Understanding Cholesterol & Triglycerides. This course has been awarded one (1) contact hour. This course expires on May 1, 2017.

Transcription

1 Understanding Cholesterol & Triglycerides This course has been awarded one (1) contact hour. This course expires on May 1, First Published: May 1, 2014 Course Expires: May 1, 2017 Copyright 2014 by RN.com All rights reserved Reproduction and distribution of these materials is prohibited without an RN.com content licensing agreement.

2 INTERVENT This course is cosponsored and coprovided by INTERVENT. INTERVENT International, LLC (INTERVENT) is a global lifestyle management and chronic disease risk reduction company based in the United States. INTERVENT develops, licenses and provides evidence-based, technology-enabled, outcomes-oriented programs for the prevention and management of multiple chronic diseases. The primary purpose of the INTERVENT programs is to improve individual and population-based measures of health while simultaneously reducing health care costs and enhancing productivity. The programs provide unique solutions for employers, health insurers, health care systems, physicians, EAP providers, pharmaceutical companies, device manufacturers, individual consumers and others. INTERVENT and its licensees serve clients in multiple countries and languages via telephone call centers and the Internet. Since INTERVENT's inception in 1997, our mission has been to optimize the health of as many people as possible by providing them with affordable and cost-effective access to credible, evidence-based, lifestyle management and chronic disease risk reduction services. We've provided unique health care solutions to numerous individual consumers and hundreds of organizations.

3 Conflict of Interest and Commercial Support RN.com strives to present content in a fair and unbiased manner at all times, and has a full and fair disclosure policy that requires course faculty to declare any real or apparent commercial affiliation related to the content of this presentation. Note: Conflict of interest is defined by ANCC as a situation in which an individual has an opportunity to affect educational content about products or services of a commercial interest with which he/she has a financial relationship. Dr. Gordon and Brenda Wright are employed by INTERVENT International, LLC. The content of this presentation has been extensively reviewed and evaluated by the Nurse Planner and determined to be free of commercial bias. There is no relevant financial relationship to disclose. The planners of the educational activity have no conflicts of interest to disclose. There is no commercial support being used for this course.

4 Acknowledgements RN.com acknowledges the valuable contributions of Neil Gordon, MD, PhD, MPH, FACC. Dr. Gordon is one of the founders of INTERVENT, a lifestyle management and population health management company. He is the CEO and medical director. Dr. Gordon obtained his M.D. and a Ph.D. in exercise physiology in South Africa, and has a master's degree in public health from the University of California, Los Angeles. He is a fellow of the American College of Cardiology and is board certified in public health and general preventive medicine. Dr. Gordon served as director of exercise physiology at the worldrenowned Cooper Institute in Dallas, Texas for six and a half years where he worked with numerous elite athletes. Dr. Gordon also served as a clinical professor of medicine at the Emory University School of Medicine (Atlanta, Georgia), vice-president of the American Association for Cardiovascular and Pulmonary Rehabilitation, a trustee of the American College of Sports Medicine and chairman of the American Heart Association Committee on Exercise, Cardiac Rehabilitation and Prevention. Dr. Gordon has authored over 100 published scientific manuscripts, eight books, and numerous scientific abstracts in the area of preventive medicine. Brenda Shepherd Wright, PhD. Brenda received a Bachelor of Science degree from the University of Texas at Austin and a master of education and a doctor of philosophy degrees from the University of North Texas in Denton. For more than 12 years she served as director of behavioral science and health promotion at the Cooper Institute in Dallas. With more than 30 years of experience in health promotion and disease prevention, Brenda has worked with a variety of clients and populations in the U.S. and internationally, including over 200 corporate health promotion programs. Her publication record includes numerous scientific abstracts and manuscripts, newsletters, books for lay and professional audiences, and other technical works. Brenda is one of INTERVENT's co-founders. In her past and current roles at INTERVENT, she has served as the primary author of educational and training materials and adapted materials for global audiences. Brenda has provided training and consultative services to lifestyle and disease management coaches on both subject matter content and coaching practices, particularly stages of change and motivational interviewing. As requested by specific clients, Brenda has developed customized on-site health promotion programs, such as fatigue management training for shift workers, interactive seminars and challenges/ competitions, and has assisted with preparation of customized evaluation reports. Purpose The purpose of this one contact hour course is to provide nurses with an overview of cholesterol and triglyceride management to lower the risk of atherosclerotic cardiovascular disease (ASCVD).

