Cholesterol How To Decrease

Lower Cholesterol Ebook

Is it possible to lower your cholesterol without harmful drugs? Thats the claim made by the e-book Beat Cholesterol in 30 Days by Scott Davis. Through this e-book you can learn the all-natural secrets that he used to lower his cholesterol 100 points in less than a month. This program reveals to people some main factors that cause their hypercholesterolemia such as smoking, high blood pressure, diabetes, obesity, and family history of heart disease. The program also covers tips to prevent the recurrence of hypercholesterolemia such as eating a low-fat and low-salt diet, stopping smoking, losing extra pounds, and maintaining a healthy weight. Davis' ability to collect such an astounding array of oftentimes obscure information and arrange it in a way that is easy for people of all ages to follow and apply to their lives immediately is itself quite an achievement. Read more...

Natural Cholesterol Guide Overview

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Are all Statins the Same

Statins are of proven efficacy in secondary prevention in high-risk groups such as PAD patients. However, we do not know if all statins are equally effective. This question can only be answered by head to head comparison trials that incorporate clinical endpoints. Potential differences between statins can conveniently be considered in the context of So far, head to head comparisons clearly show that some statins are considerably more potent, in terms of LDL-C lowering, than others 10, 27 . However, potency must not be considered in the decision-making process at the expense of safety and event-based evidence. What is less clear is whether statins differ in properties that may not be exclusively due to variations in their LDL-C-lowering capacity, the so-called pleiotropic actions 8 .

Statins

Statins yield a significant decrease in mortality, recurrent MI, recurrent episodes of unstable angina, stroke, the need for revascularization, and hospitalization in patients with established atherosclerosis.43-45 Statins reduce inflammation and stabilize vulnerable plaques and have been shown to benefit The Medical Research Council (MRC) British Heart Foundation (BHF) Heart Protection Study examined statin use in 20 536 high-risk individuals (women and men) aged 40-80 years in the UK.46 These patients either had established vascular disease or diabetes or they were men with hypertension and aged over 60 years. They were randomized to 40 mg day of simvastatin or placebo and followed for five years. The study found that statin drugs protect a great variety of individuals who were at risk for CVD events. Statins cut the risk of events in patients with CHD and with CHD equivalents, including those with normal or low cholesterol. In the study, 33 had LDL below 116 mg dl or 3.0 mmol l, 25...

Regular physical activity

Moderate levels of physical activity have significant effects on a woman's health. Burning approximately 150 kilocalories per day or 1000 kilocalories per week leads to a reduction in the risk of coronary heart disease by 50 and of hypertension, diabetes, and colon cancer by 30 .2 After adjusting for covariates such as age, smoking, alcohol use, history of hypertension, and history of high cholesterol, women who are regularly physically active are 50 less likely to develop type II diabetes (relative risk 0.54) than women who are not regularly active.8 Vasomotor and psychosomatic symptoms associated with menopause are also reduced with moderate amounts of activity.6,9 Examples of moderate levels of physical activity are depicted in Table 2.2.

Overview Of The Nuclear Receptor Superfamily

Severely impaired cholesterol and bile acid metabolism when fed with a cholesterol-enriched diet. Indeed, these mutant mice fail to induce CYP7A and consequently suffer from a dramatic accumulation of cholesteryl esters in the liver with no increase in bile acid production (Peet et al., 1998). However, it is now clear that the human CYP7A is not responsive to LXR and might even be repressed by LXRa activation (Chen et al., 2002 Goodwin et al., 2003). This difference between mouse and human is of interest as it might explain at least in part both the higher capability of mouse to face high-cholesterol diet and its increased resistance to the development of atherosclerosis. In summary, LXR is a major transcription factor, which acts as a sensor of cholesterol levels via its interaction with oxysterols and, in turn, drives the disposal of the excess of cholesterol. It also acts at the level of individual cells, by increasing the ABC transporter molecules responsible for cholesterol...

General Therapeutic Measures

Of smoking cessation programmes and antidepressant therapy, if necessary. Lipid-lowering drugs are especially indicated, with the use of HMG-CoA reductase inhibitors. Statins not only decrease cholesterol levels but also exert pleiotropic effects on the vascular wall limiting the inflammatory process within the plaques 1, 13 . Plaque regression with lipid-lowering therapy has been reported in both the aorta and carotids. An LDL cholesterol level less than 100 mg dl should be attained. The incidence of cardiac event may be minimized by appropriate control of heart rate and blood pressure. Diabetic patients should be adequately treated and monitored. Haemoglobin A1c should be less than 7 . Dietary supplementation of vitamin B12 and folic acid should be prescribed, especially in patients with hyperhomocysteinemia 25 . Exercise decreases LDL cholesterol and all patients should maintain a regular exercise regimen. Lastly, the use of anti-platelet drugs may reduce the risk of fatal and...

Improvement of Symptoms Associated with PAD

Another study 21 included 392 patients with an ankle brachial pressure index (ABPI) < 0.90 and 249 with ABPI 0.90-1.50. After adjusting for age, sex, ABPI, co-morbidities, cholesterol and other confounders, those taking statins had significantly better walk performance indices than participants not taking statins. Positive associations were slightly attenuated after additional adjustment for C-reactive protein (CRP) level but remained statistically significant for walking velocity and the summary performance score. These findings suggest that both the cholesterol-lowering and non-cholesterol-lowering actions of statins may favourably influence functioning in persons with and without PAD.

Reduction of the Risk of Vascular Events Associated with PAD

In a comparison of 318 PAD patients treated with statins versus 342 patients not on lipid-lowering drugs there were significant changes in the event rates after a mean follow-up of 39 months 1 . Sudden coronary death, fatal MI and new coronary events were all significantly reduced (p 0.0005, p 0.007 and p < 0.0001, respectively).

Clinical Evaluation of Patients with Vascular Disease

The primary goal of the clinical evaluation of patients with vascular disease is to decide which tests will help the surgeon treat the patients' problem while at the same time minimizing patient discomfort. Investigation of patients with vascular disease differs from that of other surgical patients and depends mainly on the underlying disease process. For instance, patients with lower extremity occlusive vascular disease suffer not only from their index problem (claudication, ischemic rest pain, gangrenous ulcers) but also from some of the conditions that have predisposed them to vascular disease in the first place (diabetes, hypercholesterolemia, etc.). In addition, they are likely to require a number of medications for these predisposing conditions, some of which require consideration in diagnosing and treating vascular disease. It is also important to keep in mind that the presence of occlusive vascular disease in the lower limbs indicates the likely involvement of other vessels...

Of Lipidlowering Drugs that may Benefit PAD Patients

Statins exert pleiotropic effects, which may be independent of LDL-C lowering. These effects may appear even before a change in lipid level occurs 26, 35 . Statins increase nitric oxide (NO) production and improve endothelial function (e.g. increased flow-mediated dilatation). They have antioxidant properties and they inhibit the migration of macrophages and smooth muscle cell proliferation, leading to an antiproliferative effect and the stabilization of atherosclerotic plaques. Statins have anti-inflammatory effects including a reduction in the circulating levels of CRP, inflammatory and proinflammatory cytokines e.g. interleukin-6 (IL-6), IL-8 , adhesion molecules e.g. intercellular adhesion mol-ecule-1 (ICAM-1), vascular cellular adhesion molecule-1 (VCAM-1) and other acute phase proteins. They reduce tissue factor expression and platelet activity, whereas fi-brinolysis can be enhanced. Statins improve microalbu-minuria, renal function, hypertension and arterial wall stiffness. A...

Glucose Intolerance and Insulin Resistance

People with diabetes (both non-insulin-dependent and insulin-dependent) or with impaired glucose tolerance have a higher risk of CHD than people with normal glucose tolerance.34 Some of this association is due to the coexistence of glucose intolerance with low HDL cholesterol, high blood

Diet and medical problems Diabetes

Whereas dietary fat helps to modulate the absorption of glucose, saturated fat and cholesterol should be limited in the diet. Saturated fat in the diet stimulates low-density lipoprotein (LDL) cholesterol production, and people with diabetes are more sensitive than the general population to dietary cholesterol. Less than 10 of calories should come from saturated fats, and dietary cholesterol should be less than 300 mg day. Some individuals may benefit from lowering intake further (7 saturated fat, 200 mg day cholesterol) (evidence level A). Intake of trans fatty acids should be minimized (evidence level B).

