10. Coronary Artery Disease and Hyperlipidemia






I. Definition


A. Partial or complete blockage of the coronary arteries, usually as the result of atherosclerosis; coronary vasospasm is also a cause


II. Incidence/predisposing factors/risk factors


III. Laboratory/diagnostic testing



B. 12-lead ECG/stress testing


1. Controversy exists regarding screening of asymptomatic patients in terms of resting ECG or stress testing.


2. Studies have not shown significant differences between asymptomatic individuals with and without CAD.


C. Patients should be screened for hypertension every time they seek health care.


D. Pulse pressure


1. Recent studies have suggested that the higher the pulse pressure, the greater the risk for CAD.


2. Future studies are needed to quantify such findings.


E. Cholesterol screening that uses a fasting lipoprotein profile (total cholesterol, LDL, HDL, and triglyceride [TG] levels) should be employed for all adults beginning at age 20 and at least every 5 years thereafter in accordance with the National Cholesterol Education Program.



IV. Lifestyle changes to modify risk factors


A. Initiate therapeutic lifestyle changes (TLCs) if LDL is above goal.


1. TLC diet


a. Saturated fat less than 7% of calories


b. Cholesterol less than 200 mg/day


c. Consider increased viscous (soluble) fiber (10-25 g/day) and plant stanols/sterols (2 g/day) as therapeutic options to enhance LDL lowering.


2. Weight management


3. Increased physical activity


B. Smoking cessation



D. Control of diabetes, including metabolic syndrome


E. Stress management


F. Discontinuance of oral contraceptives for women at risk for CAD who are older than age 35; consider other means of birth control


G. Consider estrogen therapy, as indicated, for postmenopausal women.


H. Control of cholesterol through modifiable means or via pharmacologic therapy—See Section V, Management of high blood cholesterol in adults, which follows.


V. Management of high blood cholesterol in adults


A. Acquire a fasting lipoprotein profile after a 9- to 12-hour fast.




D. Determine the presence of major risk factors (other than LDL) that modify LDL goals:


1. Cigarette smoking


2. Hypertension (BP 140/90 mmHg or higher, or patient is on antihypertensive medication)


3. Low HDL (less than 40 mg/dl). Note: HDL of 60 mg/dl or greater counts as a “negative” risk factor; thus, its presence removes one risk factor from the total count.


4. Family history of premature CHD (CHD in male first-degree relative younger than age 55; CHD in female first-degree relative younger than age 65)


5. Age (men age 45 or older; women age 55 or older)


6. Note: In the Adult Treatment Panel (ATP) III national guidelines, diabetes is regarded as a CHD risk equivalent.


















































































































































































































































































































































































































































TABLE 10-1 Estimate of 10-year risk for coronary heart disease Framingham point scores
From National Institutes of Health, National Heart, Lung, and Blood Institute: Third Report of the National Cholesterol Education Program, Bethesda, Md, 2001, NIH. NIH Publication # 01-3670: www.nhlbi.nih.gov/guidelines/cholesterol/atp3xsum.pdf.© NIH2001
HDL, High-density lipoprotein.
Estimate of 10-Year Risk for Men Framingham Point Scores by Age Group
Age Points
20-34 −9
35-39 −4
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 11
70-74 12
75-79 13
Framingham Point Scores by Age Group and Total Cholesterol
Total cholesterol Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Less than 160 0 0 0 0 0
160-199 4 3 2 1 0
200-239 7 5 3 1 0
240-279 9 6 4 2 1
280+ 11 8 5 3 1
Framingham Point Scores by Age and Smoking Status

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0
Smoker 8 5 3 1 1
Framingham Point Scores by HDL Level
HDL Points
60+ − 1
50-59 0
40-49 1
Less than 40 2
Framingham Point Scores by Systolic Blood Pressure and Treatment Status
Systolic BP If untreated If treated
Less than 120 0 0
120-129 0 1
130-139 1 2
140-159 1 2
160+ 2 3
10-Year Risk by Total Framingham Point Scores
Point total 10-year risk
Less than 0 Less than 1%
0 1%
1 1%
2 1%
3 1%
4 1%
5 2%
6 2%
7 3%
8 4%
Point total 10-year risk
9 5%
10 6%
11 8%
12 10%
13 12%
14 16%
15 20%
16 25%
17 or more 30% or more
Estimate of 10-year Risk for Women Framingham Point Scores by Age Group
Age Points
20-34 −7
35-39 −3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
75-79 16
Framingham Point Scores by Age Group and Total Cholesterol
Total cholesterol Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Less than 160 0 0 0 0 0
160-199 4 3 2 1 1
200-239 8 6 4 2 1
240-279 11 8 5 3 2
280+ 13 10 7 4 2
Framingham Point Scores by Age and Smoking Status

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79
Nonsmoker 0 0 0 0 0
Smoker 9 7 4 2 1
Framingham Point Scores by HDL Level
HDL Points
60+ − 1
50-59 0
40-49 1
Framingham Point Scores by Systolic Blood Pressure and Treatment Status
Systolic BP If untreated If treated
Less than 40 2
Less than 120 0 0
120-129 1 3
130-139 2 4
140-159 3 5
160+ 4 6
10-Year Risk by Total Framingham Point Scores
Point total 10-year risk
Less than 9 Less than 1%
9 1%
10 1%
11 1%
12 1%
13 2%
14 2%
15 3%
16 4%
17 5%
18 6%
19 8%
20 11%
21 14%
22 17%
23 22%
24 27%
25 or more 30% or more

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Mar 3, 2017 | Posted by in NURSING | Comments Off on 10. Coronary Artery Disease and Hyperlipidemia

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