5 Learning Objectives On completion of this course, the healthcare professional will be able to: 1. Identify desirable LDL, HDL, and triglyceride levels. 2. Discuss the goals and focus of the 2013 ACC/AHA Guidelines for Treating Blood Cholesterol to Reduce Cardiovascular Risk in Adults. 3. Define five potentially modifiable major risk factors for ASCVD and the 2013 ACC Guidelines definition of clinical ASCVD. 4. Name at least four factors that determine LDL cholesterol levels. 5. Review at least four blood tests to evaluate the risk of ASCVD and discuss reasons for inaccurate blood test results. 6. Discuss basic principles of healthy lifestyle actions that patients can incorporate into daily living. 7. Identify four specific groups of adults who can benefit most from taking statin drug therapy. Introduction Dyslipidemia (a disorder of lipoprotein metabolism) and hyperlipidemia (high cholesterol and/or triglyceride levels) affect millions of people worldwide, particularly in areas where diets high in saturated fat and sedentary lifestyles are prevalent, such as the United States. Dyslipidemia is a cause for serious concern due to the increased risk it poses for ASCVD, including coronary heart disease, stroke and peripheral artery disease. This course aims to provide nurses with the fundamental knowledge needed to understand the risks of hyperlipidemia and counsel patients effectively on modifying lifestyle risk factors to optimize cholesterol management and improve overall health outcomes.

6 Key Concepts Cholesterol is a soft, white, fat-like substance made in the liver and found in the body s cells. High blood cholesterol is one of the major modifiable risk factors for heart attacks, strokes, and other types of ASCVD. Triglycerides, another type of fat in the blood, also contribute to ASCVD. To travel to the cells, cholesterol must attach to a protein. The combination of cholesterol and protein is known as a lipoprotein. Two types of lipoproteins are most important to remember: LDL (low density lipoprotein or bad ) cholesterol and HDL (high density lipoprotein or good ) cholesterol. LDL cholesterol carries cholesterol to the arteries and causes plaque to build up in the walls of the arteries. HDL cholesterol works to remove plaque from the walls of the arteries. A total blood cholesterol level under 200 mg/dl (or 5.2 mmol/l) is generally recommended. An optimal LDL cholesterol value is generally below 100 mg/dl (or 2.6 mmol/l); if ASCVD is already present, an optimal LDL value may be below 70 mg/dl (or 1.8 mmol/l). Generally, HDL cholesterol should be 40 mg/dl (or 1.0 mmol/l) or higher in males and 50 mg/dl (or 1.3 mmol/l) or higher in females; optimal is 60 mg/dl (or 1.6 mmol/l) or higher for men and women. Generally, triglycerides should be below 150 mg/dl (or 1.7 mmol/l). The 2013 cholesterol treatment guidelines from the American College of Cardiology and the American Heart Association do not provide goal cholesterol levels. Rather, they focus primarily on identifying individuals who, in addition to practicing a healthy lifestyle, can benefit most from a class of cholesterol-lowering drugs called statins. Note! In this course, atherosclerotic cardiovascular disease is abbreviated to ASCVD. The process by which cholesterol-rich plaque builds up in the walls of arteries is called atherosclerosis. Over time, atherosclerotic plaque causes blockages in arteries. This limits the flow of oxygen-rich blood and can cause cardiovascular disease, including heart attack and stroke. Cardiovascular disease caused by atherosclerosis is termed ASCVD.

7 Knowledge Check One HDL is protective against ASCVD because it: A. Directly buffers LDL. B. Binds to triglycerides. C. Removes plaque from the walls of the arteries. The correct answer is C Guidelines for Treating Blood Cholesterol to Reduce Cardiovascular Risk in Adults In November 2013, the American College of Cardiology and the American Heart Association developed new guidelines for treating blood cholesterol in adults age 21 years or older. Their recommendations were based on a thorough and careful review of the very latest, highest quality clinical trial research. This course provides an overview of some highlights from the new guidelines. Along with cigarette smoking, high blood pressure, physical inactivity and obesity, high blood cholesterol is one of the five major risk factors for heart attacks. High cholesterol also increases the risk for strokes. Triglycerides also contribute to heart attacks and strokes. Heart attacks and strokes are usually caused by ASCVD.