Evaluation Of The Severity Of Mr

Obviously, patients should not undergo valve surgery unless there is severe regurgitation. Non-invasive imaging can provide all the information needed to gauge the severity of MR left and right ventricular function, the cause and severity of MR, the presence of pulmonary hypertension and associated valve lesions as tricuspid regurgitation and aortic valve disease Cardiac catheterisation with exercise hemodynamics and angiography is only indicated when there is discrepancy between clinical and non-invasive findings. Although ventriculography has its own limitations11, it provides an additional method to assess chamber dilation and function and to estimate MR severity. Right heart catheterisation is only indicated when there is uncertainty about MR severity and pulmonary hypertension. Coronary angiography is indicated in patients with risk factors for coronary artery disease including age, hypercholesterolemia, and hypertension.

Foods Nutrients Vegetarianism and Coronary Heart Disease

It is likely that the reduction in CHD among vegetarians is, at least partly, due to a lower serum cholesterol concentration caused by a lower dietary intake of saturated fat and cholesterol. Unfortunately, none of the five prospective studies of mortality in vegetarians has complete information on serum cholesterol concentrations in all subjects, therefore, it is currently impossible to investigate whether the difference in CHD between vegetarians and non-vegetarians can be statistically explained by the difference in cholesterol levels. Some data are available, however, on the relationships of various foods to CHD within the cohort studies of vegetarians. Meat intake was strongly positively associated with CHD among male Seventh-Day Adventists in the two large prospective studies in California.49,77 There was also a positive, but weaker, association with meat intake among women in the earlier study,77 but not in the more recent study.49 Eggs, but not dairy products, were also...

Systemic Corticosteroids

Corticosteroids are potent modulators of the immune system but have low specificity and serious side effects. Their well-known and serious side effects, including osteopaenia, weight gain, hyperglycaemia, hypercholesterolaemia, hypertension, and skin fragility, can occur with modest doses administered over relatively short periods. Despite this they are widely used in solid organ transplantation, where their combination with other immunosuppressive agents enables the use of lower doses of the individual agents with a corresponding reduction in the side effects. However, even when used in combination, the side effects from systemic administration of

Preoperative Planning

The patient's medical status must be evaluated preopera-tively, and all documented preoperative measures to prevent peri-operative ischaemia need to be taken. Initiation of -blockers and platelet inhibitors is particularly important, as are smoking cessation and the implementation of preoperative optimal regulation of blood pressure and blood glucose. Also, the use of statins seems to be associated with reduced peri-operative mortality in major non-cardiac surgery, probably due to their anti-inflammatory, plaque-stabilizing effects 57, 65 .

Creactive Protein CRP

Physical activity may lower serum CRP levels in patients with PAD 1 . Statins reduce the event rate in PAD. 7, 18 . However, there is evidence that this benefit is limited to, or at least more obvious in, the presence of high inflammatory activity. In this context, it is interesting that statins lower the circulating levels of CRP 1 . It is not clearly established if there is a dose-response relationship between the extent of LDL-C lowering (and possibly the statin dose used) and the fall in CRP levels. In this context, it is interesting that ezetimibe (a selective cholesterol transport inhibitor) lowers CRP levels further when added to a statin 7 . Some fibrates (e.g. ciprofibrate and fenofibrate) can also lower the circulating levels of CRP 7 .

Recent Recommendations on Vitamins and Chronic Disease Prevention

American Heart Association (176) Vitamin or mineral substitutes are not a substitute for a balanced, nutritious diet that limits excess calories, saturated fat, trans fat, and dietary cholesterol. Scientific evidence does not suggest that consuming antioxidant vitamins can eliminate the need to reduce blood pressure, lower blood cholesterol level, or stop smoking.

Other Markers of Inflammation

Platelet activation may play a significant role through the expression of CD40 ligand as a source of activation signals to endothelial cells. This, in turn, may modulate the inflammatory response. In this context, it is relevant that both statins and the antiplatelet agent clopidogrel may influence the CD40 activation process 13, 16 .

Guidelines For Exercise

The participants in this study were young white and black men and women (ages 1830) who completed treadmill testing and then were followed from 1985 to 2001. Glucose, lipids, and blood pressures were measured and physical activity was assessed by interview and self-reporting. Outcome measurements included hypercholesterolemia, metabolic syndrome, hypertension, and type-2 diabetes. 3. Hypercholesterolemia 11.7.

Bypass to the Popliteal Artery

A 62-year-old overweight postal worker presented with complaints of cramps in his right calf. He stated that this reproducible pain occurred each time he walked 50 yards and resolved upon sitting down. He denied tissue loss or rest pain. His past medical history was significant for hypertension, hypercholesterolemia and tobacco use, as well as coronary revascularization.

Studies Relating Very Low Meat Intake To Longevity

A group of 5000 non-vegetarians were identified using a method whereby investigators asked the vegetarians to identify friends and relatives of similar lifestyle and social class but who ate meat. These 11,000 subjects completed a food frequency questionnaire at baseline (1980-1984) with items on meat intake and were then enrolled in a 12-year follow-up. In a validation sub-study, conducted 2-4 years after baseline, it was found that the non-meat-eaters had significantly lower total cholesterol and LDL cholesterol levels. Thorogood et al.90 reported the relation between very low meat intake and all-cause mortality in this study population.

Association between high blood cholesterol and atherosclerosis

An early demonstration of the link between hy-percholesterolaemia and atherosclerosis took place in 1913 when Anitschkow in Russia observed that feeding pure cholesterol to rabbits produced elevated blood cholesterol levels as well as atherosclerosis in the aorta and coronary arteries. The causal relationship between high blood cholesterol levels and atherosclerosis is demonstrated unequivocally by the genetic disorder familial hypercholesterolaemia (FH). This disorder is an example of an inborn error of metabolism and is due to impaired production of the LDL receptor. There are two forms of FH a heterozygous form and a more severe homozygous form. FH heterozygotes inherit one mutant gene and number about one in 500 people in most ethnic groups. The cells of these individuals produce approximately half the normal number of LDL receptors. As a result, LDL is removed from the circulation at half the normal rate, the lipoprotein accumulates in blood to levels twofold above normal, and...

Endothelial dysfunction Vasomotor control

Hypercholesterolaemia and atherosclerosis profoundly impair endothelium-dependent arterial relaxation as demonstrated, for example, in the aortas of rabbits (Habib et al., 1986 Verbeuren et al., 1986), the iliac arteries of monkeys (Freiman et al., 1986) and the coronary arteries of pigs (Shimokawa & Vanhoutte, 1989) and humans (Ludmer et al., 1986 Bossaller et al., 1987 F rstermann et al., 1988a). Depletion of tetrahydrobiopterin, an essential cofactor for nitric oxide synthase, causes impaired nitric oxide generation (Schmidt et al., 1992). Stroes et al. (1997) speculated that decreased nitric oxide-dependent va-sodilation in hypercholesterolaemia could be related to a relative deficiency of tetrahydrobiopterin, resulting in impaired nitric oxide synthase activity. They then showed that tetrahydrobiopterin did indeed restore the disturbed nitric oxide-dependent vasodila-tion in patients with familial hypercholesterolaemia, at a stage when macrovascular disease had not yet...

Laboratory Evaluation of the Obese Patient

Although one could make a case for obtaining a large number of biochemical tests in the evaluation of an obese patient, a more limited initial screen seems warranted. A fasting sample of blood for glucose total, LDL, and HDL cholesterol and triglyceride levels is clearly indicated. These tests, along with an appropriate history, will provide the information necessary for cardiovascular risk stratification and can be used to rule out diabetes or impaired fasting glucose (25,57). Some have advocated obtaining a glycosylated hemoglobin (HbA1C) level to screen for diabetes. Although this test should be useful in the diagnosis of diabetes, the assay method has not been standardized and at this time there is no widely accepted diagnostic criteria for diabetes based on an HbA1C level. In addition, some have advocated obtaining a fasting insulin level to determine whether insulin resistance is present. Unfortunately, here again, methods for assaying insulin have not been standardized and...

