?
    (Chance of having an MI or Heart Attack within the next 10 Years)




• Establish an LDL goal of therapy
• Determine need for therapeutic lifestyle
  changes (TLC)
• Determine level for starting medication
Factors Contributing to Risk Level
         Determination

  • Coronary Heart Disease (CHD) or
    CHD Equivalent
  • Major Risk Factors (other than LDL)
Coronary Heart Disease (CHD)
     or CHD Equivalent

•   Clinical CHD
•   Diabetes
•   Symptomatic carotid artery disease
•   Peripheral arterial disease
•   Abdominal aortic aneurysm
Major Risk Factors (MRF): Exclusive of
           LDL Cholesterol
 • Cigarette smoking
 • Hypertension (BP 140/90 mmHg or on
   antihypertensive medication)
 • Low HDL cholesterol (<40 mg/dL)†
 • Family history of premature CHD
       – CHD in male first degree relative <55 years
       – CHD in female first degree relative <65 years
 • Age (men 45 years; women 55 years)
 †   HDL cholesterol 60 mg/dL counts as a “negative” risk
     factor; its presence removes one risk factor from the total
     count.
             Levels of Risk
• Very High Risk – CHD plus 1 major risk factor
  (MRF)
• High Risk – CHD; or at least 2 MRFs plus >20%
  chance of MI in 10 years
• Moderately High - at least 2 MRFs plus 10-20%
  chance of MI in 10 years
• Low/Moderate - at least 2 MRFs plus <10%
  chance of MI in 10 years
• Low – 0 or 1 MRFs
10-Year Risk Estimate Based on:
•   Age
•   Total Cholesterol
•   Smoker
•   HDL
•   Systolic Blood Pressure

All of the above are gender specific
            Moderate Risk
            of Heart Attack
• 10 Year Risk  10%

