Hyperlipidemia

Question 0

one of goals of Healthy People 2020 for high blood cholesterol screening

Answer 0

increase to 82.1% the proportion of adults who have been screened for high cholesterol within preceding 5 years

Question 1

General info cholesterol (why we care, intro)

Answer 1

• high blood cholesterol is major risk factor for heart dz
• heart dz is leading cause of death in US
• nearly 100 million american adults have total blood cholesterol values of 200 mg/dL and higher
• 34.5 million american adults have total blood cholesterol levels 240+*

Question 2

African americans and coronary heart disease

Answer 2

• have highest overall death rates of coronary heart disease
• earlier age of onset of CHD compared to whites
• some reasons: high prevalence and suboptimal control of coronary risk factors, lack of access to optimal care, community mistrust of medical system, institutional racism
• hypertension, hyperlipidiemia, diabetes mellitus, left ventricular hypertrophy, obesity, cigarette smoking, physical inactivity, and multiple CHD risk factors all occur more frequently in african americans compared to whites

Question 3

Latinos and cholesterol

Answer 3

• largest minority group in US
• less favorable cardiovascular risk profile than whites (greater prevalence of hyperlipidemia, more obesity, central obesity, lower HDL cholesterol and higher triglyceride levels), CHD, and cardiovascular disease mortality are approximately 20% lower among adult Latinos than among whites in US

–> even though latinos appear to have lower than expected mortality from CHD and CVD, proportion of total deaths due to these 2 dzs is similar to that for whites in US so you cannot conclude that latinos are protected from CHD and CVD or that they should be treated less aggressively than other groups

• also remember that latinos are a heterogeneous group, but most of the data is based on mexican americans

Question 4

Native Americans and cholesterol

Answer 4

• cvd mortality rates vary among diff communities, and appear to be increasing
• chd incidence rates among Native American men and women higher than whites
• -> assoc w higher mortality rates!
• significant independent predictors of CVD in Native American women: hyperlipidemia, age, obesity, LDL, albuminuria, triglycerides, hypertension

Question 5

Asian Americans, Pacific Islanders and cholesterol

Answer 5

• limited info
• south asians are growing group in US: higher CHD risk in this population (may be related in part to higher prevalence of metabolic syndrome, insulin resistance, hyperlipidemia)

efforts to reduce cholesterol and other CHD risk factors in this group is important!

Question 6

2013 ACC/AHA vs. ATP III guidelines (Summary points)

good news: they’re more simplified guidelines!

Answer 6

1. there is no evidence to support titrating statins to reach a specific LDL
2. 4 subgroups of pts def benefit from fixed dose, high-intensity statin therapy but DO NOT benefit fro targeting a specific cholesterol level
   A) clinically evidence cardiovascular disease (not incidentally discovered on CT, for ex)
   B) LDL levels > 190
   C) DM1 and DM2 (aged 40-75) with LDL
   D) 10 yr cardiovascular risk >= 7.5%
   –> this is the most controversial group bc 1) some experts have argued there are errors in online calculators and 2) not everyone agrees that 7.5% is the appropriate cutoff for balancing risks and benefits of statins

but INSUFFICIENT EVIDENCE for or against statin therapy in 3 groups:
A. age > 75 years (unless clinical CVD)
B. need for hemodialysis
C. NYHA Class II, II, IV heart failure

–> there is no evidence base to recommend any treatment for cholesterol other than statins

Question 7

Important practical considerations from ACC/AHA 2013 lipid guidelines

Answer 7

• recommendations on therapeutic lifestyle to manage cholesterol are essentially the same as ATP III
• identification of metabolic syndrome in pts is still a useful approach to reduce CV risk
• routine LDL monitoring of patients on treatment is performed to assess treatment adherence, and/or assess for expected % drop in LDL level;
• monitoring is not for assessing treatment success in reaching a target LDL level!*

–> also there is a new CV risk calculator (this tool is way controversial)
this new tool: different, and possibly more, ppl will be advised to use statin therapy based on the new 10-yr risk cutoff of 7.5%

(oi vey)

Question 8

Importance of new CV risk calculator and new 10-year risk cutoff of 7.5%

Answer 8

docs fear the 2013 calculator overestimates risk in healthy ppl, thereby leading to unnecessarily increased #s of pts taking statin thereapy

until confidence grows in a reliable risk calculator, ATP III will prob continue to be a useful way to generate a recommendation for starting statin therapy in asymptomatic ppl