Lipid Differences Between Omnivores And Vegetarian Or Vegans

The dominance of unsaturated fat to saturated fat of the vegetarian diet lowers total cholesterol and LDL-C levels. The saturated fatty acids (SFA) lauric (C12 O), myristic (C14 O), and palmitic (C16 O) are very hypercho-lesterolemic. Palmitic acid is the dominant fatty acid synthesized in the human body from excess calories that are converted to fat.42 Thus, the elderly vegetarian on a plant protein diet does not synthesize large amounts of palmitic acid. The SFA, stearic acid (C18 O), has no effect on blood lipoproteins and is considered neutral, with moderate amounts of dietary carbohydrate.43 Of all the added dietary fats, the most hypercholesterolemic are palm-kernel, coconut, and palm oils, and butter. SFA raise LDL-C by decreasing LDL receptor synthesis and activity. All fatty acids will lower fasting triglycerides if they replace carbohydrates in the diet.44 The most significant way to lower LDL-C and raise HDL is to replace carbohydrate with linoleic acid (C18 2), the...

Vertebrobasilar Ischemia Embolic Mechanism

A 51-year-old male experienced over a period of 6 months a major stroke and several transient ischemic attacks (TIAs) of vertebrobasilar distribution. The original episode consisted of loss of balance, loss of coordination, and loss of the left visual field while driving a bus, which resulted in a road accident. Since then, he had experienced four additional episodes of aphasia and paraparesis lasting for 4-5 h. A diagnosis of vertebral artery dissection was made at the local hospital and he was placed on Coumadin. Concomitant diagnoses were hypertension, non-insulin-dependent diabetes, and hypercholesterolemia. In spite of adequate international normalized ratio (INR) levels, his symptoms continued and he was referred to us.

Treatment of Hyperlipidemia

In a meta-analysis of the available epidemiolog-ical studies (450,000 patients), no association was observed between cholesterol level and overall stroke rate. However, meaningful interpretation of these data was confounded by the fact that although a higher cholesterol level was associated with an increased risk of ischemic stroke, this was offset by an increased risk of hemorrhagic stroke in patients with lower cholesterol levels. A subsequent systematic review of randomized trials indicated that statin In the U.K., there is conflicting advice regarding statin therapy. The National Service Framework for Coronary Heart Disease recommends statin therapy (cholesterol to be reduced to < 5 mmol L) in all patients with coronary heart disease or other occlusive disease (including those with TIA or stroke irrespective of cardiac status). In contrast, the National Clinical Guidelines for Stroke recommends therapeutic intervention only in patients with symptomatic cerebrovascular disease...

Why change what you eat

What you eat has an effect on your general health and well-being. Many people think that they already have a healthy diet but, on average, people in the UK eat too much fat and too many calories. This can result in high cholesterol levels and weight problems and lead to many heart attacks each year. Heart disease by reducing cholesterol levels, blood pressure, weight.

Fruits And Vegetables A Population Studies

Reductase, the rate-limiting enzyme in cholesterol synthesis. Cholesterol synthesis is suppressed and LDL receptor activity is augmented by the carotenoids te-carotene and lycopene, similar to that seen with the drug fluvastatin. When lycopene supplements (60 mg day) were given to men for a 3-month period, a 14 reduction in their LDL cholesterol levels occurred.44 Therefore, lycopene may be useful for decreasing the risk of coronary heart disease. The regular use of red wine is suggested for lowering the risk of heart disease. Two possible mechanisms explain this effect. First, alcohol raises HDL cholesterol levels.58 Second, wine inhibits the formation of blood clots. Since purple grape juice and dealcoholized red wine inhibit platelet aggregation, it is clearly not an effect of alcohol, but appears to be related to the flavonoid pigments in the grape juice or wine.59,60 Dealcoholized red wines and red grape juice inhibit platelet aggregation by blocking thromboxane B2 synthesis in...

Screening of asymptomatic individuals

Overweight (BMI > 25 kg m2) First-degree relative with diabetes Member of a high-risk ethnic population Diagnosed with gestational diabetes Delivered a baby weighing over 4.1 kg Hypertension with blood pressure > 140 90 mmHg HDL cholesterol < 35 mg dl Triglycerides > 250 mg dl

Nuts Seeds And Oils

While 73 to 95 of the calories in nuts come from fat, they are low in saturated fat. On average, nuts contain about 60 of their calories from monounsaturated fat, which facilitates a reduction in blood total- and LDL cholesterol levels, without lowering the HDL cholesterol levels. A number of clinical trials have demonstrated the effectiveness of diets that contain either almonds, pecans, peanuts, hazelnuts, macadamia nuts, pistachios, or walnuts to significantly lower blood cholesterol levels.122-129 Human feeding trials that incorporated these nuts into the diet produced significant reductions in LDL cholesterol levels ranging from an 8 decrease with macadamia nuts to a 16 decrease with walnuts. Except for the studies with almonds and pistachios, all of the clinical trials involved normocho-lesterolemic subjects. Only in the case of the pistachio study did HDL cholesterol levels increase (up 12 ).129 In an analysis of the nut-feeding studies, Kris-Etherton reports that the...

Diseasespecific Guidelines

Coronary Heart Disease (CHD) is the major cause of death in industrialized and emerging nations and is the most common and serious form of cardiovascular disease. Elevated blood lipids and related disorders of lipoprotein metabolism are implicated in the progression of atherosclerosis and subsequent obstruction of coronary blood vessels and development of atherosclerotic heart disease. Atherosclerosis is infrequently hereditary in origin and there is an extensive body of epidemiologic, laboratory, and clinical evidence of an association between diet and the incidence of CHD. Recent clinical trials provide evidence that reducing serum cholesterol levels through diet, drugs, or both decreases the incidence of CHD. Although much attention has been focused on the effect of dietary fat and cholesterol on blood lipids, diet may influence other steps in the pathogenic sequence leading to atherosclerosis or to a cardiac event. For example, dietary factors may influence the propensity toward...

Cerebral Arteriosclerotic Vascular Disease

Patients with diabetes who have cerebral vascular arteriosclerotic disease should be on ACE inhibitors, statins, and platelet antagonists. Stroke is the third leading cause of death in this country, with more than 160,000 deaths occurring each year, and diabetic patients are at significantly increased risk.

Efficacy Of Lowcarbohydrate Diets On Fasting Lipids

A principal concern about low-carbohydrate approaches is that the high-fat content of the diet may adversely affect serum lipids and increase the risk for cardiovascular disease. As discussed in a review by Volek et al. (31), preliminary findings challenge this argument. In studies that compared low-carbohydrate and low-fat diets over the course of 6 to 12 mo, there were no differences in total cholesterol or low-density lipoprotein (LDL) cholesterol concentrations between groups (8-12,21). One study reported that the low-carbohydrate diet was less effective than the low-fat diet in reducing total cholesterol and LDL cholesterol at 1 yr (13). Only one study reported a small, transient increase in total cholesterol and LDL cholesterol during the third month of a 1-yr treatment (8). Furthermore, compared with the conventional group, those in the low-carbohydrate group experienced greater improvements in high-density lipoprotein (HDL) cholesterol (8,12) and triglycerides (8-10,12). Only...

Risk Factors for Abdominal Aortic Aneurysm

Factors associated with an increased risk of aneurysmal development in the infrarenal aorta include increasing age, male sex, ethnic origin, family history, smoking, hypercholesterolemia, hypertension, and prior vascular disease. Studies suggest that of these, male sex and smoking are the most important, increasing the chances of AAA development by 4.5 and 5.5 times, respectively. A positive family history (first-degree relative affected) alone doubles the risk of AAA presentation and is more likely if the affected relative is a female. Interestingly,

Posterior Duodenal Ulcer

Icteric dry mucous membranes xanthelasma (due to hypercholesterolemia) scratch marks and excoriations over skin mild firm hepatomegaly splenomegaly no evidence of ascites. Direct hyperbilirubinemia serum alkaline phosphatase markedly elevated mild elevation of serum transaminases markedly raised anti-mitochondrial antibody titers hypercholesterolemia lipoprotein X present. Cholestyramine resin to control pruritus immunosuppressants consider liver transplantation.

