Atherosclerosis is the primary cause of coronary heart disease. Markedly lowering blood cholesterol can halt and even reverse to some extent the progression of atherosclerosis. For these reasons, prevention should be the goal, with the focus on decreasing elevated blood cholesterol. About 20% of Americans between 20 and 75 years of age have blood total cholesterol levels above 240 mg/dL, a level requiring management, and up to 40% of some middle aged groups have this elevation.
Although hypercholesterolemias are linked to specific genetic mutations, most have a multifactorial basis that can respond to lifestyle changes. Even though the physician is justified in immediately prescribing a cholesterol-lowering drug to patients with very high blood cholesterol and additional risk factors, strong advice should also be given on the need and benefits of adding life style changes. These changes include reduction of body weight; decreased dietary total fat, choles terol, saturated fatty acids, and trans fatty acids; and increased exercise and stress management. In fact, a recent study employing intensive lifestyle changes in patients with coronary heart disease achieved a 37% lowering of LDL (low-density lipoprotein) cholesterol, a 91% decline in anginal episodes, and a decline in coronary artery stenosis within a year—all without drugs. A prescription for lifestyle changes should accompany the one for a hypocholesterolemic drug.
WHEN TO TREAT HYPERCHOLESTEROLEMIAS?
Principal risk factors for heart disease are elevated levels of LDL cholesterol, a family history of heart disease, and hypertension. Other risks include being male, smoking, low levels of high density lipoprotein (HDL) cholesterol, diabetes mellitus, hyperhomocystinemia, high levels of lipoprotein a (Lpa), and high blood levels of C-reactive protein. (Table 23.1). C-Reactive protein is a marker for cellular inflammation.
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