Question 9

Comparison of guidelines for focus of ATP III and current

Answer 9

ATP III: elevated LDL cholesterol is major cause of coronary heart dz, thus atp 3 identifies elevated LDL as the PRIMARY target of cholesterol-lowering therapy

basic principle of prevention: intensity of risk reduction therapy and specific target levels of cholesterol are adjusted based on persons absolute risk

–> risk assessment based on measurements of LDL cholesterol and identification of accompanying CV risk factors, focused on coronary heart disease

treatment is intensified until target levels have been reached

ATP 3 largely based on expert opinion (modest #s of recommendations based on evidence from RCTs)

Question 10

Summary of ACC/AHA 2013

Answer 10

• statin therapy is proven intervention for reduction of cardiovascular risk (thus newest guidelines identify at risk groups that would benefit most from statin therapy)
• basic prevention principle: at risk pts should be started on moderate or high intensity statin therapy, unless they cant tolerate these doses
• risk assessment based on measurement of LDL cholesterol and identification of accompanying cardiovascular risk factors (broadened to include stroke)

–> monitoring of lipid levels is not necessary once on statin therapy

–> ACC/AHA has greater proportion of recs based on evidence from RCTs

Question 11

Hyperlipidemia step 1: screening

Answer 11

atp 3: adults 20+: 9-12 hr fasting lipoprotein profile (total cholesterol, low density lipoprotein LDL cholesterol, high density lipoprotein HDL cholesterol, and triglyceride TG) should be performed once every 5 years
–> if fasting lipid panel cant be done, appropos to check only total choelsterol and HDL

but now 2013 ACC/AHA: recommend traditional risk factor assessment (similar to atp 3) every 4-6 years from age 20-79, w addition of new 2013 risk calculator at same interval starting at age 40

Question 12

ATP III classification of LDL, total, and HDL cholesterol (mg/dL)

Answer 12

1. LDL cholesterol: Primary target of therapy
   = 190 very high
2. total cholesterol:
   =240 high
3. HDL cholesterol
   60 high

*BUT: new guidlines dont provide guidance on targets or definitions of cholesterol levels (high, optimal, etc.) but rather shift focus
FROM absolute LDL level targets
TO expected percent LDL reduction with statins

Question 13

Screening recommendations from other bodies (esp USPSTF)

Answer 13

strongly recommends

screening in men 35+ for lipid disorders
screening in women 45+ for lipid disorders

recommends screening
men 20-35 for lipid disorders
women 20-45 for lipid disorders
…if they are increased risk for coronary heart disease

makes no recommendation for or against routine screening for lipid disorders in
men age 20-35
women age 20-45

…who are not at increased risk for coronary heart dz

optimal interval for screening uncertain

–> on basis of other guidelines and expert opinion: reasonable options include every 5 years, shorter for ppl w lipid levels close to those warranting therapy and longer in those not at increased risk whove had repeatedly normal lipid levels

Question 14

Assessment ATP III: Step 2 (Assessment for presence of high risk coronary heart disease equivalents)

Answer 14

atp 3 identifies clinical atherosclerotic dz (CHD risk equivalents) that confers high risk for coronary heart dz events:

• clinical chd
• symptomatic carotid artery dz
• peripheral artery dz
• abdominal aortic aneurysm (AAA)
• diabetes is considered a chd risk equivalent in atp 3
• note: AAA and diabetes are not considered CHD risk equivalents in 2013 guidelines
• CORONARY artery dz (CAD, CHD), cerebrovascular dz (stroke), and peripheral artery dz* are together referred to as “ASCVD” or atherosclerotic cardiovascular disease

Question 15

Assessment ATP III: Step 3 (Assessment of major risk factors)

Answer 15

in atp 3, next step is to assess for major risk factors (other than LDL) whose presence would modify LDL goals:

• cigarette smoking
• htn (bp >140/90 or on antihypertensive meds)
• low HDL cholesterol (< 55 yrs; CHD in female 1st deg relative < 65 yrs)
• age (men >45 yrs, women >55 yrs)

*HDL cholesterol > 60 counts as a “negative” risk factor; its presence removes one risk factor from the total count

Question 16

NEW GUIDELINES: start w 10 yr cardiovascular risk calculator, rather than 2 step process in atp 3;

Answer 16

Risk factors used in 2013 risk calculator are similar to atp 3:

1. gender
2. blood pressure
3. treatment for blood pressure (yes/no)
4. total cholesterol
5. HDL cholesterol
6. diabetes
7. smoking status

but in 2013 calculator race was added (African American or not)
and fam hx not included!!!