MI Studies Addressing Dyslipidemia and Diabetes Dietary Intervention Study in Children

The Dietary Intervention Study in Children (DISC) was a multicenter, randomized controlled trial sponsored by the National Heart, Lung, and Blood Institute to assess the efficacy of dietary counseling to decrease elevated serum lipids (LDL-C). Children with elevated LDL-C entered the initial clinical trial when they were 8 to 10 yr of age (34). As the intervention cohort moved into adolescence, the investigators elected to add an MI-based intervention to renew adherence to the prescribed diet among the original intervention group (there was no control group for this phase). The counselors were primarily masters-level health educators and dietitians who received 18 h of MI training. Each study participant received one in-person MI session and one follow-up session that was conducted either in person or by telephone. Twenty-four-hour recall data from the first 127 youths to complete the two-session protocol indicated that the proportion of calories from fat and dietary cholesterol was...

Protocol Considerations

Early studies using inbred mice required the use of a modified diet to generate a hyperlipidemic state, with subsequent development of atherosclerotic lesions. The most common modification was to have mice consume a diet highly enriched in saturated fat, cholesterol, and cholate (10). This diet is often referred to as the Paigen diet, after the investigator who popularized it. However, in the era in which genetically modified mice are available, such pronounced dietary manipulations are not needed. The apoE- - mouse develops hypercholesterolemia and atherosclerosis when maintained on a normal diet. However, many studies have been performed on these mice during feeding of a diet that is primarily enriched with saturated fat and cholesterol to a level present in the diet of western industrial nations. This diet contains 40 of calories from fat (21 by weight) and is colloquially referred to as the western diet. It has been demonstrated that feeding this diet accelerates the development...

Coronary Heart Disease

A number of genes have been shown to play a role in the causation of coronary heart disease, including more than a dozen that encode proteins involved in lipid metabolism and transport. The best known of these genes encodes the receptor for low-density lipoprotein (LDL). Mutations in the LDL receptor produce a deficit in receptor abundance or activity, resulting in increased circulating LDL levels and familial hypercholesterolemia. This autosomal dominant disease affects approximately 1 in 500 individuals and results in cholesterol levels that are approximately twice the normal level (i.e., roughly 300- 100 mg dl). The consequence is a 3- to 4-fold increase in the risk of coronary heart disease in heterozygotes. Homozygotes, who have a prevalence of approximately 1 in 1,000,000, present1 with cholesterol levels that are several times higher than normal. If untreated, most die of myocardial infarction before the age of 30.

Drugs on the Near and Distant Horizons

The results of four phase III trials of rimonabant for the treatment of obesity have been presented. These reports are posted on the Sanofi website (82) only one exists in the form of a peer-reviewed publication at the time of this writing (82,83). The summary of these trials, therefore, comes primarily from these Sanofi press releases. The first trial to be announced was called the Rio-Lipids trial. This was a 1-yr trial that randomized 1018 obese subjects equally to placebo, 5 mg d rimonabant, or 20 mg d rimonabant. The subjects in this trial had untreated dyslipidemia, a BMI between 27 and 40, and a mean weight of 96 kg. Weight loss was 2 in the placebo group and 8.5 in the 20-mg rimonabant group. In the 20 mg d rimonabant group, waist circumference was reduced 9 cm, triglycerides were reduced by 15 , and HDL cholesterol was increased by 23 , compared with 3.5 cm, 3 ,and 12 respectively in the placebo group. In the 20 mg d group the LDL particle size increased, adiponectin...

Protein Differences Between Omnivores And Vegetarians Or Vegans

Additional advantages from the decrease or elimination of animal protein for the elderly can be seen in the lower serum lipid levels of vegetarians or vegans. The type of dietary protein, animal or plant, is the primary factor in the effect of proteins on serum cholesterol levels. Thus, the amino acid composition of the protein is a controlling factor for serum cholesterol levels.19 Sixteen references in this cited paper indicate that the lysine arginine ratio in proteins explains the effect of proteins on the level of serum cholesterol and, in turn, atherogenesis.19 Figure 11.1 shows the relationship between animal and vegetable protein on serum cholesterol levels. Soy protein from the soybean is a plant protein source that has been successfully used in long-term studies to decrease the level of serum cholesterol in hypercholesterolemic subjects. A high saturated fat intake however, can mask the soy protein effect.20 As the level of cholesterol in serum is decreased, the plasma...

The answer is d Fauci 14e pp 21162118 Gynecomastia is

The answer is c. (Fauci, 14 e, p 1976. Tierney, 39 e, p 1070.) Patients may use anabolic steroids to improve athletic performance. The risks associated with use of these agents include mood swings, aggressiveness, paranoid delusions, psychosis, gynecomastia, infertility, testicular atrophy, hepatic tumors, peliosis hepatis, hypertension, and decreased HDL cholesterol levels. Patients with prolactinomas (pituitary tumors) generally present with galactorrhea, reduced libido, erectile dysfunction, amenorrhea, infertility, and visual field defects. Chronic cocaine use may

Aortofemoral Graft Infection

A 66-year-old man, an ex-smoker with hypertension and hypercholesterolemia, had undergone a Dacron bifurcated aortic graft and bilateral ureteric stents for an inflammatory aortic aneurysm with ureteric obstruction at another hospital 4 years previously. The left limb of the graft had been anastomosed to the common femoral artery and the right limb to the common iliac bifurcation. Postoperatively he had suffered a mild groin wound infection, which had healed with antibiotics. At follow-up he complained of left calf and thigh claudication. On examination, he appeared generally well with a midline abdominal scar and a left vertical groin scar. He had good right femoral pulse but an absent left femoral pulse.

Initiation of Atherosclerosis and Role of Endothelial Dysfunction

Initiation Atherosclerosis

To explain the process of developing atherosclerosis, several theories have been proposed. For example, the plaque cluster could result from the monoclonal proliferation of modified SMC originating from a single progenitor (monoclonal theory) 2 . Another theory considers the role of a small accumulation of SMC, which acts as a primordial stage of stem cells prone to playing a role in the development of atherosclerosis (intimal cell hypothesis) 49 . Although some isolated cases are perhaps relevant, none of these theories is able to completely explain all the aspects of ongoing atherosclerosis. This suggests that the eventual onset of atherosclerosis is also determined by superimposed extrinsic factors such as increased cholesterol levels, smoking, etc.

The Effect Of A Vegetarian Diet On Performance

Nineteen long-term (mean of 46 years) vegetarian and 12 non-vegetarian, healthy, physically active elderly women (mean age of 71 years) were compared on a variety of hematological, anthropometric, and metabolic factors.30 Although the vegetarian subjects had significantly lower blood glucose and cholesterol levels, no differences between groups were found for submaximal and maximal cardiorespiratory and electrocardio-graphic parameters measured during graded treadmill testing. The authors Animal product intake was measured and related to VO2max in a group of 80 women who varied widely in age, body mass, maximal aerobic power, and meat intake (1.1 to 31.6 meat exchanges per day).33 Maximal aerobic power was not related to meat intake, an animal product index, or dietary cholesterol. Multiple regression analysis, using models to control for age and body composition, failed to alter these findings.

Ehlersdanlos Syndrome

Diet, exercise and cholesterol-lowering drugs (althought HMG-GoA reductase inhibitors are ineffective in homozygous FH patients due to complete lack of LDL. receptors). Consider portocaval anastamosis or liver transplantation. Familial hypercholesterolemia is also called type II hyperlipoproteinemia it is an autosomal-dominant defect in LDL receptor with a gene frequency of 1 500. Homozygotes may have an LDL count eight times that of normal.

