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Primary Care Approach to Dyslipidemia David Thom, MD, PhD Associate Professor Family Community Medicine

2. Overview. Introduction Epidemiology Definitions Pathophysiology Screening Treatment. . 3. Introduction: Goals of screening and Treatment. Primary and secondary prevention of cardiovascular events CHD (MI, SCD, revascularization, angina) Stroke PVD Renal disease Maintain/improve

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Primary Care Approach to Dyslipidemia David Thom, MD, PhD Associate Professor Family Community Medicine

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    1. 1 Primary Care Approach to Dyslipidemia David Thom, MD, PhD Associate Professor Family & Community Medicine

    2. 2 Overview

    3. 3 Introduction: Goals of screening and Treatment

    4. 4 Introduction: Principals of Risk Factor Reduction

    5. 5 Epidemiology of CHD ..

    6. 6

    7. 7 Epidemiology of CHD: Fixed Risk Factors

    8. 8 Epidemiology of CHD: Modifiable, Established Risk Factors

    9. 9 Epidemiology of CHD: Modifiable, Possible Risk Factors ..

    10. 10 Figure 2. Cumulative Incidence of Recurrent Myocardial Infarction or Death from Coronary Causes, According to Whether the Achieved LDL Cholesterol or CRP Levels Were above or below the Median. The approximate median value of LDL cholesterol was 70 mg per deciliter (1.8 mmol per liter), and the median value of CRP was 2 mg per liter. The median value of each marker is included for the sake of completeness, since no patient had the exact median value of either marker.Figure 2. Cumulative Incidence of Recurrent Myocardial Infarction or Death from Coronary Causes, According to Whether the Achieved LDL Cholesterol or CRP Levels Were above or below the Median. The approximate median value of LDL cholesterol was 70 mg per deciliter (1.8 mmol per liter), and the median value of CRP was 2 mg per liter. The median value of each marker is included for the sake of completeness, since no patient had the exact median value of either marker.

    11. 11 Figure 3. Cumulative Incidence of Recurrent Myocardial Infarction or Death from Coronary Causes, According to the Achieved Levels of Both LDL Cholesterol and CRP. The median value of each marker is included for the sake of completeness, since no patient had the exact median value of either marker.Figure 3. Cumulative Incidence of Recurrent Myocardial Infarction or Death from Coronary Causes, According to the Achieved Levels of Both LDL Cholesterol and CRP. The median value of each marker is included for the sake of completeness, since no patient had the exact median value of either marker.

    12. 12 Figure 3. Cumulative Incidence of Recurrent Myocardial Infarction or Death from Coronary Causes, According to the Achieved Levels of Both LDL Cholesterol and CRP. The median value of each marker is included for the sake of completeness, since no patient had the exact median value of either marker.Figure 3. Cumulative Incidence of Recurrent Myocardial Infarction or Death from Coronary Causes, According to the Achieved Levels of Both LDL Cholesterol and CRP. The median value of each marker is included for the sake of completeness, since no patient had the exact median value of either marker.

    13. 13 Epidemiology of CHD: Established Lipid Risk Factors

    14. 14 Epidemiology: Possible Lipid Risk Factors

    15. 15 Measurement of Lipid Types ..

    16. 16 Pathophysiology: Medical Conditions Associated with Dyslipidemia

    17. 17 Pathophysiology: Role of Oxidized LDL in Atherosclerosis

    18. 18 Screening The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.

    19. 19 Screening

    20. 20 Treatment: General Principals The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.

    21. 21

    22. 22

    23. 23 Treatment: Rules to Remember The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.

    24. 24 Treatment: Rules to Remember The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.

    25. 25 Treatment: Target levels1 ..

    26. 26 Treatment: Target levels (see figure)

    27. 27 Treatment: Diet and Exercise

    28. 28 Treatment: Diet and Exercise

    29. 29 Treatment: Statins The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.

    30. 30 Treatment: Statins The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.The Diagnostic and Statistics Manual of Mental Disorders or DSM defines 3 major categories of depression. We will be discussing the first, Major Depression. We will not include bipolar disorder, which requires a diagnosis of both major depression and mania, and which has a different epidemiology and treatment profile. We will also not discuss what is commonly termed Minor Depression – which, by the way, is not necessarily minor in terms of it’s impact on patients’ lives. In practice, however, many of the same drugs approved to treat major depression are also used to treat minor depression. The third category, dysthymia, is often thought of as a chronic, low level depression. It is thought to be more closely linked to personality and is generally less responsive to pharmacologic treatment.

    31. 31 Treatment: Statins - Choosing

    32. 32 Comparison of Statins1 ..

    33. 33 Treatment: Side Effects of Statins ..

    34. 34 Treatment: Side Effects of Statins ..

    35. 35 Treatment: Fibrates

    36. 36 Treatment: Nicotinic Acid (Niacin)

    37. 37 Treatment: Other Medications

    38. 38 Comparison of Other Lipid-Lowering Drugs1 ..

    39. 39 Treatment: Other – 3-omega acids

    40. 40 Treatment: Other – Red Yeast Rice

    41. 41 Treatment: Other –Soy

    42. 42 Figure 1. Net Changes in Serum LDL Cholesterol Concentrations in 31 Clinical Trials of the Effects of Soy Protein on Serum Lipids. These 31 trials presented data on LDL cholesterol for a total of 564 subjects. The values shown are the mean changes in LDL cholesterol concentrations while subjects received the diet containing soy protein minus the changes during the control diet, with 95 percent confidence intervals. A and B indicate separate studies reported in a single published article, listed here in the same order as in Table 1. To convert values to millimoles per liter, multiply by 0.02586.Figure 1. Net Changes in Serum LDL Cholesterol Concentrations in 31 Clinical Trials of the Effects of Soy Protein on Serum Lipids. These 31 trials presented data on LDL cholesterol for a total of 564 subjects. The values shown are the mean changes in LDL cholesterol concentrations while subjects received the diet containing soy protein minus the changes during the control diet, with 95 percent confidence intervals. A and B indicate separate studies reported in a single published article, listed here in the same order as in Table 1. To convert values to millimoles per liter, multiply by 0.02586.

    43. 43 Treatment: Other – Garlic ..

    44. 44 Treatment: Other – Barley Bran and Oil

    45. 45 Treatment: Special Groups

    46. 46 Treatment: Special Groups

    47. 47 Treatment: Special Groups treatment.treatment.

    48. 48 Treatment: Adherence

    49. 49 Treatment: Improving adherence

    50. 50 Treatment: Cultural aspects

    51. 51 Treatment: Cultural aspects ..

    52. 52 Treatment: Monitoring

    53. 53 Summary

    54. 54 References

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