Hypocholesteremia And Nursing Care of Cardiovascular Risk Factors

Nursing Care for Hypocholesterimia 

Cardiovascular Risk Factors Hypercholesteremic, Diagnostic Findings, Framingham Projections10-year Scores, Assessment, Treatment

Cardiovascular Risk Factors Hypercholesteremic

    Coronary heart disease (CHD) is a major cause of morbidity and premature mortality in men and women in the United States, the industrialized world, and many developing countries. Atherosclerotic-CHD processes begin early in life and are influenced over time by the interaction of genetic and potentially modifiable environmental factors including health-related lifestyle behaviors. 

    Hypercholesterolemia, elevated serum total cholesterol (TC), is recognized as an independent risk factor for CHD. Low-density lipoprotein cholesterol (LDL-C), the major atherogenic lipoprotein, typically constitutes 60%-70% of serum TC and is the primary target of cholesterol-lowering therapy. 

    In 1988, based on available epidemiological and clinical data, the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) issued the first guidelines for identifying and managing hypercholesterolemia in adults. 

    Throughout the past 16 years, results of numerous randomized controlled trials confirmed that lowering LDL-C was important in primary and secondary prevention of CHD. The most recent revision of these guidelines (Executive Summary of the Third Report of the National Cholesterol Education treated.

Diagnostic Findings 

    ATP III (Adult Treatment Panel III) continues to define hypercholesterolemia as TC ≥ 240 mg/dl (6.21 mmol/L) for individuals 20 years of age and older; TC levels of 200-239 mg/dl are considered borderline high and < 200 mg/dl is considered desirable. 

    LDL-C levels are categorized as follows: very high (2190 mg/dl), high (160-189 mg/dl), borderline high (130-159 mg/dl), above optimal (100-129 mg/dl) , and optimal (<100 mg/dl). 

    Results of very recent clinical trials suggested that LDL-C lowering beyond 100 mg/dl in secondary prevention (after an acute coronary event) was associated with improved cardiovascular outcomes and raised questions regarding the currently established cut points for LDL-C (Cannon et al. ., 2004; Nissen et al., 2004; Topol, 2004). 

    The National Cholesterol Education Program (NCEP) has not revised the 1991 definitions and guidelines for management of hypercholesterolemia in children and adolescents in the United States; however, the American Heart Association's (AHA) recent guidelines for primary prevention are consistent with NCEP definitions: acceptable TC (< 170 mg/dl [4.4 mmol/L), borderline TC (170-199 mg/dl), elevated TC 2 200 mg/dl) ( Kavey et al., 2003). 

    Similar to adults, both lipid and nonlipid risk factors are addressed, LDL-C levels are targeted as the basis for treatment decisions, and TLC is the cornerstone of treatment. LDL-C levels s 110 mg/dl are considered acceptable for children and adolescents without comorbidities; LDL-C < 100 mg/dl is recommended for children and adolescents with diabetes. 

    ATP III recommends a fasting lipoprotein profile (TC, LDL-C, high-density lipoprotein cholesterol [HDL-C), and triglyceride) should be obtained once every 5 years in adults aged 20 years or older. A basic principle of prevention is emphasized throughout ATP III: the intensity of risk-reduction therapy should be adjusted to an individual's absolute risk.

Framingham Projections10-year Scores 

    The Framingham projections of 10-year absolute CHD risk ( i.e. ., the percent probability of having a CHD event in 10 years) are used to identify and risk-stratify individuals. 

    In addition to LDL-C, risk determinants include: presence or absence of CHD and other clinical forms of atherosclerotic disease, cigarette smoking, hypertension (blood pressure 2140/90 mm Hg or on antihypertensive medication), low HDL-C (< 40 mg /dl), family history of premature CHD, and age (men 2 45 years, women 2 55 years).