Chronic Critical Limb Ischemia

An 85-year-old male with a history of diabetes, hypertension, hypercholesterolemia, coronary artery bypass, and active tobacco use presented with a gangrenous right first toe. The patient stated that he had no history of trauma to the area, and complained of rest pain in the foot. The patient had been in otherwise good health since his coronary artery bypass 12 years ago. On physical examination, the patient was in no physical distress. The patient had a well-healed median sternotomy scar. Auscultation of the heart revealed a regular rate without any murmurs. He was obese. Abdominal examination revealed no palpable masses. The patient had bilateral femoral and popliteal pulses but no pedal pulses. The patient had bilateral, well-healed scars from the greater saphenous vein harvest sites. The right gangrenous toe was dry without any evidence of infection.

Chylomicrons VLDL and Idl Vldl Remnants

In capillaries of adipose tissue (and muscle), apoC-II activates lipoprotein lipase, the fatty acids released enter the tissue for storage, and the glycerol is retrieved by the liver, which has glycerol kinase. The chylomicron remnant is picked up by hepatocytes through the apoE receptor thus, dietary cholesterol, as well as any remaining triglyceride, is released in the hepatocyte. The receptor may recycle to the surface, the LDL is degraded, and cholesterol is released into the ceU. Expression of the gene for LDL receptors (apoB-100 receptor) is regulated by the cholesterol level within the cell. High cholesterol decreases expression of this gene. HDL cholesterol picked up in the periphery can be distributed to other lipoprotein particles such as VLDL remnants (IDL), converting them to LDL. The cholesterol ester transfer protein facilitates this transfer, shown in Figure 1-15-6. HDL cholesterol picked up in the periphery can also enter cells through a scavenger receptor, SR-B1. This...

Multiple Riskfactor Reduction

The Heart Outcomes Prevention Evaluation (HOPE) trial, which was a nonhypertensive trial, showed the superiority of 10 mg of the ACE inhibitor, ramipril with statistically significant reductions in myocardial infarction, stroke, and overall cardiovascular mortality and morbidity, independent of blood-pressure effect and medications that were concomitantly used, including aspirin, statins, and other antihypertensive drugs. This data was especially impressive in the diabetic subgroup, where there was a 22 reduction in combined cardiovascular events that was statistically significant. Additionally, the HOPE trial demonstrated a 24 reduction in total mortality, a 24 reduction in overt The HPS (16) involved almost 6000 patients with diabetes. This represented more patients than all other studies with statins and diabetic patients combined. Of the close to 2000 patients with diabetes and known coronary disease, tremendous benefit was derived by simvastatin therapy at any level of LDL. The...

Epidemiology

Coronary artery disease (CAD) has been recognized as the leading cause of death since the late 1940s. Hypertension, hypercholesterolemia, cigarette smoking, and diabetes mellitus were identified as key contributors to atherosclerosis and the development of cardiovascular risk. These risk factors are also related to cere-brovascular and peripheral vascular disease (Table 1.2).

Hyperlipidemia

An estimated 50 of American adults have total blood cholesterol levels of 200mg dL and higher, and about 20 of American adults have levels of 240mg dL or higher. Levels of 240mg dL or higher are considered high risk and levels from 200 to 239 mg dL are considered borderline high risk. Evidence linking lipids to atherosclerosis has grown, suggesting that lowering serum cholesterol, whether through diet and lifestyle modification alone or in combination with cholesterol-lowering pharmacother-apy, decreases the incidence of vascular events. For example a 1 mg dL increase in high-density lipoprotein (HDL) cholesterol concentration is associated with a 2 to 3 decrease in CAD and a 4 to 5 decrease in cardiovascular mortality. Data from the Multiple Risk Factor Intervention Trial (MRFIT) demonstrate a strong, graded, positive correlation between serum cholesterol and cardiovascular mortality rate (Neaton and Wentworth, 1992). Elevations in lipoprotein (a) Lp(a) constitute a more recently...

Question

Postoperative outcome in patients undergoing major vascular surgery has been improved in those taking beta-blockers and statins. Medical therapy may reduce the need for additional preoperative testing for coronary artery disease as the incidence of perioperative cardiac mortality is reduced to less than 1 percent, and may even reduce the indications for preoperative coronary revascularization. D. Beta-blockers and statins are independently associated with an improved postoperative outcome.

Endurance training

Endurance training can reduce some of the risk factors associated with cardiovascular disease, such as hypertension, high cholesterol, and inactivity. As little as two to three days per week are required to gain health benefits from a moderate-intensity (50 maximum oxygen consumption) endurance-training program. These health benefits include a reduction in systolic and diastolicblood pressure, total cholesterol, andbody mass index, and an increase in HDL cholesterol.26,27 Brisk walking for three or more hours per week can reduce the risk of cardiac events in middle-aged women (relative risk 0.65).28 Becoming physically active in middle age also reduces the risk of cardiac events. Exercise can be used as preventive medicine.

Lipoproteins

Alterations of LDL metabolism may create species of LDL particles with higher protein-lipid concentrations. Increased levels of these types of particles (termed small, dense LDL) are associated with increased risk of atherosclerotic disease and with elevated triglycerides (TGs) and low levels of HDL cholesterol. The mechanism linking these particles and hypertriglyc-eridemia relates to the production of chylomicrons and VLDL that are particularly rich in TGs. Catabolism of these TG-saturated VLDL particles produce LDL particles that have higher than normal TG content. These TG-rich LDLs are susceptible to further lipolysis by hepatic lipase, producing a decrease in size and increase in the density of the particle. Small, dense LDLs are believed to be more susceptible to oxidative modification and hence are thought to be highly atherogenic. Metabolic disorders such as diabetes and insulin resistance syndrome often produce this lipid particle.

Commentary

Q1 A This high frequency of cardiac complications is related to the high prevalence of coronary artery disease 54 percent of patients undergoing major vascular surgery have advanced or severe coronary artery disease and only 8 percent of patients have normal coronary arteries 2 . Perioperative cardiac complications are equally caused by prolonged myocardial ischemia or by coronary artery plaque rupture with subsequent thrombus formation and coronary artery occlusion 1, 3 . Q1 B, C, D Prolonged perioperative myocardial ischemia usually occurs from either increased myocardial oxygen demand or reduced supply, or from a combination of the two. There are several perioperative factors that can increase myocardial oxygen demand including tachycardia and hypertension resulting from surgical stress, postoperative pain, interruption of beta-blocker use, or the use sympathomimetic drugs. Decreased oxygen supply, on the other hand, can occur as a result of hypotension,...

Response to Injury

The response-to-injury hypothesis initially proposed that endothelial denudation was the first step in atherosclerosis. More recent data suggest that endothelial dysfunction rather denudation is the primary problem. According to this model, atherogenesis is a response to injury of the vascular endothelium. At its mildest, atherosclerosis may represent a repara-tive process that leads to thrombus formation and smooth muscle cell proliferation at the site of endothelial injury. The production of the endothelial injury may be from hypertension, cytotoxic molecules, or blood flow changes. Atherosclerosis develops at sites exposed to unusual shear stress, such as in the abdominal aortic bifurcation. Hypercholesterolemia, hyperhomo-cystinemia, and smoking may all contribute to endothelial injury.

Prologue

The diets of all groups of vegetarians were found to be adequate in all the parameters studied. An obvious difference was seen in the cholesterol levels of the adult groups the higher the intake of animal fat in the diet, the higher the blood cholesterol level. While the paper on the adequacy of vegetarian diets for adults, pregnant women, and adolescents was accepted with little comment, the paper showing the relationship of animal fat and cholesterol stirred up an unexpectedly wide interest. The focus of nutritional research appeared to shift. What was the difference between plant and animal fat Soon the literature and the medical and nutritional worlds were speaking of saturated, unsaturated, and polyunsaturated fats. Cholesterol was chemically taken apart, the lipids were characterized, and some were deemed good while others were bad. One thing followed another. In 1958, Stare and Hardinge published a paper showing a relationship between fiber in the diet and blood cholesterol...

