karusmle
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a 42 year old man comes for a routiene health maintanence examination. there is n o history of coronary artery disease and he does not smoke,his weight is appropriate for height.his BP is 120/80.his serum lipid studies shows serum cholesterol level of 190 and HDL cholesterol level of 40,and triglyceride level of 150,which of the foloowing is the most appropriate management??
a.recommend the step 2 national cholesterol education programme diet
b.measure serum LDL cholesterol now
c.meaasure totoal serum cholesterol level in 5 years
d.prescribe prophylactic aspirin
e.begin treatment with lovastatin
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| dr in trouble
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I will go for c
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| MAZI
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the recommended screening test is:
person with risk factor( family hx. obesity,...): male----20__35y/o
female----20__45y/o
person without risk factor( like above): male---35
female---45
there is no risk factor and no abnormality in lipid profile then
answer A
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| eva
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b
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| AAAAA
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A
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| AAAAA
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A weight loss of 10 kg will reduce the B/P from 6-20 mmHg.
A diet DASH with high in fruits and vegetables and low in high fat dairy products will significantly reduce the cholesterol level
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| Jinx
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b
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| karusmle
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dr in trouble why did u chose c???plz explain
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| MAZI
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the best test for screening is, total chol & HDL (without fasting)
if total chol>200 or HDL<35 in men or HDL<45 in women then u order fasting complete lipid profile.
plz send your oponion, tx
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| achilles
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i'll go for C in this pt but was also confused about B. but everything seems to be ok with this pt and she has no risk factors too so i'll go for C-recheck in another 5 yrs.
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| MAZI
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dear achilles
u know that the treatment of hyperlypidemia is based on the LDL level & risk factor.
the major risk factor is:
1.age ( male>=45,female>=55)
2.hypertension
3.cigarret
4.low LDL( <40)
5.family HX of premature coronary heart desease (male<55, female<65)
(CHD=CORNARY HEART DISEASE)
RISK FACTOR-----------GOAL OF TREATMENT-------DIET THERAPY-------------DRUG THERAPY
* CHD -----------------------<100------------------------>=100------------- -------->=130
* 0 or 1----------------------<130------------------------>=130------------- ------->=160
* 2 or more------------------<160------------------------>=160-------------- ------>=190
in this case u can calculate LDL, (TOTAL CHOL=HDL+TG/5+LDL) , LDL=120, NO RISK FACTOR and NO CHD and then the goal of treatment is LDL<160, the level of LDL that the diet has been start is>=160 and the level for drug therapy is>=190
this person need no diet (NCEPD 2) no drug and no need for measure of LDL( because we can calculate LDL from above parameter), i think that he has no indication for ordering of complete lipid pofile in this age ,and now whats your oponion
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| achilles
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thats good info mazi(i guess its from UW).
i agree that the Rx is based on LDL levels but what i thought was that this pt right now does not have any risk factors and all her screening tests are also normal and in another 5 yrs she will be 47 yrs. routine screening is indicated in men > 35yrs and women >45 yrs. so in another 5 yrs she should anyways be having another screening test as per recommendations of screening for lipid disorders.
as of now just like you also said, she will not be needing any drugs or dietary modifications. everything is normal with her right now so nothing else is indicated. eating less fat in diet is always a good idea but she does not necessarily have to eat a low fat diet.
LDL levels are obtained if the screening test is not normal as it is a fasting test and is more expensive. total cholesterol and HDL levels can be obtained without fasting. and as in this pt the screening test was normal so getting LDL levels right now is also not indicated.
ps: in the risk factors list, the 4th risk factor should be HDL < 40mg/dl and in the table i think "0 or 1" and "2 or more" got interchanged. i am sure you know this already and it was just a typing error.
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| sachida
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Thanks mazi - i did not know the forumla for total cholesterol-- now I do.