Question 17

ATP 3 step 4: if 2 or more major risk factors other than LDL present, then assess 10-yr risk

Determine the risk category

Answer 17

if 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10 yr (short term ) CHD risk (see Framingham tables)

new guidelines: dont use the concept of “risk categories” but instead recommend that docs obtains an estimate of 10yr cardiovascular in all pts

3 levels of 10 yr risk in atp 3:
>20%
10-20%
20%means that 20/100 ppl will develop coronary heart dz or coronary event within 10 yrs

Question 18

ATP 3 step 5: determine risk category

Answer 18

2 cholesterol guidelines (old and new) differ in their approach to deciding who should be recommended for treatment

Question 19

ATP 3 methodology for determining risk category

Answer 19

1. establish LDL goal of therapy
2. determine need for therapeutic lifestyle changes (TLC)
3. determine level for drug concentration

Question 20

CHD or CHD risk equivalents (10 yr risk factor > 20%)
LDL Cholesterol goals and cutoff points for therapeutic lifestyle changes (TLC) and drug therapy in different risk categories

Answer 20

LDL goal: < 100
LDL level at which to initiate TLC: >= 100
LDL level at which to consider drug therapy: >=130 (100-129: drug optional)*

• some recommend use of LDL lowering drugs in this category if an LDL cholesterol < 100 cant be achieved by therapeutic lifestyle changes
  others prefer use of drugs that primarily modify triglycerides and HDL (nicotinic acid and fibrate)

clinical judgment may also call for deferring drug therapy in this subcategory

Question 21

2+ risk factors (10 yr risk factor <= 20%)
LDL Cholesterol goals and cutoff points for therapeutic lifestyle changes (TLC) and drug therapy in different risk categories

Answer 21

LDL goal: < 130
LDL levels at which to initiate TLC: >= 130

LDL at which to consider drug therapy:
if 10 yr risk 10-20%: >= 130
if 10 yr risk < 10%: >= 160

Question 22

0-1 risk factor
LDL Cholesterol goals and cutoff points for therapeutic lifestyle changes (TLC) and drug therapy in different risk categories

Answer 22

LDL goal: =160

LDL level at which to consider drug therapy: >= 190 (160-189: LDL lowering drug optional)

Question 23

2013 ACC/AHA methodology for lipid levels

Answer 23

Recommends that cardiovascular risk drive choice of statin therapy offered!
–> no recommendations for or against specific LDL or non-HDL targets for either primary or secondary prevention of ASCVD (Grade N)
bc of insufficient RCTs (to indicate which targets should be, magnitude of additional ASCVD risk reduction achieved w one level compared to another, added benefit from treating to target or to very low LDL levels esp when weighed against adverse effects)

2013 guidelines have new algorithm to estimate cardiovascular risk over 10 yrs (some believe it may overestimate cv risk, while others argue 7.5% cutoff is too low)

Question 24

After estimating 10 year CV risk the next evidence based step in 2013 guidelines is to identify pts in one of 4 statin benefit groups

Answer 24

1. individuals with clinical ASCVD (grade A strong recommendation)
2. individuals with primary elevations in LDL-C > 190 (grade B moderate recommendation)
3. individuals 40-75 w diabetes in LDL-C 70-189; moderate intensity statin unless 10 yr ASCVD risk > 7.5% or higher, then high intensity statin; (grade A strong recommendation)
4. individuals without clinical ASCVD or diabetes who are 40-75 w LDL-C 70-189 and an estimated 10 yr ASCVD risk of 7.5% or higher (moderate to high intensity statin) (grade A strong recommendation)

*did not provide recommendations for initiation of statin therapy in patients w congestive heart failure (Class II, III, IV) or a need for hemodialysis (insufficient RCT evidence)

Question 25

Therapeutic lifestyle changes (both old and new guidelines recommend)

Answer 25

• saturated fat <200 mg/day (grade A strong rec)
• follow dietary pattern emphasizing intake of vegetables, fruits, whole grains; include low fat dairy products, poultry, fish, legumes, non tropical vegetable oils and nuts; limit sweets, sugar sweetened beverages and red meats
  (DASH diet, USDA food pattern, or AHA diet) (strong grade A rec)
• reduce % of calories from saturated fat (strong grade A rec)
• reduce % of calories from trans fat (strong grade A rec)
• increased aerobic activity: (3-4 sessions per week or moderate to vigorous intensity activity lasting at least 40 mins/session (moderate grade b rec)
• wt mgmt (cornerstone of lifestyle change in both old and new) (strength of rec not evaluated)
• consider increased viscous (soluble) fiber (10-25 g/day) and plant sterols (2g/day) as therapeutic options to enhance LDL lowering (not evaluated in 2013 guidelines)