Prevention

Additionally, large epidemiological studies have demonstrated that lower cholesterol levels are associated with a lower overall risk of morbidity and mortality due to CAD (Martin et al., 1986). Numerous clinical trials support these epidemiological data, and show that cholesterol lowering therapies lead to a significant reduction in morbidity and mortality associated with CAD. Additionally, these benefits extend to a population presenting with peripheral arterial disease as well. The benefits of statin therapy to decrease risk is seen as early as the first year of treatment and extend not only to prevention of cardiovascular disease but also to the quality of life. In this era of evidence-based medicine, it would be difficult not to treat patients identified at risk with statin therapy based on these data. Recommended treatment guidelines are given in Table 1.5. medication Low HDL cholesterol (< 40mg dL) Family history of premature coronary artery disease in male first-degree...

Controversy

The importance of treating patients to lower the cholesterol levels and to lessen the risk of developing atherosclerosis is well accepted. However, the question remains whether there is a threshold below which cholesterol reduction may translate into clinical benefit. On average drug therapy with simvastatin loweres LDL cholesterol levels by 35 and reduces heart risk by 34 (Pedersen et al., 1998). The goal of this study was to reduce total cholesterol below 200. However, many patients achieved reductions greater than this and were associated with continuing but progressively smaller reductions in heart attack risk. This subgroup analysis estimated a 1 reduction in LDL, reducing the risk of major coronary events by 1.7 . However, at what point this benefit can

Prevention of PAD

In the Program on the Surgical Control of Hyperlipid-emias (POSCH) 9 the effect of cholesterol-lowering induced by partial ileal by-pass in patients (n 838) with a previous MI and hyperlipidaemia was assessed. The incidence of new cases of claudication was significantly lower relative risk (RR) 0.66, 95 confidence interval (CI) 0.20-0.90 p 0.009 in the intervention group when compared with the control (nonintervention) group 4 years after the closure of the trial.

Hyperlipidaemia

Therefore, lowering plasma lipid levels with drugs such as statins benefits patients at risk of cardiovascular events. The current recommendation of treating only total cholesterol over 5 mmol l has been challenged by evidence that statins may have a direct beneficial effect on atherosclerosis (Shearman, 2002). Results from studies currently underway are needed to evaluate this in greater detail, in particular the cost-effectiveness of more widespread use of these drugs (Leng et al., 2001).

Concluding Comments

Although statins can improve both clinical outcomes and symptoms in PAD, it is possible that further benefit can be obtained if LDL-C levels are lowered beyond the older targets for high-risk patients from 96-100 mg dl (2.5-2.6 mmol l) to 70-77 mg dl (1.8-2.0 mmol l) . However, we do not know if these new LDL-C targets provide further symptomatic improvement or a more effective prevention of events in PAD. These issues need to be resolved by appropriately designed trials.

Limiting fat intake

In the average American diet, approximately 36 of calories come from fat. To reduce the risk of heart disease, the fat content of the diet should be limited to 30 or less. Some have taken this much lower (see Pritikin and Ornish diets, pp. 29). To control cholesterol levels and heart disease risk, reduction in saturated fat intake is generally recommended. Modifying the type of fat in the diet to replace saturated fats with polyunsaturated fat will reduce the risk of coronary artery disease.1 Considering both heart disease and cancer risk, less than 10 of the total calories per day should come from each category of fat (saturated, monounsaturated, polyunsaturated). Providers should recommend use of low-fat dairy products, limited amounts of lean meats, and avoidance of added fats. For cooking, high monounsaturated oils (olive, canola) are preferable.

Obesity

Obesity has many different metabolic effects, some of which would tend to increase the risk of CHD. In particular, obesity increases serum total cholesterol while reducing HDL cholesterol, raises blood pressure, and induces glucose intolerance.44 Data from prospective studies also indicate that obesity is an important risk factor for CHD.45,46

Cholesterol

Normal ranges will vary with age, diet, and geographic location. Since there are many variables that affect plasma cholesterol levels, most references give a desirable range based primarily on age. Under most circumstances, an upper limit of 200 mg dl or less is desirable. Variations from Normal. High levels of cholesterol are associated with atherosclerosis and an increased risk of coronary artery disease. Other diseases linked to elevated cholesterol include uncontrolled diabetes, obesity, and hypothyroidism. Type II familial hypercholesterolemia is an inherited disorder characterized by high levels of plasma cholesterol and early evidence of atherosclerosis. Hyperlipidemia type IIA is another name for type II familial hypercholesterolemia. Interfering Circumstances. Pregnancy and removal of the ovaries will cause elevated cholesterol results. Drugs that cause an increased cholesterol level include adrenocorticotropic hormone, anabolic steroids, oral contraceptives,...

Heart disease

C.B. is a 58-year-old woman who presents for hospital follow-up. She is now four weeks after her first heart attack and still stunned that this happened to her. At hospital discharge, she declined cholesterol-lowering medication, saying she really doesn't want more drugs. She asks what she can do with her diet to reduce her risk of another heart attack. Soy protein intake has been found consistently to induce modest reduction of serum cholesterol. The US FDA and the American Heart Association now agree that 25 g per day of soy protein, in conjunction with a low-fat diet, may reduce the risk of heart disease. Fenugreek, a legume used as a supplement, has also shown cholesterol-lowering effects in preliminary studies.17

Diabetes Mellitus

It has been observed that low cholesterol levels, caused either by diet or by drugs, are associated with increased rates of death due to suicide or violence 114-116 . The most plausible explanation is that lowered cholesterol levels result in decreased serotoninergic activity in the brain 116 . Nonetheless, this very interesting observation warrants further investigation.

Case Studies

Crystal Hampton is a 60-year-old female with a diagnosis of type IV hyperlipi-demia. In reviewing her record, you discover that the physician has ordered a lipid profile. What is a lipid profile and what specific substances does it measure Project what the results might be in Mrs. Hampton's case One of the fats being measured is called good cholesterol, what is the medical term for good cholesterol and what is the function of this type of cholesterol How would the test results differ if this were a male patient

Conclusion

The most important, well-established, diet-related risk factors for CHD are high serum cholesterol, high blood pressure, and high BMI. Compared with non-vegetarians, Western vegetarians have a lower plasma cholesterol concentration (by about 0.5 mmol l-1) and lower body mass index (by about 1 kg m2), and may have slightly lower blood pressure. The low cholesterol levels of vegetarians would be expected to cause an approximately 25 reduction in mortality from CHD, and a pooled analysis of prospective studies has shown that CHD mortality is 24 lower in vegetarians than in non-vegetarians.

Dyslipidemia

Abnormal lipid profiles are well recognized in patients with atherosclerosis. The relationship between cholesterol level and CAD risk is continuous, with no obvious safe cut-off point. Patients with PAD are likely to be identical. A number of studies investigated cholesterol in PAD and found it to be a significant, though weak, risk factor for claudication, and above the age of 55 years to correlate with ABI. Reduced HDL is associated with increased PAD severity,6 with strong inverse relationships between HDL cholesterol and PAD that persist after adjustment for other risk factors. Furthermore, elevated serum triglyceride levels have been reported in both cross section and longitudinal studies. It has been suggested that the link between increased triglyceride level in patients with PAD and the development of the disease might be explained by the increase in low-density lipoprotein (LDL) providing the enhanced vascular risk. More recently, the Heart Protection Study (HPS) demonstrated...

Fibrinogen

Therapy had significantly less inflammation (hs-CRP p< 0.001, fibrinogen p 0.007, albumin p< 0.001 and neutrophils p 0.049) and better survival adjusted hazard ratio (HR) 0.52, p 0.022 and event-free survival rates (adjusted HR 0.48, p 0.004) than patients not treated with statins 18 . However, the short-term effect of statins on plasma fibrinogen levels remains controversial. In contrast, fibrates (with the possible exception of gemfibrozil) consistently lower plasma fibrinogen levels 7 .

Creatinine

Future studies should determine whether correcting or preventing impaired renal function will result in a decreased risk of vascular events. In this context, there is evidence that treatment with statins and antihypertensive drugs results in improved renal function or a delay in renal disease progression 6, 7 .