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| MAZI
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thank u achilles u are right
4.HDL<40
SUBSTITUTE 0 or 1 with 2 or more in the table
[left]but achilles the american collegeof physicians does not recommend a specific intervale for repeated testing but does recognize that patient with more risk factor for atherosclerosis disease should be tested more frequently[/left]
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| achilles
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that's right mazi. the interval at which pt must be tested is not clear. but they do recommend testing for men>35 yrs and women>45 yrs but there are no strict guidelines for the interval at which they must be tested regularly.generally for asymptomatic pts with no risk factors its 3 to 5 yrs but for pt with risk factors screening tests must be done more frequently. this info is from UW and i also read it somewhere in US preventive services website. so i guess it should be C.
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| achilles
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about the renal stone question mazi, did i get the explanation right?pls let me know if i have missed something in that question.
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| MAZI
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thank you for your explanation achilles go to that
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| AAAAA
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There are very strict guidelines for testing cholesterols.
But it depends on which guidelines.
USPHS (U.S. Public Health Service) recommends testing for men for cholesterol at age 35 if there is no risk factors, women at age 45 if there are no risk factors.
Other guidelines recommend testing starting at 20 years old !
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| AAAAA
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karusmle wrote:
a 42 year old man comes for a routiene health maintanence examination. there is n o history of coronary artery disease and he does not smoke,his weight is appropriate for height.his BP is 120/80.his serum lipid studies shows serum cholesterol level of 190 and HDL cholesterol level of 40,and triglyceride level of 150,which of the foloowing is the most appropriate management??
a.recommend the step 2 national cholesterol education programme diet
b.measure serum LDL cholesterol now
c.meaasure totoal serum cholesterol level in 5 years
d.prescribe prophylactic aspirin
e.begin treatment with lovastatin
Even this patient may not have any risk factors and the USPHS recommends testings at age 45 years old, in the mean times, step 2 National cholesterol Education Program diet is a reasonable answer !@
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| AAAAA
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Step I , Step II and TLC Diets
The American Heart Association "no longer" uses the terms “Step I” and “Step II” in reference to heart-healthy diets. These terms, however, still appear in some older materials and journal articles. !!!!!!!!!!!!!!!
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| AAAAA
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History
The Step I and Step II diets were created by the National Heart, Lung, and Blood Association’s National Cholesterol Education Program (NCEP). The American Heart Association endorsed them. Both diets were designed to reduce risk of cardiovascular disease by reducing high blood cholesterol levels.
The Step I diet restricted total fat to no more than 30 percent of total calories, saturated fat to no more than 10 percent of total calories, and cholesterol to less than 300 mg/day. It was intended as the starting point for patients who had high cholesterol levels.
The Step II diet goals were lower for saturated fat (less than 7 percent) and cholesterol (less than 200 mg/day). They were intended for people already at the Step I goals or for patients with a high-risk cholesterol level (240 mg/dL or higher) or who had had a heart attack.
For people at high risk or who have known cardiovascular disease, we have adopted the Therapeutic Lifestyle Changes (TLC) diet. This is the “next generation” of the Step II diet recommended in May 2001. That's when the NCEP released new guidelines for cholesterol management in its Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]). (For more information about this diet, see below.)
ATP III continues to recommend the Step I diet for the general public.
What do the American Heart Association dietary guidelines recommend?
In October 2000 we updated our dietary guidelines. They put more emphasis on foods than on percentages of food components, such as fat. Our guidelines offer goals for healthy adults in these four areas:
overall healthy eating pattern
appropriate body weight
desirable cholesterol profile
desirable blood pressure
The guidelines also consider the special needs of children and older people. Please see the entries on “Dietary Guidelines for Healthy American Adults” and “Dietary Guidelines for Healthy Children” in this Encyclopedia for more information.
For people at higher risk, the new (TLC) dietary goals offer dietary therapy for subgroups of people with specific medical conditions and risk factors such as these:
high LDL cholesterol or other lipid disorders
coronary heart disease or other cardiovascular disease
diabetes mellitus, insulin resistance or metabolic syndrome
What does the TLC diet recommend?
In May 2001 the NCEP released new guidelines for cholesterol management. These new guidelines are in the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]). The American Heart Association accepted and endorsed this report and began incorporating these recommendations into its materials on dietary and lifestyle change for people with high blood cholesterol.
