Case Study: Alf Landerman

Alf is a 55-year-old Indigenous man well known to you who presents for a well man check-up.  Alf works for the Cairns Airport as an air traffic controller.  He lives with his wife Cynthia and one child.

Patient: Alf Landerman, 55-year-old Indigenous male

Medical History:

• Quit smoking 5 years ago
• Systolic blood pressure: 145 mmHg
• Total cholesterol: 5.5 mmol/L
• HDL cholesterol: 1.2 mmol/L
• Currently takes ramipril 10mg OD in the morning for elevated blood pressure
• No history of atrial fibrillation (AF), diabetes, kidney disease, or familial hypercholesterolemia

Location: Cairns, QLD 4870

Alf has a intermediate risk of CVD in the next 5 years, but as he is an Indigenous man, his risk has been elevated by one category to high risk.

So, the question is – do we treat Alf’s elevated cholesterol levels? 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.

Targeting CVD risk assessment to recommended age groups enables people at high risk of CVD to be identified early before they develop overt disease.  This approach helps direct pharmacological strategies for intensive CVD risk factor management to people at high risk and diverts unnecessary interventions away from people at lower risk.  Cardiovascular disease (CVD) risk assessment and management in people without known CVD involves:

• identifying the appropriate people to be assessed;
• using the Australian cardiovascular disease risk calculator (Aus CVD Risk Calculator) to estimate their risk;
• identifying their risk category (see below);
• communicating their risk to them; and managing their risk.

Irrespective of the management approach, for example non-pharmacological (SNAP and weight management) approach, or drug and non-drug approach, we need a target in mind to aim for.  The information below provides targets for cholesterol levels based upon level of risk.

Now, understanding this, let’s reconsider Alf.  You will remember Alf’s CVD risk over the next 5 years was 10% (we elevated the category due to his Indigeneity).

If we consult the AusCVD risk guideline and look at the Overview of CVD risk management according to risk category, we would find the following information:

According to the treatment strategy, we would:

• Commence lifestyle changes PLUS
• Commence lipid lowering drug therapy.

We would target Alf’s cholesterol level to which of the following?  If we consider the information on target cholesterol levels, we would be aiming for the following cholesterol levels:

• LDL-C target: At least 50% reduction in LDL-C from baseline and less than 1.8 mmol/L, whichever is lowest
• non–HDL-C target: less than 2.6 mmol/L
• triglycerides target: less than 1.7 mmol/L

… remember, the relationship between cholesterol levels and CVD risk is continuous, that is the lower the cholesterol level, the lower the risk… so we try to get it to target level, but any progress towards that level is better than no progress at all.

📺 Watch video: Lipid targets. (1:34 min)