Question 26

Nutrient composition of therapeutic lifestyle changes diet (old)

this is prob just a reference

Answer 26

sat fat: <200 mg/d; total calories balance energy intake and expenditure to maintain desirable body weight/prevent weight gain

*keep trans fats low; carbs should be derived predominantly from foods rich in complex carbs including grains, esp whole grains, fruits, and veggies; daily nrg expenditures should include at least moderate physical activity (contribute approximately 200 kcal/d)

Question 27

Drug therapy in hyperlipidemia

atp 3

(both old and new approaches are being used by physicians)

Answer 27

LDL cholesterol goals and cutoff pts for drug therapy in diff risk categories, by atp III

1. CHD or CHD risk equivalent (10 yr risk factor > 20%):
   LDL goal < 100; LDL level at which to consider drug therapy: >= 130 (100-129 drug optional)
2. ) 2+ risk factors (10 yr risk factor < 130; LDL level at which to consider drug therapy (10 yr risk 10-20% >=130 , if 10 yr risk < 10% >= 160)
   3) 0-1 risk factor, LDL goal is < 160; LDL at which to consider drug therapy >= 190 (160-189: LDL lowering drug optional)

–> consider drug simultaneously w TLC for chd and chd equivalents; consider adding drug to TLC after 3 months for other risk categories

Question 28

Considering therapy in 2013 guidelines

Answer 28

after estimating risk, next evidence based step in 2013 guidelines is to identify pts in 1 of 4 statin benefit groups who are recommended to initiate high intensity statins:

1. ppl w ascvd (grade a strong rec)
2. ppl w primary elevations of LDL-C>190 (grade b moderate rec)
3. ppl 40-75 yrs w diabetes and LDL-C 70-189; mod intensity statin unless 10 yr ascvd risk > 7.5%, then high intensity statin (grade e expert opinion rec)
4. ppl without clinical ascvd or diabetes age 40-75 w LDL-C 70-189 AND estimated 10 yr ascvd risk >= 7.5% (moderate to high intensity statin) (grade A strong rec)

• important considerations:
  1. 2013 guidelines didnt provide recommendations for initiation of therapy in pts w chf (class 2, 3, or 4) or need for hemodialysis, due to insufficient rct evidence
  2. in ppl w diabetes < 40 or > 75 yrs, statin therapy should be individualized based on considerations of ascvd risk reduction benefits, potential for adverse effects, and drug-drug interactions, and patient preferences (grade e expert rec)

Question 29

Statin therapy intensity

Answer 29

High
approximate LDL lowering >=50%
ex: atorvastatin >= 40 mg

Moderate
approximate LDL lowering < 30%
ex: pravastatin 10-20 mg, lovastatin 20

Question 30

Cornerstone of lipid therapy

Answer 30

statins!

Question 31

Drugs affecting lipoprotein metabolism:

HMG-CoA reductase inhibitors (statins)

Answer 31

ex: lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, cerivastatin

lipid/lipoprotein effects:

LDL decrease 18-55%
HDL increase 5-15%
TG decrease 7-30%

side effects: myopathy, increased liver enzymes

contraindications:
absolute: active or chronic liver disease
avoid mixing with grapefruit juice

relative: concomitant use of certain drugs (cyclosporine, macrolide antibiotics, various antifungal agents, cytochrome P-450 inhibitors (fibrates and niacine should be used with appropriate caution)

clinical trial results: reduced major coronary events, CHD deaths, need for coronary procedures, stroke, total mortality

Question 32

Bile acid sequestrants

Answer 32

ex: cholestyramine, colestipol, colesevelam

LDL decrease 15-30%
HDL increase 3-5%
TG no change or increase

side effects: GI distress, constipation, decreased absorption of other drugs

contraindications:
absolute: dysbetalipoproteinemia, TG> 400
relative: TG>200

clinical trial results: reduced major coronary events and CHD deaths

Question 33

Nicotinic acid

Answer 33

ex: immediate release (crystalline) nicotinic acid, extended release nicotinic acid, sustained release nicotinic acid