ATP III recommends that therapy for elevated cholesterol begin with more intensive life-habit intervention to lower cholesterol and reduce the risk for developing heart disease and having a heart attack. This approach is referred to as the “Therapeutic Lifestyle Changes (TLC)” diet. It’s targeted to people whose LDL cholesterol is above the goal level for their category of risk for heart disease. These are the essential components of TLC:
Component Recommendation
LDL-raising nutrients
Saturated fats* Less than 7% of total calories
Dietary cholesterol Less than 200 mg/day
Therapeutic options for LDL-lowering
Plant stanols/sterols 2 grams per day
Increased viscous (soluble) fiber 10–25 grams per day
Total calories (energy) Adjust total caloric intake to maintain desirable body weight/prevent weight gain
Physical activity Include enough moderate exercise to expend at least 200 kcal per day
* Trans fatty acids also raise LDL and should be kept at a low intake.
TLC Diet in ATP III
Nutrient Recommended Intake as Percent of Total Calories
Total Fat1 25–35%
Saturated Less than 7%
Polyunsaturated Up to 10%
Monounsaturated Up to 20%
Carbohydrate2 50–60% of total calories
Protein Approximately 15%
Cholesterol Less than 200 mg per day
Total Calories3 Balance energy intake and expenditure to maintain desirable body weight and prevent weight gain
The 25–35% fat recommendation allows for increased intake of unsaturated fat in place of carbohydrates in people with the metabolic syndrome or diabetes.
Carbohydrate should come mainly from foods rich in complex carbohydrates. These include grains (especially whole grains), fruits and vegetables.
Daily energy expenditure should include at least moderate physical activity (contributing about 200 Kcal a day).
Options include adding 10–25 grams of viscous (soluble) fiber; 2 g/day of plant-derived sterols or stanols. Soy protein may be used as a replacement for some animal products.
Related AHA publications:
An Eating Plan for Healthy Americans
Understanding and Controlling Cholesterol
Easy Food Tips for Heart-Healthy Eating (also in Spanish)
"How Can I Cook Healthfully?", "How Do I Follow a Low-Fat Diet?" and "How Can I Manage My Weight?" in Answers By Heart kit (also in Spanish kit)
"What About Eating Out?", "How Do I Read Food Labels?", "How Do I Change Recipes?" and "Why Should I Lose Weight?" in Answers By Heart kit
Detailed Research
Third Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), Circulation. 2002;106:3143-3421. (Web site)
Bonow, Robert O, Primary Prevention of Cardiovascular Disease, Circulation. 2002;106:3140-3141. (Web site)
AHA Scientific Statement: AHA Dietary Guidelines: Revision 2000, #71-0193 Circulation. 2000;102:2284-2299; Stroke. 2000;31:2751-2766
AHA Conference Proceedings: Summary of the Scientific Conference on Dietary Fatty Acids and Cardiovascular Health, #71-0200 Circulation. 2001;103:1034-1039
AHA Scientific Statements:
AHA Dietary Guidelines: Revision 2000
Fatty Acids Conference Summary
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| AAAAA
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karusmle wrote:
a 42 year old man comes for a routiene health maintanence examination. there is n o history of coronary artery disease and he does not smoke,his weight is appropriate for height.his BP is 120/80.his serum lipid studies shows serum cholesterol level of 190 and HDL cholesterol level of 40,and triglyceride level of 150,which of the foloowing is the most appropriate management??
a.recommend the step 2 national cholesterol education programme diet
b.measure serum LDL cholesterol now
c.meaasure totoal serum cholesterol level in 5 years
d.prescribe prophylactic aspirin
e.begin treatment with lovastatin
After reviewing this question much more carefully, I, AAAAA, stated this question should be deleted because it is a much older questions and Step 2 National Cholesterold Education program no longer existed.
But very good discussion and excellent argument.
Also this is a male patient not a female patient !
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| dtt
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C is right. the desirable total cholesterol is <2oo. the paitent does not have any risk factor. right now we do nothing. but the chol level should be survillance at regular interval.
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| dtt
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the total cholesterol is normal. so LDL is not required to measure
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