Primary Care Management of Women with Hyperlipidemia. Julie Marfell, DNP, BC, FNP, Chairperson, Department of Family Nursing

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1 Primary Care Management of Women with Hyperlipidemia Julie Marfell, DNP, BC, FNP, Chairperson, Department of Family Nursing

2 Objectives: Define dyslipidemia in women Discuss the investigation process leading to problem identification of dyslipidemia Design an intervention for women with dyslipidemia Women represent 53% of deaths from CVD q Higher than breast cancer

3 Definition Hyperlipidemia is an excess of fat in the blood. Specifically triglycerides or cholesterol These are transported as lipoproteins Risk factor for cardiovascular disease

4 Statistics for women Total cardiovascular disease 42% q White 35% Black 49 % Mexican American 34% q White women highest for tobacco 20% q Black women highest for stroke 4%, HTN 47%, diabetes and pre diabetes, 13 % & 21% Elevated cholesterol 48% q Mexican American women highest for cholesterol > 200 mg/dl 50%, LDL > 130 mg/dl 30%

5 Measurement Lipid Panel Total cholesterol (normal: mg/dl) LDL (normal: less than 100 mg/dl) HDL (normal: mg/dl) Triglycerides (normal: less than 150 mg/dl) Done after a 9-12 hour fast 8 weeks after an acute event

6 Physical findings Xanthomas, Xanthelasma, Lipemia reintalis, Acanthosis nigricans Corneal arcus

7 Risk factors Age q Women > 55 years Family history q Primary relative with cholesterol >240 mg/dl HDL < 40 mg/dl Smoking Diabetes Hypertension Obesity Sedentary lifestyle

8 Risk Assessment Tool for Estimating 10- year Risk of Developing Hard CHD Tool used to predict development of coronary heart disease and myocardial infraction Uses these measurement to calculate risk: q q q q q Age Gender Cholesterol (total and HDL) Systolic blood pressure Smoking e=prof

9 Use of the assessment tool Anyone with two identifiable risk factors should complete this tool This will give you a percentage that will indicate your chance of developing heart disease within the next 10 years. This calculation and the LDL is used to decide when to initiate pharmacological therapy for hyperlipidemia.

10 Risk factor classification High-risk individuals q Cardiac disease, PAD, Triple A, Carotid artery disease, diabetes OR 2 or more risk factors and a 10 year risk of > 20% Moderate high risk q 2 or more risk factors and a 10 year risk of >10-20% Moderate risk q 2 or more risk factors an a 10 year risk of <10 %

11 Management Lifestyle modifications q Reduced intakes of saturated fats and cholesterol q Therapeutic dietary options for enhancing LDL lowering q Weight reduction q Increased regular physical activity

12 Reduced intake of saturated fats Less than 7 % of total calories Omega-3 fatty acid intake and supplementation q q Oily fish twice a week Supplements mg of EPA and DHA in women with heart disease 2-4 grams in women with high triglycerides LDL can be decreased by 8-10 % with a decrease in to 7% of saturated fats of total calories Cholesterol can be decreased 2-5% if intake is less than 200 mg

13 Therapeutic dietary options for enhancing LDL lowering Increasing the amounts of plant stanols/sterols to 2 grams per day q Reduction of LDL by 6-15% Increasing viscous/soluble fiber to grams per day. q Reduction of LDL by 3-5 %

14 Therapeutic dietary options for enhancing LDL lowering Increase intake of soy protein q 40 gm per day, 5% reduction in LDL Vitamin C and Vitamin E Moderate alcohol consumption

15 Therapeutic Lifestyle Changes (TLC) Increase physical activity q minutes of moderate-intensity every day Weight reduction q 10 lb loss Decrease in LDL by 5-8%

16 Pharmacotherapy TLC should be evaluated every 6 weeks for the first three visits and increased as needed. If after 12 weeks the LDL goal is not met, pharmacotherapy should be considered.

17 Goal of therapy High risk: High moderate risk: Moderate risk: LDL 70 mg/dl LDL 100 mg/dl LDL 130 mg/dl

18 Medications Statins (HMG-COA reductase inhibitors) q First line of management q 30-40% reduction in LDL atorvastatin, fluvastatin lovastatin, pravastatin, rosuvastatin, simvastatin q Major risks: Myopathy and hepatic injury q Minor risk: Myalgias, muscle aches and weakness without elevated CK

19 Medications Bile acid sequestrants q Lower LDL levels when combined with other meds Colesevelam, cholestyramine resin, colestipol Colesevalam Cat B q Contraindications: Triglycerides >200 mg/dl q Side effects: gastrointestinal symptoms, changes absorption of other medications

20 Medications Fibrates q Excellent for rapidly lowering very high triglycerides Fenofibrate (Antara, Lofibra, Tricor) q Contraindications: Liver or renal disease, pregnant or lactating women q Avoid statins

21 Medications Lipid regulating agent q Omega-3 ethyl esters q Lowers triglycerides (TG) q Used for individuals with TG > 500 mg/dl q Contraindications: Fish allergy, pregnancy and lactating women q Side effects: Infection, flu syndrome, dyspepsia, eructation, rash, back pain, taste perversion, angina, increase ALT

22 Nicotinic acid derivatives Lowers triglycerides & increases HDL q Contraindicated in liver disease, peptic ulcer disease, pregnancy and lactating women q Effective when used with a statin q Side effect- flushing q Slow increase in dosage, no caffeine or alcohol, take with food and sustained or extended release formulation will decrease the flushing

23 Medications Cholesterol absorption inhibitor q Lowers LDL and triglycerides q Contraindications: Liver disease, pregnant or lactating women q Side effects: Headache, myalgia, myopathy, increase serum transaminases, pain in extremity Combinations q Advicor- lovastatin and niacin q Vytorin- simvastatin and ezetimibe q Pravigard Pac- pravastatin and aspirin

24 References National Heart, Lund and Blood Institute, National Cholesterol Education Program. Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, NIH Publication No Washington, DC: NIH; q 3_rpt.htm

25 References Mosca, L. et al (2007) Evidence base guidelines for cardiovascular disease prevention in women: 2007 Update. Circulation: Feb 19. American Heart Association (2006) Health Professionals. Go Red for Women. ofessionals/statements_guidelines.html

26 References German, D., Lee, A. (2007) Nurse Practitioner s Prescribing Reference. MPR, New York, NY. Spring: Wyner, E., Marfell, J., Karsnitz, D., Rousseau, M.E., (2007) Cardiovascular Disease in Women. In Hackley, B., Kriebs, J. Rousseau, M.E. (ed.) Primary Care of Women. Jones and Bartlett, Boston, MA. pp

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