SECTION 3 Preventive medicine and public health or diabetes mellitus. Achieving this target exercise, and smoking cessation) before prescribing a lipid Isually requires aggressive statin therapy along with good lowering medication, such as an HMG-CoA reductase diet and ise(see Table 17-1). inhibitor(statin drug). When CAD becomes symptomatic, lifestyle modifications and drug treatment(usually statins) TRIGLYCERIDE AND VERY-LOW-DENSITY LIPOPROTEIN LEVEL should be started as soon as possible. When statins are not well tolerated or do not achieve targeted lipid reductions on The VLDL level can be determined for most patients by their own, newer drugs, such as ezetimibe, are available dividing the triglyceride(TG) level by 5. The desired TG level Although newer drugs may improve lipid numbers, however, is less than 150 mg/dL. Although levels greater than 200 mg/ as yet there is no good evidence that these improve patient dL were previously considered reasons for concern and treat outcomes, such as preventing heart attacks and strokes or ment,the clinical perspective on TG levels is evolving. Some delaying death experts believe that treating high tG levels may not be helpful in mitigating the risk of cardiovascular disease, and C. Hypertension >500 mg/dL)to reduce the risk of pancreatitis In the United States, 43 million to 50 million people are estimated to have hypertension, and approximately half have TOTAL CHOLESTEROL-TO-HIGH-DENSITY LIPOPROTEIN RATIO not yet been diagnosed. Groups at increased risk include pregnant women, women taking estrogens or oral contra Some investigators monitor the TC/HDL ratio. Using this ceptives, elderly persons, and African Americans. Children approach, one group reported that angiograms in patients also are at risk for hypertension ith a TC/HDL ratio greater than 6.9 showed progression of The Joint National Committee on Prevention, Detection coronary atherosclerosis during the study, whereas those in ivaluation, and Treatment of High Blood Pressure (NC) patients with a lower TC/HDL ratio did not show progres- convened by the National Heart, Lung, and Blood Institute n.Currently, a TC/HDL ratio of less than 4.5 is recom- It publishes period reports addressing the diagnosis, treat mended if atherosclerotic disease is absent, and a ratio of less ment, and prevention of hypertension. According to the than 3.5 is recommended if atherosclerotic disease is present. Seventh Joint National Committee Report (NC 7), hyper- tension is defined as an average systolic BP of 140 mm Hg or TRIGLYCERIDE-HIGH-DENSITY LIPOPROTEIN RELATIONSHIP greater, or an average diastolic BP of 90 mm Hg or greater, when blood pressure is properly measured on two or more Research suggests that the combination of an HDL level less occasions in a person who is not acutely ill and not taking than 30 mg/dL and a TG level greater than 200 mg/dL places antihypertensive medications. These levels are high enough an individual at high risk for CAD, and the possibility of for treatment to bring proven benefits. New recommenda- genetic hyperlipidemia should be considered. This pattern is tions from JNC 8 are expected in 2012 often associated with insulin resistance and hypertensi sometimes referred to as the metabolic syndrome. This adverse pattern, as noted earlier, may be concealed by a normal"total cholesterol level. This is one reason why lipid Hypertension may be detected by community or occupa screening should generally include the standard panel rather tional screening, by individual case finding (e.g., when a than total cholesterol alone person seeks care for dental problems or for medical prob ems unrelated to hypertension), or when a person develops HOMOCYSTEINE LEVEL one or more common complications of hypertension, such as visual problems, early renal failure, congestive heart Elevated homocysteine levels are associated with an increased failure, stroke, or MI. Over the last 20 years, the risk of mor risk of atherogenesis. Thus far, however, interventions tality from CAD and stroke in hypertensive individuals has through dietary supplements of folic acid, pyridoxine, or decreased, in part because of the early detection and vitamin B,2 have not shown improved outcomes. Some improved management of high blood pressure. However, believe that homocysteine is merely a marker for the true" much still remains to be done Only slightly more than one culprit. Likewise, all the lipid fractions, lipoprotein particles, third of patients with hypertension are"well controlled and indices previously discussed may actually be markers of (up from 29% in 2000). This fact underscores how the true culprits; none is consistently explanatory, and lives could be saved and how much disability could be improving the patient's numbers, even for the most explan vented if we were better at delivering consistent car patien mponents, does not consistently lead to improved Chapter 28) Table 17-2 provides information regarding the evaluation and staging of hypertension, based on average systolic BP 2. Therapy and Symptomatic Stage Prevention and diastolic BP. In addition to listing the ranges for normal BP and prehypertension, Table 17-2 shows the ranges for two Any primary care clinician should be able to treat patients stages of hypertension with a moderately elevated total cholesterol level or abnor ma! lipid levels and should be aware of the therapeutic 2. Therapy and Symptomatic Stage Prevention probably should be treated by specialists, however. In the After the stage of nyp following actions(see also Table pertension has been determined primary prevention of CAD, clinicians should recommend a JNC 7 recommends trial of lifestyle modifications(dietary changes, increased 17-2). Individuals with normal blood pressure should be