8 What is ASCVD and Why is it Important? The ultimate goal of the November 2013 guidelines is to reduce a person s risk of heart attack, stroke and death. Heart attacks and strokes are usually caused by ASCVD. For this reason, the guidelines focus on identifying whether someone already has or is at heightened risk for ASCVD and, therefore, could benefit most from cholesterol treatment. The process by which cholesterol-rich plaque builds up in the walls of arteries is called atherosclerosis. Over time, atherosclerotic plaque causes blockages in the arteries. This limits the flow of oxygen-rich blood and can cause heart attacks, strokes and other disorders. The November 2013 guidelines defined clinical ASCVD by the inclusion criteria for the secondary prevention statin randomized clinical trials, namely, acute coronary syndromes, or a history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin. Risk of Developing ASCVD The likelihood or risk of developing ASCVD in the future can be estimated based on a number of factors. Typically, for persons aged years, an estimate is made of their risk of developing ASCVD in the next ten years. For younger individuals (20-59 years of age), an estimate can be made of their risk of developing ASCVD during their lifetime (also referred to as lifetime risk). Like people with ASCVD, those at higher risk for ASCVD require more intensive treatment to help prevent ASCVD from developing in the future. Note! To learn your ten year and/or lifetime risk of ASCVD, you can complete a confidential, free Health Risk Assessment (HRA) upon completion of this course.

9 What is Cholesterol and Why is it Important? Cholesterol is a soft, white, fat-like substance made in the liver and found in the body s cells. It plays an important role in the production of cell membranes and sex hormone, as well as in the digestion of certain foods. Cells throughout the body remove cholesterol from the blood for use in various important cellular activities. It is the liver, however, that plays the most important role in determining blood cholesterol levels. Only about 7% of the cholesterol in the body circulates in the blood. But this small amount is enough to be dangerous, as cholesterol can t dissolve in blood. To travel to cells, cholesterol must attach to a protein. The combination of cholesterol and protein is known as a lipoprotein. There are several different lipoproteins, but the two most important lipoproteins involved in cholesterol transport are LDL (low density lipoprotein) and HDL (high density lipoprotein).

10 Facts about the Liver and Cholesterol Levels As blood flows through the liver, special receptors on the surface of the liver cells remove some of the LDL cholesterol. These LDL receptors pull the cholesterol into the liver cells where it is changed into bile acids, which are eventually eliminated as waste. The more LDL receptors the liver has and the more active they are, the more LDL is removed from the blood and the lower the LDL cholesterol. The number of LDL receptors a person has is largely due to genetics. Some people are born without any liver receptors. They have very high cholesterol levels and may experience heart attacks at a very early age, even before their teens. The more dietary saturated and trans fat ( unhealthy fat) that is consumed, the less efficient the LDL receptors are at clearing LDL cholesterol. When the LDL receptors are less efficient, liver cells also start to make more cholesterol, which further increases the LDL cholesterol level. LDL is referred to as bad cholesterol because it causes atherosclerotic plaque to build up inside arteries and block the flow of blood. Having a high LDL cholesterol level increases the risk for heart attack, stroke and other types of ASCVD. HDL is referred to as good cholesterol because it acts as a kind of scouring pad to remove cholesterol from the walls of arteries. Having a high HDL cholesterol level reduces the risk for heart attack, stroke and other types of ASCVD. Triglycerides are fatty substances found in the bloodstream. Most of the body s fat is stored in the form of triglycerides for later use as energy. High triglycerides are associated with the buildup of blockages inside arteries. Extremely high triglycerides can also cause disease of the pancreas (i.e., acute pancreatitis). People with low LDL cholesterol, high HDL cholesterol, and low triglycerides may be at the lowest risk for ASCVD.

11 Knowledge Check Two People at the lowest risk for ASCVD have: A. Low LDL cholesterol, low triglycerides, and high HDL cholesterol. B. Low LDL cholesterol, high triglycerides, and high HDL cholesterol. C. Low LDL cholesterol, low triglycerides, and low HDL cholesterol. The correct answer is A. Major Factors Determining LDL Cholesterol Level Genetic Factors Lifestyle Factors Other Factors Number of LDL receptors present at birth Activity level of LDL receptors Amount of cholesterol produced by the liver Amount of saturated and trans fat ( unhealthy fat) consumed in the diet Amount of dietary cholesterol consumed in the diet Certain diseases, such as thyroid problems (i.e. hypothyroidism), liver disease, diabetes, and kidney disease Some medications, such as diuretics, betablockers, and steroids

