Pocket ObGyn – Lipid & Cholesterol

Pocket ObGyn – Lipid & Cholesterol
See Abbreviations

Definitions and Treatment

Definitions for cholesterol
LDL – primary target	<100	Optimal
	100–129	Near optimal
	130–159	Borderline high
	160–189	High
	³190	Very high
Total cholesterol	<200	Desirable
	200–239	Borderline high
	³240	High
HDL	<40	Low
	³60	High

Cardiovascular dz is the leading cause of death (all ages) in women (24%)
Start screening total cholesterol, HDL at 20 yo, then once every 5 y
ACOG: Start every 5 y from age 45; at well-woman visits or initial OB or w/ PCP

When to treat cholesterol (www.nhlbi.nih.gov/guidelines/cholesterol/risk_tbl.htm)
Risk category	LDL goal (mg/dL)	LDL level to initiate lifestyle changes	LDL level to con- sider drug therapy
CHD or CHD risk equivalents (10-y risk >20%)	<100 (optional <70)	³100	³130 (100–129 optional)
2+ risk factors (10-y risk <20%)	<130	³130	10-y risk 10–20% and ³130 or 10-y risk <10% and ³160
0– risk factor	<160	³160	³190 (160–189 optional)

• CHD risk equivalents: Clinical coronary, symptomatic carotid dz, peripheral artery dz, abdominal aortic aneurysm, DM.

• CHD risk factors: Cigarette smoking, HTN (BP ³140/90 or on an anti-HTN med), HDL

£40, FHx of premature CHD (M <55 yo, F <65 yo in 1st-degree relative), age (F ³55 yo).

• 10-y risk calculated using Framingham point risk scores w/ points for age, total cholesterol, smoking, HDL, & SBP.

• For latest guidelines see: J Am Coll Cardiol 2013 (PMID 2422016).

Lipid/cholesterol treatment guidelines
Therapy	LDL	HDL	TG = tri- glycerides	Side effects
Diet & exercise	Trial for 6 mo–1 y; includes decreased saturated fat (<7% total calories) total daily cholesterol intake <200 mg (NCEP diet), decreased salt intake, exercise 30 min most days of the week
Statin (1st line): HMG-CoA reductase inhibitor: Simvastatin, atorvastatin	20–60% ¯	15%	30% ¯	*Check LFTs prior to starting GI distress, myalgias, myopathy (10%), rhabdomyolysis rare
Resins: Bile acid sequestrants: Cholestyramine, colestipol	15–30% ¯	5%	Possibly increased	*Can raise TGL, do not use in TGL >250 Bloating, hard stool, constipation
Ezetimibe (choles- terol absorp inhibitor)	20% ¯	5%	—	Dose: 10 mg/d; monit LFTs as w/ statins
Nicotinic acid (niacin)	10–15% ¯	15–30%	40% ¯	Flushing (take w/ meals, tx w/ ASA); monit uric acid gluc, LFTs, DM pts only use w/ A1C <7%
Fibrates: Fenofibrate	5–15% ¯	10–20%	30–50% ¯	GI discomfort, rash, pruritus

Hormone effects on lipids:

Estrogen: ¯ LDL, HDL, & TG

Progestin: Antagonized estrogen changes ® LDL, ¯ HDL, & ¯ TG

ACOG recommends: LDL >160 or multi CAD risk factors, counsel toward nonhormonal 2´ MI risk in  w/o CAD on hormonal therapy
Postmenopausal women on HRT (estrogen &/or progestin) ® 29% in CHD events;

no indication for HRT to prevent CHD. Women on HRT had a 41% in stroke events (JAMA 2002;288:321). Newer data since the WHI trial sugg younger postmenopausal women (<50 yo) on HRT do not have CHD. See Chap. 5.

See Abbreviations

Definitions and Treatment

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