     The category of highest risk (10-year risk > 20%) includes CHD and CHD risk equivalents (other clinical forms of atherosclerotic disease, diabetes) has a goal of LDL-C defined as < 100 mg/dl. The intermediate risk category (10-year risk 20%) includes multiple (2+) risk factors and has goal LDL-C as 130 mg/dl; the lowest risk category (10-year risk < 10%) includes 0-1 risk factors with LCL-C goal of 160 mg/dl.

Assessment 

    Assessment and management of hypercholesterolemia and other lipid abnormalities is an important component of both individual/high risk and population-based approaches to CVD risk reduction. 

    Current evidence-based guidelines, including ATP III and the AHA primary prevention guidelines for children and youth, consider both lipid and non-lipid risk factors, target LDL-C in algorithms for assessment and treatment considerations, and emphasize TLC as the cornerstone of treatment . 

    Therapeutic regimens including pharmacotherapy and TLC are based on the individual's risk status; Treatment outcomes are optimized with case management by nurses within the context of a multidisciplinary team approach. 

    Directions for future research build on and extend current programs of nursing and multidisciplinary research focused on innovative models for primary and secondary prevention of CVD across the life span and with emphasis on both quality and cost as outcomes (Allen et al., 2002) . 

    In addition, current recommendations emphasize family-based approaches to CVD risk reduction; however, minimal data exist regarding strategies for effective implementation in clinical practice.

Treatment 

    The cornerstone of treatment for hypercholesterolemia and other lipid abnormalities is therapeutic lifestyle change (TLC) with emphasis on dietary modification, increased physical activity and normalization of body. weight. 

    Important components of the TLC diet are saturated fat (less than 7% of total calories), polyunsaturated fat (up to 10% of total calories) and monounsaturated fat (up to 20% of total calories). Less than 200 mg/ day of dietary cholesterol, 50-60% of total calories from carbohydrates and approximately 15% of total calories from protein are recommended. 

    Other key components of the TLC diet include viscous fiber, plant stanols/ sterols, and soy protein. Considerable variation in response to dietary modification has been observed in males and females across the life span. 

    Variations in serum TC, for example (ranging from 3% to 14%) are attributed to individual differences in biological mechanisms, baseline TC levels, nutrient composition of baseline diets, and adherence over time to the prescribed dietary regimen.

     The first priority of pharmacological therapy is to achieve the appropriate LDL-C goal (as defined by the individual's category of risk). ATP III recommends the use of HMG-CoA reductase inhibitors (statins) as first-line therapeutic agents. 

    In a meta-analysis of clinical trials, the average reduction in TC in over 30,000, middle-aged men followed for over 5 years was 20%, the average reduction in LDL-C was 28%, and the decline in triglyceride averaged 13%. (LaRosa, He, & Vupputuri , 1999). 

    Results of a very recent secondary prevention trial suggested that early and continued lowering of LDL-C with an intensive lipid-lowering (statin) regimen provides greater protection against death or major cardiovascular events than a standard regimen (Cannon et al., 2004). 

    Other pharmacological agents currently used in treatment of dyslipidemia in adults include bile-acid binding resins, niacin, and fibrates. Decisions to initiate LDL-C lowering drug therapy, the type and dosage of agent to be used, and the schedule for monitoring individual response to therapy are based on the individual's baseline risk status. 

    Normally, the patient's response is evaluated about 6 weeks after starting drug therapy. Relatedly, TLC continues through- out (and beyond) the duration of pharmacotherapy. 

    Consistent with recommendations of the 33rd Bethesda Conference on preventive cardiology ( Ockene , Hayman, Pasternak, Schron , & Dunbar-Jacob, 2002), ATP III identifies and targets adherence-enhancing interventions that consider the characteristics of the individual patient, the provider, and systems of health care delivery. 

    Case management by nurses within the context of multidisciplinary team approaches is considered an integral component of increasing adherence to therapeutic regimens for hypercholesterolemia and other lipid abnormalities.