Management of High  Blood Lipid Levels

The primary approach to prevention of heart disease through management of the
blood lipids is to address the problem of high cholesterol. We especially focus on
the LDL cholesterol because it is the most serious cause of premature heart
attacks. However, after cholesterol, the triglycerides also represent an important
risk factor for the later development of heart disease. Fortunately, there are very
effective ways to treat elevated levels of triglyceride. The first step is to
understand why it has happened. There are a few forms of inherited risk for high
triglycerides. At the present time, nothing can be done about this. In the distant
future, we might have the possibility of changing our genetic background but we
have to be realistic and do what is best for us today. In other words, whether the
high triglycerides are caused by an inherited problem or are due to your present
lifestyle, the treatment approach is going to be the same. For more than 95% of
patients, the serum triglyceride level is high because of some acquired problem.
For 80% of the people who live in America, a high triglyceride level is associated
with obesity, cigarette smoking, or both. Diabetes is associated with high
triglycerides especially when it is not well controlled. Other medical problems
that cause high triglyceride levels include nephrotic syndrome (a kidney disease
where protein is spilled into the urine), and low thyroid. Estrogen replacement
may be associated with fall in LDL-cholesterol and a rise in triglyceride. Some
patients who take Tamoxifen for breast cancer can have very high levels of
triglyceride. Sometimes medications cause the problem: the usual beta blockers
may cause the triglyceride levels to go up whereas the new beta blocker
carvedilol (Coreg) might lower it. Cortisone and prednisone cause high
triglyceride levels.

A major risk of high triglyceride levels is to develop pancreatitis. Three types of
patients are most likely to have this occur:
• The most common patient to develop pancreatitis from high triglyceride
levels is a poorly-controlled diabetic with a history of high triglyceride levels. In
this case the administration of insulin will rapidly lower the serum triglycerides.
• An alcoholic patient with high triglyceride levels.
• A non-diabetic, non-alcoholic, nonobese patient with diet- or druginduced

Treatment Recommendations:

The experts recommend that the treatment for high triglyceride levels be based
upon the lab test result.

• When triglycerides are borderline high (150-199 mg/dL) the emphasis is on
weight reduction and increased physical activity.
• When triglycerides are high (200- 499 mg/dL) we recommend a treatment of the
high level indirectly. That is, we calculate the non-HDL cholesterol by
subtracting it from the total cholesterol level.

First we treat the LDL cholesterol. The non-HDL cholesterol becomes a
secondary target of treatment after the LDL cholesterol has been treated first.
Drug therapy can be considered in high-risk patients, including those who have
had a heart attack, in order to reach the non-HDL cholesterol goal. These goals
may be achieved by intensifying the treatment with an LDL-cholesterol lowering
drug, by adding nicotinic acid, or a fibrate, such as Lopid. (The non-HDL
cholesterol is measured by taking the HDL cholesterol and subtracting it from the
total cholesterol result. This  value should be 30 points higher than the LDL-
cholesterol goal.) • When triglycerides are very high (greater than 500 mg/dL) the
initial goal is to prevent pancreatitis by quickly lowering the triglycerides with a
combination of nonpharmacologic therapy and a triglyceride-lowering drug such
as a fibrate or nicotinic acid. Once the triglycerides are below 500 mg/dL, the
LDL cholesterol goals should be addressed. Patients in this category MUST
absolutely avoid any alcohol consumption at all. In this setting, drinking alcohol
is like throwing gasoline on a fire.

Non-Pharmacologic Therapy:

High triglyceride levels are often caused by or made worse by secondary,
potentially correctable problems. Therefore, a nonpharmacologic approach is the
mainstay of treatment in all patients. For people who are overweight or obese,
weight loss is critical. Aerobic exercise is of major benefit. All patients should
avoid concentrated sugars, such as desserts, sweets and soda pop. As a
general rule, patients should avoid all foods that are high in calorie content and
low in nutrition value. For diabetic patients, strict control of blood sugar is the
first-line of therapy. To prevent heart problems, high blood pressure and smoking
have to be addressed. Alcohol abuse must be avoided because it can cause large
increases in triglyceride levels. This is a place where common sense is needed.
Regular intake of alcohol in low amounts helps protect against the development
of heart trouble, and is antiinflammatory. More than 14 drinks per week for men,
or more than 7 drinks per week for women puts a person at the threshold where
alcohol is no longer beneficial, and instead it has serious health problems. Fish
oil therapy is beneficial for patients with high triglyceride levels. Over-the
counter preparations are good. For patients with triglyceride levels above 300
mg/dL, the prescription form of Lovaza should be covered by the health care
insurance plan, and it is a superior form of treatment.

A Related Topic – Low HDL-Cholesterol

HDL-cholesterol abbreviated HDL-C is the good, protective cholesterol. It is an
antiinflammatory agent and an antioxidant. It removes cholesterol from the
peripheral blood vessels and sends the cholesterol to the liver, where it is then
excreted into the intestinal system. Low HDL-C is associated with metabolic
syndrome, which typically leads to the development of diabetes, and is also
associated with diabetes itself, overweight and obesity. Anotherxcause of low
HDL-C is elevation of the triglyceride levels. An increase in HDL-C by just 1
mg/dL is associated with a decrease in the chance of cardiovascular death of
almost 5%.  There are very few things that are effective in helping us to increase
this healthy form of cholesterol. Here is one clear-cut thing for low HDL-C.
Smoking causes low levels. Therefore, anyone who smokes and has a low HDL-C
should stop smoking completely. This is not rocket science! Medications have
been used to try to raise the HDL cholesterol but they may only increase the HDL-
C by 2-3 mg/dL. Recently a research study tested an investigational drug that
caused substantial increases in HDL-C, but unfortunately, that drug had a
prohibitive number of side effects, and it will never make it to market. As it turns
out, the best thing we can do to raise HDL cholesterol is to quit smoking
cigarettes, exercise and lose weight. Of course, these are the same things we
have just recommended as the means to lower triglyceride levels. As often
happens, elements of a healthy lifestyle have multiple benefits in a variety of
Heart Health for Women