LDL decrease 5-25%
HDL increase 15-35%
TG decrease 20-50%

side effects: flushing, hyperglycemia; hyperuricemia (or gout); upper GI distress, hepatotoxicity

contraindications:
absolute: chronic liver dz; severe gout
relative : diabetes, hyperuricemia, peptic ulcer dz

Question 34

Fibric acids

Answer 34

ex: gemfibrozil, fenofibrate, clofibrate

LDL decrease 5-20% (may be increased in pts w high TG)
HDL increase 10-20%
TG decrease 20-50%

side effects: dyspepsia, gallstones, myopathy; unexplained non CHD deaths in WHO study

contraindications:
absolute: severe renal dz, severe hepatic dz

clinical trial results: reduced major coronary events

Question 35

Ezetimibe

Answer 35

• relatively new anti lipidemic drug
• class of lipid lowering compounds that selectively inhibits intestinal absorption of cholesterol and related phytosterols
• used as adjunct w statin when statin alone doesnt achieve LDL goals or
• used alone if statins not tolerated or contraindicated in pt

*despite remarkable drop in LDL and CRP levels when ezetimibe used in conjunction w statin, in pts w familial hypercholesterolemia, combined therapy with ezetimibe and simvastatin did not result in sig diff in changes in intima media thickness (compared w simvastatin alone) in NEJM study

Question 36

Omega 3 fatty acids

Answer 36

• some clinical trials suggest relatively high intakes of omega 3 fatty acids in form of fish, fish oils, or high linolenic acid oils may reduce risk for major coronary events in ppl w established CHD (secondary prevention)

more clinical evidence needed before making recommendations on higher doses for primary prevention

Question 37

Evidence of effectiveness of combination lipid lowering meds

Answer 37

LInes of treatment

1. lifestyle modifications
2. statins

–> if current statin dose not enough : raise statin dose or add a 2nd lipid lowering med

evidence for combo therapy:
1. insufficient to conclude that combo therapy –> lower rates of clinical events and death (all cause mortality and vascular death) than statin monotherapy
clinical events include: MI, strokes, need for invasive vascular procedures

2. evidence insufficient to assess whether any combo regimen provides greater reduction in LDL cholesterol than statin monotherapy; evidence also isnufficient for other intermediate outcomes, including total choelsterol, HDL cholesterol, and coronary artery and carotid intima thickening
3. evidence insufificient to draw conclusions about rates of adverse events of combo therapy compared w statin monotherapy; adverse events assessed in these studies include elevation of liver enzymes, myalgia, rhabdomyolysis, cancer

Question 38

2013 guidelines for combo therapy

Answer 38

1. statins are the only evidence based treatment for cholesterol
2. medium or high intensity fixed dose statin therapy is recommended based on cardiovascular risk (low dose only in cases of tolerability concerns)
3. combination drugs are no longer recommended

Question 39

Metabolic syndrome

Answer 39

Identify metabolic syndrome and treat (if present) after 3 months of therapeutic lifestyle changes

Any 3 of the following musts be present for clinical identification of metabolic syndrome

1. abdominal obesity (waist circumference) 
men > 102 cm (40 in)
women > 88 cm (35 in)
2. triglycerides
>= 150
3. high density lipoprotein cholesterol
men < 40
women < 50
4. blood pressure >=130/>=85
5. fasting glucose >= 110

• overweight and obesity are associated with insulin resistance and the metabolic syndrome; however, the presence of abdominal obesity is more highly correlated w the metabolic risk factors than is an elevated body mass index
• -> thus simplest measure of waist circumference is recommended to identify body wt component of metabolic syndrome

–> some male pts can develop multiple metabolic risk factors when waist circumference is only marginally increased (a few inches); such pts may have strong genetic contribution to insulin resistance and should benefit from changes in life habits (similar to men w categorical increase in waist circumference)

Question 40

Measuring waist circumference

Answer 40

• locate upper hip bone and top of right iliac crest
• place measuring tape in horizontal plane around abdomen at level of iliac crest
• before reading tape measure ensure tape is snug but does not compress skin, and is parallel to floor
• measurement made at end of normal expiration
• abnormal waist circumference measurements: men > 40 inches; women > 35 inches

Question 41

Treatment of metabolic syndrome

Answer 41

1. treat underlying causes (overweight/obesity and physical inactivity):
   - intensify weight mgmt
   - increase physical activity
2. treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies:
   - treat htn
   - use aspirin for CHD patients to reduce prothrombotic state
   - treat elevate triglycerides and/or low HDL

