2.16 Treatment for Elevated Cholesterol is now based on Patients AusCVD Risk

…. So the question is – do we treat Alf’s elevated cholesterol levels and if so, what are our agreed cholesterol lowering targets and how do we reduce his cholesterol and monitor progress?

Let’s leave the how and monitoring for a later section.  Let’s focus on the ‘do we treat’ and ‘what are the targets’ part of the problem.

The approach to cholesterol lowering is based on the individual’s CV risk

The risk of the individual patient developing cardiovascular disease in the next 5 years directs the therapeutic approach to the management of diabetes.   Adults without established cardiovascular disease who are 45 years or older (or 30 years or older if Aboriginal and Torres Strait Islander) should have their CV risk calculated.

Patients with established cardiovascular disease do not need their risk calculated as they are at high risk by virtue of having established CV disease. These people will benefit from an absolute risk reduction strategy as they will be in the high risk (or very high) category. Remember that we are providing secondary prevention in these patients and the associated treatment targets are often lower (more aggressive treatment) compared to primary prevention.

Back to primary prevention – CV risk in Australia is calculated using the AusCVDRisk tool. This tool considers:

• Age
• Gender
• Smoking status
• Cholesterol ratio
• Systolic blood pressure
• Diabetes
• Use of medication
• History of atrial fibrillation
• Socioeconomic status.

Presented as a 5-year risk as a percentage. It calculates the risk and stratifies the risk into 3 categories: high risk, intermediate risk and low risk.

Patients with a high risk of CV disease in the next 5 years

Based on Alf’s high risk of cardiovascular risk in the next 5 years (let’s assume 10%), he is at high risk of developing cardiovascular disease in the next 5 years.  Patients in the high risk group should be provided intensive lifestyle advice aimed at lowering cholesterol and blood pressure as well as pharmacotherapy for cholesterol and blood pressure.

Patients with an intermediate risk of CV disease in the next 5 years

Patients with an intermediate risk should be considered for reclassification as either low or high risk. If after consideration they remain at intermediate risk, they should be provided with intensive lifestyle advice and considered for pharmacotherapy considering overall CV risk, patient preferences and benefits and risks.

Patients with a low risk of CV disease in the next 5 years

Patients with elevated cholesterol with a low absolute risk of developing cardiovascular disease in the next 5 years should be provided lifestyle advice to reduce lipid levels naturally and repeat the lipids every 5 years. Lifestyle modifications known to reduce cholesterol include:

• Weight reduction – a 2.3kg loss in body weight can double the lipid lowering effect of dietary modification alone, it also reduces the rate of production of VLDL (and thus LDL), decrease triglyceride levels and slightly increase HDL cholesterol. The target BMI should be > 25.
• Dietary modification – intensive dietary intervention can decrease total cholesterol and LDL cholesterol by up to 30%. The general aim of dietary modification is to decrease the intake of saturated fat and cholesterol containing foods and increase the proportion of polyunsaturated and monounsaturated fat, consume moderate amounts of lean meats, fish, eggs, tofu, nuts and seeds, dairy such as milk, yoghurt and cheese, moderate amounts of fruit and a larger proportion of vegetables, legumes and beans and larger proportion of grains and cereals. Dietary modification can also enhance the effects of lipid lowering drugs. Visit the following link to review the Australian Guide to Healthy Eating.
• Alcohol reduction or elimination – there is a linear relationship between serum triglyceride levels and increased alcohol consumption.  The effect of alcohol upon HDL cholesterol is less certain with some patients experiencing an increase in HDL-C and some a reduction in HDL-C.
• Physical exercise – exercise elevates HDL-C levels
• Smoking cessation – smoking increases plasma cholesterol levels with an association between each cigarette and a subsequent increase in plasma cholesterol levels.