12 Understand the Numbers Blood cholesterol levels should be measured in all adults. Understanding total blood cholesterol, LDL cholesterol, HDL cholesterol and triglyceride values is key to determining the risk for heart attack, stroke and other types of ASCVD. When interpreting blood test results, it is important to consider a variety of factors, including the following: To get an accurate reading of LDL cholesterol and triglycerides, the patient must fast for 8-12 hours before the blood sample is taken. Blood results can be inaccurate due to a number of different reasons, including the fact that cholesterol levels may be very inaccurate for several weeks after a heart attack, heart surgery, and acute illness or pregnancy. Looking at the total cholesterol number in isolation of other values can be misleading. A total blood cholesterol level under 200 mg/dl (or 5.2 mmol/l) is generally recommended. However, it is possible to have a normal total cholesterol level due to a high LDL cholesterol together with a low HDL cholesterol. But a high LDL and a low HDL are a bad combination and increase the risk for ASCVD. Note! It is also possible to have a high total cholesterol level due to a high HDL (good) cholesterol, which is desirable if the LDL (bad) cholesterol is low. Tests to Evaluate the Risk of ASCVD To evaluate the risk of ASCVD and whether a patient may benefit from cholesterol-lowering drug therapy, fasting cholesterol values (total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides) are needed, together with the following information: A past medical history: Including any cardiovascular disease and/or events and the presence of any vascular disease. Additional risk factors: Age, race/ethnicity, co-existing disease such as diabetes, cigarette smoking, and hypertension. Other lifestyle habits and medical conditions: May include any previous drug treatments and family history of high cholesterol, myocardial infarction, or strokes at an early age.

13 Results of Additional Tests If questions remain about the risk of ASCVD or whether the patient might benefit from cholesterol-lowering medication, additional tests may be necessary, including: Coronary artery calcium score (CAC): Shows the presence of plaque build-up in the coronary arteries. High-sensitivity C-Reactive Protein (CRP): Measures the amount of CRP; a marker of inflammation or irritation in the body (higher levels have been associated with an increased risk of heart attack and stroke). Ankle brachial index: Measures the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD or blockages in the arteries to the legs). Genetic or familial hypercholesterolemia: Presence of very high level of LDL cholesterol due to family history or genetics. Knowledge Check Three Which of the following diagnostic test is performed to confirm peripheral artery disease? A. Coronary artery calcium score (CAC) B. High-sensitivity C-Reactive Protein (CRP) C. Ankle brachial index The correct answer is ankle brachial index.

14 Optimal Numbers Generally, an optimal LDL cholesterol value is below 100 mg/dl (or 2.6 mmol/l); if a patient already has ASCVD, an optimal value may be below 70 mg/dl (or 1.8 mmol/l). Generally, HDL cholesterol should be 40 mg/dl (or 1.0 mmol/l) or higher in males and 50 mg/dl (or 1.3 mmol/l) or higher in females; optimal is 60 mg/dl (or 1.6 mmol/l) or higher for men and women. Generally, triglycerides should be below 150 mg/dl (or 1.7 mmol/l). For additional information on classification of cholesterol and triglyceride levels in adults, return to the Facts about the Liver and Cholesterol Levels section. Note! Whereas previous cholesterol-treatment guidelines focused on goal cholesterol levels, the November 2013 guidelines do not provide goal cholesterol levels. Rather, they focus primarily on identifying individuals who, in addition to practicing a heart-healthy lifestyle, can benefit most from treatment with a class of cholesterol-lowering drugs called statins. Knowledge Check Four An optimal LDL cholesterol value for a healthy individual is below 100 mg/dl (or 2.6 mmol/l). A. True B. False

15 The correct answer is true. Classification of Total Cholesterol, LDL Cholesterol, HDL Cholesterol, and Triglycerides in Adults The classification below is based on recommendations published by the National Heart, Lung and Blood Institute, American College of Cardiology and American Heart Association prior to the release of the November 2013 guidelines: Total Cholesterol (mg/dl) LDL Cholesterol (mg/dl) < Desirable Borderline high High < Optimal* Near optimal/above optimal Borderline high High Very high HDL Cholesterol (mg/dl) Triglycerides (mg/dl) Desirable for men Desirable for women Optimal < Normal Borderline high High Very high *<70 may be optimal in certain individuals with ASCVD

16 Foundation of a Healthy Lifestyle A healthy lifestyle is the foundation for cholesterol management and ASCVD risk reduction efforts. In order to reduce the risk of ASCVD, it is important for nurses to educate patients about the positive impact they can make on their health by making meaningful and sustained lifestyle changes. To help lower LDL cholesterol and/or keep it at a healthy level, patients should be advised to: Eat less saturated fat Eat less trans fats Eat less cholesterol Eat more fiber To increase HDL cholesterol and/or keep it at a healthy level, patients should be advised to: Exercise regularly Manage their weight Not use tobacco To lower triglycerides and/or keep them at a healthy level, patients should be advised to: Eat less saturated fat Eat fewer foods with added sugar Eat less refined carbohydrates Eat more omega-3 polyunsaturated fats Exercise regularly Manage their weight Drink alcohol only in moderation or not at all