Question 42

ATP classification of serum triglycerides (mg/dL)

Answer 42

):

= 500 very high

Question 43

Treat elevated triglycerides

Answer 43

treatment of elevated triglycerides (>= 150 mg/dL)

• primary aim of therapy is to reach LDL goal
• intensify weight mgmt
• increase physical activity
• if triglycerides are > 200 after LDL goal is reached, set secondary goal for non-HDL cholesterol (total minus HDL) 30 mg/dL higher than LDL goal

Question 44

Comparison of LDL cholesterol and non-HDL cholesterol goals for 3 risk categories

Answer 44

1. CHD or CHD risk equivalents (10 yr risk factor > 20%)
   LDL goal < 100
   non HDL goal < 130
2. 2+ risk factors (10 yr risk factor < 130
   Non-HDL goal: < 160
3. 0-1 risk factor
   LDL goal < 160
   non-HDL goal: < 190

Question 45

If triglycerides 200-499 after LDL goal is reached, consider adding drug if needed to reach non-HDL goal

BUT 2013 guidelines dont include recommendations for treating high triglycerides, low HDL, or non-HDL cholesterol due to a lack of RCT evidence

Answer 45

• intensify therapy w LDL lowering drug or

- add nicotinic acid or fibrate to further lower VLDL

Question 46

If triglycerides >= 500, first lower triglyceride to prevent pancreatitis

BUT 2013 guidelines dont include recommendations for treating high triglycerides, low HDL, or non-HDL cholesterol due to a lack of RCT evidence

Answer 46

• very low fat diet (

Question 47

Treatment of low HDL cholesterol

BUT 2013 guidelines dont include recommendations for treating high triglycerides, low HDL, or non-HDL cholesterol due to a lack of RCT evidence

Answer 47

1. first reach LDL goal
2. intensify wt mgmt and increase physical activity
3. if triglycerides 200-499, achieve non hdl goal
4. if triglycerides < 200 (isolated low hdl) in chd or chd equivalent consider nicotinic acid or fibrate

BUT 2013 guidelines dont include recommendations for treating high triglycerides, low HDL, or non-HDL cholesterol due to a lack of RCT evidence

Question 48

ACC/AHA 2013 calculator uses:

Answer 48

• sex
• age
• race
• African American or not
• total cholesterol
• HDL cholesterol
• systolic bp
• on treatment for high bp
• diabetes
• smoking

Question 49

Therapeutic lifestyle changes diet

beware the wording of questions…

Answer 49

True:

• diet low in saturated fat, transfatty acids, and cholesterol and that contains soy protein and plant sterols/stanols can be just as effective as a statin at decreasing serum total cholesterol and LDL levels
• substitution of low-fiber carbohydrates for saturated fatty acids can decrease HDL and increase triglycerides
• for every 1% increase in calories from saturated fatty acids as a percent of total energy, serum LDL rises about 2%
• increased soluble fiber in the diet

False: total fat consumed is not the primary target!

Question 50

Controversies surrounding lipid mgmt:

Answer 50

• 7.5% 10 yr risk not universally recognized as proper threshold at which to consider statin therapy; trtmt w 10 yr risk for cvd events >= 7.5% while another source said recommend statin therapy for adults w 10 yr risk > 20%
  others pointed out general acknowledgement that there is more obesity and cv risk in us pop now than before
• equations appears to overestimate cardiovascular risk and also contain an error (inaccurate calculator)
• primary care orgs many did not participate in 2013 lipid guidelines
• about half the recommendations are “expert opinion”
• other stuff

Question 51

Sociocultural issues in primary care and hyperlipidemia

Answer 51

• therapeutic lifestyle changes are paramount in clinical mgmt of hyperlipidemia
• increasing pt and pub awareness about effects of high cholesterol on cv health of individuals and communities is also important
• teaching pts about cholesterol regimens and their risks and benefits can lead to better adherence to treatment
• physicians are in unique role! can educate and support pts, their fam, and communities
• improved outcomes can be achieved w specific counseling to address pts needs (individualized diet counseling incorporating culturally appropriate foods, specific approaches integrating exercise into pts everyday lifestyle, provide targeted advice to pts knowledge base on tobacco dangers, create regimen w pt that is sensitive to their SES realities)
  –> must assess and understand pt sociocultural background and how it affects their health beliefs in individual behaviors
  –> understand how the pt perceives their illness, culturally responsive health education, avoid unnecessary medical testing, –> better understanding bw you and your pt
  -