Block

A 62-year-old woman with hypertension, diabetes, hypercholesterolemia, and a long smoking history comes to the emergency department with altered mental status. She is started on supplemental oxygen, and an intravenous catheter is inserted. Oxygen saturation is 95 on 3 L nasal cannula, pulse is 102 beats min, temperature is 96-2 F, and the blood pressure is 78 42 mmHg. The chest has scattered rhonchi. but the patienl is unable to cooperate enough to take a deep breath.

Tibolone

Tibolone is a steroid compound with estrogenic, progestogenic, and androgenic properties.66 It is effective for reducing the frequency and severity of hot flushes and improving vaginal dryness and libido. Tibolone has been shown to increase bone mineral density, with little effect on the breast or endometrium. It should not be used in women with a history of coronary artery disease, stroke, or liver disorders. Caution is also advisable in women with kidney disease, epilepsy, migraine, diabetes, and high cholesterol. Tibolone may interact with some drugs, including anticoagulants. Its androgenic properties may cause oily skin and extra hair growth. Breast symptoms are rare. It is not available in the USA.

Atherosclerosis

The causal relationship between high blood cholesterol levels and atherosclerosis is well established (Levine et al., 1995). Hypercholesterolaemia may be thought of as any plasma cholesterol level above 160 mg 100 mL. Cholesterol-lowering therapy is effective in both the primary prevention of coronary artery disease and the secondary prevention of subsequent cardiac events in patients with established coronary disease.

Relapses

Relapse with this particular combination therapy when compared with standard antimicrobial therapy alone.79 There are anecdotal reports of successful therapy using metronidazole followed by oral Lactobacillus,80 vancomycin in combination with rifampin or cholestyramine,81-83 tapering or pulse doses of vancomycin,84 rectal instillation of stool or mixed broth cultures,85 and intravenous immune globulin.86,87 None of these therapies appear to be uniformly effective, and their use is empirical for any particular patient. With increasingly worrisome antibiotic-resistant enteric organisms (e.g., vancomycin-resistant enterococci), clearly the need is increasing for chemotherapeutic or immunologic agents (other than antimicrobials) that block the dramatic effects of the toxin(s),88 such as antitoxic antibody, pharmacologic blockers such as phospholipase A2 or cyclooxygenase inhibitors, or platelet-activating factor antagonists.89

Future Perspectives

Because estrogen monotherapy has been linked to increases in the risk of endometrial cancer (202), progestins have usually been included to reduce this risk (203). The role of progesterone in combination with estrogen in cardioprotection is currently controversial. A number of previous investigations have proposed that progestins counteract the beneficial antiatherogenic effects of estrogen by its negative influence on serum lipids, particularly HDL cholesterol (204). However, these findings have recently been challenged (205), and as mentioned previously, estrogen-induced beneficial effects on serum lipoproteins accounts for less than 50 of the total cardioprotective effects of this hormone. Recent studies have demonstrated that those postmenopausal women, using both estrogen and progesterone replacement, exhibited a significantly lower incidence of cardiovascular deaths than those using estrogen monotherapy (206). These observations support a beneficial role for progesterone in...

Smoking

Smoking by women causes 1.5 times as many deaths from CHD as from lung cancer.9 Active or passive exposure to nicotine and its by-products impairs endothelial function. Exposure to nicotine increases clotting proteins (fibrinogen), enhances the reactivity of platelets (making thrombosis more likely), and increases the viscosity of the blood. Smoking also decreases the advantageous HDL cholesterol.11 Nicotine exposure injures the endothelium and destabilizes previously established atherosclerotic plaques by promoting plaque rupture and the development of superimposed coronary thrombosis. The process ofplaque ruptures and superimposed thrombosis is the sequence of events now accepted to be at the root of most MIs.

Physical inactivity

Over 70 of USA and UK women do not get adequate physical exercise.1,2 Active women have a graded reduction in CHD risk compared with sedentary women.30,31 Regular physical activity can also help to lower blood pressure, prevent diabetes, decrease total and LDL cholesterol, raise HDL cholesterol, and help to treat or prevent obesity.32 Every woman should accumulate 30 minutes or more of moderate-intensity physical activity on most days of the week.33,34 Strength training and flexibility are two other additional components of physical fitness.12,32

Conclusions

19 Lemaitre, R.N., Psaty, B.M., Heckbert, S. R., et al. Therapy with hydroxymethyl-glutaryl coenzyme A reductase inhibitors (statins) and associated risk of incident cardiovascular events in older adults - evidence from the cardiovascular health study. Arch. Intern. Med. 2002 162 1395-400. 20 Downs, J. R., Clearfield, M., Weis, S., et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels results of AFCAPS TexCAPS. J. Am. Med. Assoc. 1998 279 1615-22. 21 Sacks, F. M., Pfeffer, M. A., Moye, L. A., et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels cholesterol and recurrent events trial investigators. N. Engl. J. Med. 1996 335 1001-9. 23 LaRosa, J. C., He, J. and Vupputuri, S. Effect of statins on the risk of coronary disease a meta-analysis of randomized controlled trials. J. Am. Med. Assoc. 1999 282 2340-46. 24 Yeung, A. C. and Tsao, P. Statin therapy...

Jo Ann Rosenfeld

Case M.M. is a 54-year-old obese woman who has not seen a physician in two years. She has a history of hypertension and high cholesterol. She works full time as an accountant for a medium-sized firm and has spent all her spare time for the past two years caring for her mother, who died two years after being incapacitated by a stroke. She has two married daughters who live across the country. She wants to control her hypertension so she doesn't end up like her mother and as a burden to her children.

Secondary prevention

As with primary prevention, there are several modifiable risk factors. Changing to a low-fat, low-salt diet, reducing or eliminating alcohol and tobacco use, controlling diabetes and cholesterol levels, reducing weight, and increasing exercise are important. Although evidence as to whether hypertensive control is as important in reducing the risk of a second stroke is disputed,25 anticoagulation of individuals with atrial fibrillation will also reduce the risk of a second stroke.16

Items 356360

A 34-year-old schizophrenic man with a history of Hodgkin's disease in remission since treatment 10 years ago presents with a right middle cerebral artery territory stroke. He is found to have bilateral carotid bruits. There is no history of hypertension, diabetes, or hypercholesterolemia. He does smoke cigarettes. (SELECT 1 SUBSTANCE)

Items 388390

On more detailed questioning regarding the patient's medical history, you learn that she is being followed for elevated cholesterol by her primary care doctor, although she does not take any cholesterol-lowering medication. You tell the patient that estrogen has which of the following effects on the lipid profile

Legumes

A number of studies have shown that legumes, such as beans and lentils, lower blood cholesterol levels, improve blood sugar control, lower triglyceride levels, and lower the risk of heart disease.74-76 While beans are good sources of polyunsaturated fat, folic acid, potassium, copper, and soluble fiber, they also contain a variety of important phytochemicals such as flavonoids, protease inhibitors, saponins, phytates, and phytosterols that have cardio-protective and cancer-preventive properties.3,77,78 The anthocyanin pigments isolated from the bean seed coat of Phaseolus vulgarus, the common bean, exhibit strong antioxidative activity.79 These pigments may provide protection against oxidative damage of cell membrane lipids and cell contents. Over the past 20 years, a number of human studies have shown that the consumption of 30-60 g of soy protein decreases total and LDL cholesterol levels by as much as 10-20 in persons with elevated blood cholesterol levels.86-88 In some instances,...

Whole Grains

Brans have various effects on blood lipid levels. Rice bran and oat bran are both effective for lowering cholesterol levels while wheat bran has little, if any, effect. Rice bran oil effectively lowers blood cholesterol levels, due to its rich content of unsaturated fat, as well as y-oryzanol, triterpene alcohols (cycloartenol and 24-methylene cycloartanol), plant sterols (P-sitosterol and campesterol) and P- and y-tocotrienols, all of which interfere with cholesterol metabolism.115 Wheat germ also lowers cholesterol and triglyceride levels in hypercholesterolemic subjects.116

Diagnosis

Concomitant coronary artery disease is present in 40 to 50 of patients with supra-aortic trunk disease. Inevitably, these patients have other cardiovascular risk factors including hypercholesterolemia, history of stroke, TIAs, peripheral vascular disease, hypertension, diabetes, and renal insufficiency. A prior history of smoking is present in 78 to 100 of patients with supra-aortic trunk disease. Accordingly, cardiac evaluation is advisable, especially if any major reconstructions were planned.