• Men
  – Score  12


• Women
  – Score  20
             LDL Goal Based On Risk Level

                             LDL Goal        Initiate TLC if   Initiate Drug Therapy
    Levels of Risk
                              (mg/dL)        LDL (mg/dL):         if LDL (mg/dL):
     Very High Risk                                                      100
                             Consider <70      Consider 70
     (CHD & MRF)                                                (70–99: drug optional)
       High Risk
(CHD or 2 MRF plus >20%          <100             100                  100
     chance of MI)
   Moderately High Risk
                                 <130                                   130
(2 MRF plus 10-20% chance                         130
                             Consider <100                     (100–129: drug optional)
          of MI)
    Low-Moderate Risk
(2 MRF plus <10% chance of       <130             130                  >160
           MI)
        Low Risk                                                        190
                                 <160             >160
        (0-1 MRF)                                              (160–189: drug optional)
  Treating Elevated LDL via Therapeutic
            Lifestyle Changes
Major Features
• TLC Diet
   – Reduced intake of cholesterol-raising nutrients
       • Saturated fats <7% of total calories (10 gms in 1500 cals)
       • Dietary cholesterol <200 mg per day (1 egg or 8 oz of meat)
       • Avoid trans fats (partially hydrog. veg. oil) – also lowers HDL
   – LDL-lowering therapeutic options
       • Plant sterols/stanols (2-3 g/d) – nuts, seeds, legumes, & plant
         oils provide on avg 0.2g/d. Need to use enriched spreads (ex:
         Smart Balance, Benecol) to reach maximum therapeutic benefit
       • Viscous (soluble) fiber (10–25 g per day) – 2 gms from: ½ cup
         of beans, ¾ cup of dry oats, 1 cup of carrots or brocolli, a
         medium orange or pear, or 2 medium apples
• Weight reduction (drop 2 for every lb. lost)
• Aerobic exercise (60-80% of max heart rate, 45
  min/day most days)
    Other Things To Lower Your
               Risk
•   Eat deep sea fish once per week
•   Baby aspirin over 50
•   Glass of wine (4 oz)
•   Avoid depression
•   Don’t smoke
•   Folate 1 mg/day
•   Omega 3 Fatty Acids
          LOW HDL
TREATMENT / PREVENTION
• DIET
  – Beans, Peas
  – Lentils, Oats
  – Avoid trans fats
• AEROBIC EXERCISE
• ALCOHOL (Wine preferred)
  – Moderate intake
     • Males: 1-2 drinks/day
     • Females: 1 drink/day
     Treating Elevated LDL via
              Medication
HMG CoA Reductase Inhibitors (Statins)
• Reduce LDL 20–50% & TG 7–30%
• Raise HDL 5–15%
• Major side effects (2-5%)
   – Myopathy
   – Increased liver enzymes
• Contraindications
   – Absolute: liver disease
   – Relative: use with certain drugs
  The Metabolic Syndrome as a Secondary
           Target of Therapy
General Features of the Metabolic Syndrome
• Abdominal obesity (males >40 in, females >35 in)
   – ADA criteria (males >36.9 in, females > 31.8 in)
• Elevated triglycerides >150
• Low HDL cholesterol
   – Males < 40
   – Females <50
• Elevated blood pressure (>130/85)
• Insulin resistance—Fasting Glucose > 109
   –   ADA criteria > 100
   What Reverses Heart Disease
• Dean Ornish Holistic Approach
  –   Vegan vegetarian diet
  –   Community
  –   Exercise
  –   Spiritual
• Statins
             C-Reactive Protein
                  (CRP)
•   Marker for inflamation
•   Marker for increased risk of Coronary Dz
•   Negative or less than 1.0 is good
•   Treat with Statins
    – Treat underlying inflammatory conditions
      Prostatic Specific Antigen
                (PSA)
• Marker for Prostate Cancer
• Can be elevated for a lot of non-cancer
  reasons
• Far from a perfect screening test
  – But best we have
• Less than 4.0 is good
• But, PSA velocity of increasing 0.7 ng/dl
  per year is bad (even if PSA < 4.0)
Questions
                Background
• In 2001 a panel of experts released the National
  Cholesterol Education Program’s (NCEP)
  guidelines known as the Adult Treatment Panel
  (ATP) III Report
• In Jul 04 the Report was updated based on a review
  of 5 additional major clinical trials. The update
  recommended more aggressive treatment of
  elevated cholesterol
• The following information & recommendations are
  based on the initial Report and subsequent update
           CHOLESTEROL
      WHAT’S ACCEPTABLE?

                      Desirable    Borderline-   High
                                   High Risk     Risk
Total Cholesterol      <200         200-239      >240

LDL                    <130         130-159      >160
                    <100 optimal

HDL                     >60          40-60       <40
           ATP III Lipid and
        Lipoprotein Classification

Cholesterol – fat-like substance produced in the
 liver and used throughout the body. It is affected
 by diet, weight, gender, exercise, age, smoking &
 family history.
Total Cholesterol (mg/dL)
<200        Desirable
200–239     Borderline high
240        High
          ATP III Lipid and
   Lipoprotein Classification (continued)
Low Density Lipoprotein (LDL) – the major
  cholesterol carrier. If too much circulates, will
  build up in arterial walls. Affected by weight,
  exercise, and saturated & trans fat intake.

LDL Cholesterol (mg/dL)
<70          Optimal (for folks at very high risk)
<100         Optimal
100-129      Near optimal/above optimal
130–159      Borderline high
160–189      High
190         Very high
         ATP III Lipid and
  Lipoprotein Classification (continued)

High Density Lipoprotein (HDL) – appears to
  carry cholesterol away from the arteries and
  to the liver. Affected by diet (fiber, fish oil,
  alcohol), weight, exercise & smoking.


HDL Cholesterol (mg/dL)
<40     Low
60     Desirable
           ATP III Lipid and
    Lipoprotein Classification (continued)
Triglycerides (TG) – type of fat affected by
  weight, exercise, and simple sugar, fat &
  alcohol intake.
Classification of Serum Triglycerides
•   Normal                  <150 mg/dL
•   Borderline high         150–199 mg/dL
•   High                    200–499 mg/dL
•   Very high               500 mg/dL

								
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