17 Foundation of a Healthy Lifestyle The November 2013 guidelines emphasized that lifestyle modification (i.e., adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight) is a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol lowering drug therapies. Specific healthy diet and lifestyle modifications that were recommended to lower LDL cholesterol and/or increase HDL cholesterol include: Follow a meal plan that is rich in vegetables, fruits, and whole grains. Include low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts. Limit sweets, sugar-sweetened beverages, and red meats. Reduce saturated and trans fat (ideally saturated fat should be only 5-6% of total daily calories). Adapt the dietary recommendations to each patient s personal and cultural food preferences and other medical conditions to create healthy meal plans that are realistic and sustainable. Engage in aerobic physical activity 3-4 times a week with each session lasting an average of 40 minutes. Moderate (e.g., brisk walking or jogging) to vigorous (e.g., running) physical activity is recommended for most people. Note that the amount of physical activity recommended is congruent with the amount of physical activity recommended in 2008 by the Federal government for overall health, namely that most health benefits occur with at least 150 minutes (2 hours and 30 minutes) a week of moderate intensity physical activity, such as brisk walking. Don t smoke cigarettes. Note: Ideally, saturated fat should be only 5-6% of total daily calories.

18 Understanding the Role of Statin Therapy The expert panel that compiled the November 2013 guidelines found extensive and consistent evidence supporting the use of statins for the prevention of ASCVD in many higher risk primary and all secondary prevention individuals without NYHA class II-IV heart failure and who were not receiving hemodialysis. In view of this, the November 2013 guidelines focused primarily on identifying individuals who, in addition to a heart-healthy lifestyle, can benefit most from treatment with statins. Indications for Statin Therapy Four specific groups of adults appear to benefit most from taking moderate- or high-intensity statin therapy. Moderate-intensity means a statin dose that lowers LDL cholesterol on average by approximately 30-49%. High-intensity means a statin dose that lowers LDL cholesterol on average by 50% or more. The four groups are as follows: 1. Individuals with clinical ASCVD (and without NYHA class II-IV heart failure or receiving hemodialysis). 2. Individuals with primary elevation of LDL cholesterol to very high levels (i.e., 190 mg/dl or 4.9 mmol/l or higher). 3. Individuals years of age with diabetes and LDL cholesterol of mg/dl or mmol/l (without clinical ASCVD). 4. Individuals without clinical ASCVD or diabetes, who are years of age with LDL cholesterol of mg/dl or mmol/l and have an estimated ten year ASCVD risk of 7.5% or higher. Note! There is extensive and consistent evidence supporting the use of statins for the prevention of ASCVD in many higher risk primary and all secondary prevention individuals without NYHA class II-IV heart failure and who were not receiving hemodialysis.

19 Additional Factors Influencing Statin Therapy In addition to patients in the four abovementioned groups, in selected individuals, additional factors influencing ASCVD risk and potential ASCVD risk benefits and adverse effects should be considered together with drug-drug interactions and patient preferences for statin treatment. These additional factors include: Primary elevation of LDL cholesterol to 160 mg/dl (or 4.1 mmol/l) or higher or other evidence of genetic hyperlipidemias. Family history of premature ASCVD with onset before 55 years of age in a first degree male relative or before 65 years of age in a first degree female relative. High-sensitivity C-reactive protein of 2 mg/l (or 19 nmol/l) or higher. Abnormal results from other special tests (e.g., coronary artery calcium score or ankle brachial index). Elevated lifetime risk of ASCVD. Drug therapy should always be used along with lifestyle management.

20 Conclusion Nurses are health advocates. By understanding the dangers of hyperlipidemia you can counsel patients on the importance of modifying their lifestyle to improve health and wellness. In addition to counseling others, nurses should be aware of their own health risks for cardiovascular disease and take steps to improve their own health and wellness. Health Risk Assessment INTERVENT has partnered with RN.com to offer nurses a free, HIPAA compliant, confidential health risk assessment (HRA) and detailed personal report of your cardiovascular risks. Click here to complete a brief HRA.

21 References American Heart Association [AHA], (2013) ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Retrieved from: American Heart Association [AHA], (2013) ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Retrieved from: American Heart Association [AHA], (2013) AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Retrieved from: American Heart Association [AHA], (2014b). Hyperlipidemia. Retrieved from: CM_434965_Article.jsp INTERVENT Lifestyle Management Program, (2014). Understanding Cholesterol and Triglycerides. INTERVENT Lifestyle Management Program, (2014). Preventing and Managing High Cholesterol and Triglycerides. National Heart Lung & Blood Institute (2013a). Risk Assessment Tool for Estimating Your 10- year Risk of Having a Heart Attack. Retrieved from: National Heart Lung & Blood Institute (2013b). Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Retrieved from: