HighHopes
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An asymptomatic 47 year old man comes for a preemployment examination. Ha has never been hospitalized. He is a computer programmer and plays handball once weekly. His maternal grandma had DMII and paternal uncle had heart disease. BP is 126/80, exam is normal his total cholesterol is 225. what is the next best step in the management?
A. Step 2 American Heart associate cardiat diet
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| HighHopes
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sorry the rest of options did go through,
B.Serum lipid study while fasting
C.Execise stress test
D.Oral Cholestyramine and niacin therapy
E.Oral Pravastatin therapy at bed time
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| icemaiden
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B?
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| frank100
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A
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| HighHopes
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Frank, would you explain why?
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| frank100
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according to AHA guidelines for total (fasting) blood cholesterol, levels between 200 and 239, is considered a borderline heart risk, plus family history of heart disease, is enough to follow this ghyīs lipid profile up, but first letīs give him the oportunity of normalizing his lipid profile by dieting, and then perfom another serum lipid study (b) while fasting, to have a better situation view. excersice stress test is not a good guess since he is still asymptomatic for CAD (c), thay didnīt mention LDL levels so I asume it is either normal or not imortant in this setting, and farmacological treatment (d and e)is not a good way to start with in those cases.
he wonīt die in a couple of months while dieting, and when e comes back, and lipid profile keeps un-normal, then iīll take care of his LDL, HDL, VLDL, cholesterol,etc...attempt to meka a diagnosis and...work him medically up.
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| HighHopes
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question didn't say fasting cholesterol....
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| frank100
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I knew you were going to say that, but the best next step wonīt change too much if didnīt do it.
but, diet is always the first step, with some exceptions. perhaps the person did this question wanted to teach us the cheapest way to approach this cases. so: if there is not an underlying disease, diet is better.
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| frank100
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post he answer DR. high hopes, please. since you are very avid with my answer (to whch I still hold on to), perhaps this is not the answer
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| GDS2008
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Isn't the management of hyperlipidemia based on LDL levels??
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| HighHopes
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Thanks ifor your inputs
this is one of NBME Qs, I have picked the B, but wasn't sure .... if I undrestand you correctly the first screening test for cholesterol is normal serum cholesterol(not fasting) and then if it's high you start you treatment or life style modification based on AHA. am I following you ? second question : when do you order fasting lipid profile?
I have one more question regarding risk factors , when we talk about family history of CVD how far is the cut of for family history? for example in this question " paternal uncle had heart disease" do you consider that as a risk factor?
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| icemaiden
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Doesnt The NCEP state that if the preson has risk factors ,his LDL cholesterol should be looked into???Please take a look at this link---NCEP ,ATP 3 guidelines----according to which the first step is obtaining a complete fasting lipid profile,then identify CHD risk equivalent,then identify major risk factos,then identify the risk category and then initiate therapeutic lifestylt changes and drug tretment. Since this guy has 2 risk factors,his LDL must be maintained at 130 and so isnt it best u get a baseline LDL and then go forward with the diet?
The link is http://www.nhlbi.nih.gov/guidelines/cholesterol/a...
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| achilles
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i'll go for B. the next step should be B. he has abnormal total cholesterol levels and this is always followed by fasting LDL levels and then the treatment is based on the LDL levels and the number of risk factors present.
total cholesterol is a screening test and is not supposed to be a test on which one can decide intervention.
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| achilles
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checked up in CMDT also .... it says the same. the test must be repeated and this time it should be a fasting LDL levels and then the Rx is based on LDL levels. and if HDL is more than 40 then that is a protective factor and it negates one risk factor.
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| achilles
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paternal uncle has heart disease is not a risk factor. it should be more specified like the age of relative. generally it's <50 for men and <60 for women. and it includes the onset of CAD or h/o of heart attack.
Edited by achilles on 08/14/06 - 06:18 PM
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| GDS2008
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Agree with achilles 100%
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| HighHopes
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Thanks..
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| fongch
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Based on what I read from UW, you don't need to measure fasting cholesterol level.
So I will go w/ A.
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| zaidsuror
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I have studied that a patient with one or no ridk fosctors for coronary artery disease should receieve diet therapy when LDL is above 160 and should receive drug therapy when LDL is above 190.I dont ,however, know what the guidline are for total cholesterol.
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| zaidsuror
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So according to achilis we the answeer is B (we do a fasting LDL test)and then base treatment on LDL and risk factors.One more question and please add the source from which you add the information.My question exactly what stands for risk factors?i know there are major and minor ones .Major such as SMOKING ,HYPERTENSION,DIBETUS,AND HYPERCHOLESTREMIA.Minor ones are :OBESITY(PLEASE QUANTIFY AND DEFINE OBESITY),MALE GENDER,FAMILIAL HISTORY(U MENTIONED MEN UNDER 50 ,BUT WHO FATHER ,UNCLE ,COUSIN( I REMEMBER THAT THE RISK OF OCCURANCE OF MULTIFACTORIAL DISEASES RAPIDLY DROPS IN REMOTE RELATIVES),TYPE A PERSONALITY, HYPERCYSTEINEMIA.
ARE ALL THOSE CONSIDERED EQUALLY AS RISK FACTORS ???
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