Figure

In addition, exercise promotes weight loss, blood pressure reduction, decreases in triglyceride and LDL cholesterol levels, and increases in HDL cholesterol level. In stable patients, exercise is usually recommended at an intensity of 60 to 75 percent of predicted maximal heart rate for 20 to 40 minutes, three to five times per week. Referral to a formal cardiac rehabilitation program is recommended when feasible to optimize safety in the conditioning process. Adherence to therapeutic regimens is clearly improved in these programs because of the expertise of the staff and the supportive environment offered. Meta-analy-sis of rehabilitation programs shows a reduction of 20 to 25 percent in cardiovascular and all-cause mortality in patients who participated and kept with the program.50

Clinical Trials

These collective studies involving thousands of diabetic cohorts from many countries and spanning several years all confirm the benefit of statins and fibrates for the diabetic patient subset. Currently available data seems to be very promising in pointing the way toward future approaches and perhaps toward a softening of the warning on combination use (particularly in the case of fenofibrate, which is metabolized in a different area of the liver than the cytochrome P-450 system and involves glucuronidation in the liver). This is important because the risk for potential toxicity increases when statins are combined with other potentially myotoxic drugs. The major concern with gemfibrozil interaction with the statins and the reason for the increased area under the curve is largely because of the area of the liver where gemfibrozil is metabolized. Gemfibrozil is glucuronidized in a similar area of the liver to all of the statins, with the exception of pravastatin and fluvastatin. This is...

And Nutrition

389, The answer is d. (Hardman, pp 9.> 4-935.) Chenodeoxycholic acid (chenodiol) and ursocliol have proved to be effective in some patients with cholesterol gallstones. Lovastatin lowers blood cholesterol levels but has no effect on gallstones. Methyl tertiary butyl ether and a new agent, monoctanoin, are infused directly into the common duct and will dissolve gallstones.

Sirolimus Rapamycin

Side effects from the use in transplantation have been reported for rapamycin, such as raised lipid and cholesterol levels, hypertension, anaemia, diarrhoea, rash, thrombocytopenia, decreases in platelets and haemoglobin however, these are generally less serious. Rapamycin effectively inhibits wound healing and should therefore not be applied after surgery. Positive effects on experimental animal models of autoimmune uveitis were described, but studies on the effect of sirolimus in uveitis patients have not yet been published.

Motivation

The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) was released in 2001 and updated the existing guidelines for clinical management of high cholesterol. The guidelines were meant to supplement clinical judgement and identified individuals as candidates for intensive preventative management based on their absolute 10-year risk of coronary heart disease 13 . Models to estimate the absolute risk of coronary heart disease were developed based on the Framingham data and are included in the NCEP ATPIII guidelines. The models were developed as follows.

Serum lipids

Treatment with antihypertensive medications Low HDL cholesterol Diabetes mellitus target LDL levels for primary prevention include age (men over 45, or women over 55), family history of premature CHD, current cigarette smoking, hypertension or treatment with antihypertensive medications, low HDL cholesterol, and diabetes mellitus. Lipid management is also critically important in patients with the metabolic syndrome, because it maybe involved in most premature CHD in women.17 The metabolic syndrome exists in women when more than three of the following are present abdominal obesity (waist circumference > 88 cm), triglycerides above 150 mg dl or 17 mmol l, HDL cholesterol below 50 mg dl or 1.3 mmol l, blood pressure above 130 > 85 mmHg, and fasting glucose above 110 mg dl or 1.0 mmol l. Approximately 24 of American adults and 43 over the age of 60 have the metabolic syndrome.18 Women with the metabolic syndrome should be treated promptly with a diet of less than 7 saturated fat and...

Review Questions

A 42-year-old man presents with a chief complaint of intermittent claudication during exercise. His family history is significant for the presence of cardiovascular disease on his father's side, but not on his mother's side. Physical exam reveals xanthelasmas and bilateral tendon xanthomas. A plasma lipid profile reveals a cholesterol level of 340 mg dL, with a high LDL HDL ratio. He is given instructions for dietary modifications and a prescription for Zocor (simvastatin).

Items 373374

The National Cholesterol Education Program has developed a two-step diet plan for persons with high cholesterol. Persons are considered at moderate risk of developing cardiovascular disease if their total cholesterol is between 200 and 239 mg dL (5.26.2 mmol L) and at high risk if their total cholesterol is 240 mg dL or more (> 6.2 mmol L). b. Total dietary cholesterol

Lipid Control

The Prevention Study Texas Coronary Atherosclerosis Prevention Study (3). This study randomly assigned patients with average cholesterol levels of 221 mg dL, LDL of 150 mg dL, and lower than normal HDL of 36 mg dL for men and 40 mg dL for women, to 20-40 mg day of lovastatin or placebo, and followed them for an average of 5.2 years. Of these patients, 155 were diabetic. In this study, lovastatin led to a relative risk (RR) reduction of 0.56 for any arteriosclerotic event (fatal or nonfatal myocardial infarction, unstable angina, or sudden death) and an absolute risk reduction of 0.04. Despite LDL levels of 115 mg dL and HDL levels of 39 mg dL at the end of the study, the differences in the patients with diabetes were not statistically significant. 3. The Helsinki Heart Study (5) randomly assigned men aged 40-55 years with elevated non-HDL cholesterol levels to 600 mg of gemfibrozil twice daily or to placebo. The starting mean total cholesterol was 290 mg dL and the mean HDL was 47.6...

Diabetes And Fats

Because the essential component of the diabetic paradigm is atherogenesis, it is critically important for patients with diabetes to limit their intake of dietary cholesterol, saturated fat, and trans-fatty acids. These remain important determinants of the plasma LDL cholesterol. For many years, the ro-6 polyunsaturated fats (linoleic acid) were perceived to have cholesterol-lowering effects. Linoleic acid has been reported to lower the serum total cholesterol level approximately half as much as saturated fatty acids raise the levels with additional subsequent reduction in LDL cholesterol. However, this concept has not been proven with experimentation. Postulated mechanisms for this effect include the following Approximately 4 g of ro-3 fatty acids can reduce serum triglycerides by 35 , increasing LDL cholesterol by 5-10 and increasing HDL cholesterol by 1-3 . Various meta- Dietary cholesterol has no role in preventing chronic disease and can enhance athero-genesis. Thus, intake should...

Answers

The answers are 310-e, 311-c, 312-a. (Fauci, 14 e full text , pp 2145-2146, 1350-1352. PARAN, J Resp Dis., 19 5612, 1998. USPS Task Force, 2 e.) For patients in a precontemplative stage of change, advising them to quit and personalizing the message to their risk factor is the best approach. It is important to continuously assess smoking status and advise to quit at every encounter to help motivate patients until they are ready for action. Those who are not ready to quit are unlikely to follow through on a quit date, go to smoking cessation classes, or use nicotine replacement therapy or self-help materials. According to the National Cholesterol Education Program (NCEP) guidelines, persons with borderline-high cholesterol 200 to 239 mg dL with two or more risk factors for coronary heart disease (CHD), in this case, smoking and male 45 years of age, should have a lipoprotein analysis performed, even if the HDL is 35 mg dL. Dietary therapy would be the recommendation (no CHD,...

Clinical Studies

Njoku et al. (2001) report a series of 25 patients with falciparum malaria treated with an aqueous extract of A. indica. Unfortunately, the only parameter reported is the patients' cholesterol levels, which were reduced compared to a non-malaria-infected control group, but not significantly different from those of malaria patients treated with chloroquine.

Lower Your Cholesterol In Just 33 Days

Lower Your Cholesterol In Just 33 Days

Discover secrets, myths, truths, lies and strategies for dealing effectively with cholesterol, now and forever! Uncover techniques, remedies and alternative for lowering your cholesterol quickly and significantly in just ONE MONTH! Find insights into the screenings, meanings and numbers involved in lowering cholesterol and the implications, consideration it has for your lifestyle and future!

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