New guidelines recommend lipoprotein profiles for all cholesterol screenings
New guidelines recommend lipoprotein profiles for all cholesterol screenings
Accuracy key to patients’ health
There’s a hierarchy to good cholesterol screening based on the accuracy of measurement, says Russell Luepker, MD, MS, professor and head of the division of epidemiology at the school of public health at the University of Minnesota in Minneapolis.
A person is most likely to get an accurate measurement when a large medical or hospital laboratory is involved. The next best location is a physician’s office if there is a machine available for an accurate screening and good quality control is maintained. It is the most difficult to obtain quality control in field settings, such as shopping malls.
"What the Adult Treatment Panel (ATP) III recommended, the fasting screening, rarely occurs in field settings because most don’t schedule appointments and things like that," says Luepker, who was a member of the ATP III panel that recently revised the cholesterol guidelines for the National Choles-terol Education Program. The program is coordinated by the National Heart, Lung, and Blood Institute in Bethesda, MD. To do a complete lipoprotein profile, a person has to be fasting for nine to 12 hours in order to calculate low-density lipoprotein (LDL), or "bad cholesterol."
An alternative strategy recommended by the ATP III panel for a nonfasting patient is to measure total cholesterol and high-density lipoprotein (HDL) cholesterol. If people were above 200 mg/dL for total cholesterol and below 40 mg/dL for HDL cholesterol, then additional follow-up would be required, says Luepker.
A number of companies make small home devices to measure cholesterol, but experts find the results questionable because of the devices’ variability and their inability to provide accurate measurements. Another factor that impacts results is the skills of the person doing the self-test. It’s easy to make a mistake, says Luepker.
The trouble with many field settings and self-tests is that there is no connection for follow-up care. "A cholesterol level number in and of itself isn’t enough," says Luepker.
The guidelines the ATP III panel released in May advise healthy adults age 20 and older to have a lipoprotein profile once every five years. This profile measures levels of LDL, total cholesterol, HDL, and triglycerides.
The panel defines optimal LDL as 100 mg/dL and high LDL as 160-189 mg/dL and a desirable total cholesterol level as 200 mg/dL with 240 mg/dL as high. Low HDL now is defined as being less than 40 mg/dL; previously, it was defined as 35 mg/dL. An HDL level of 60 mg/dL or more is considered protective against heart disease because this lipoprotein helps remove cholesterol from the blood and prevent fatty buildup in the arteries.
May require additional testing
The new guidelines issued by the National Cholesterol Education Program will mean some revisions in the guidelines for public lipid testing and counseling created at Deborah Heart and Lung Center in Browns Mills, NJ.
"I will need to revise our guidelines to reflect the new recommendations about major risk factors and goals. Also, we will seriously consider testing for LDL cholesterol along with the other cholesterol levels since the initial approach is to lower LDL levels according to the risk category of the individual," says Nell Kapeghian, MSN, RN, patient care services programs director at Deborah.
For example, Deborah’s counseling guidelines recommend that people with high cholesterol reduce intake of saturated fat to less than 10% of total calories, while the new ATP III guidelines have lowered that figure to less than 7% of calories. Counselors also recommended that those at high risk for coronary events based on cholesterol levels reduce their daily cholesterol intake to no more than an average of 300 mg. The new guidelines, however, lowered that number to 200 mg a day.
Screenings planned with care
Deborah Heart and Lung Center does not often conduct public screenings because of the cost, which runs about $10 per person. When one is planned, however, cost vs. benefit to the hospital and the community is carefully scrutinized. The screenings Deborah does provide are very popular, says Kapeghian.
A pharmaceutical company funded one large screening Deborah conducted at the Philadelphia convention center at a three-day event called the NBC-10 Fit Fest. People registered on the day of the event and were given an appointment time; therefore, they were not required to fast, and only total cholesterol and HDL were measured. "We scheduled one person per phlebotomist every 15 minutes," says Kapeghian. They had two machines and two phlebotomists for the event.
The facility conducted a small screening at a local Spanish-speaking church, arranged as a thank-you to the minister who is on-call at Deborah for Spanish-speaking patients who ask to see a member of the clergy. People were not required to register in advance, but it was announced that those who intended to be tested should fast.
The third screening the Deborah Heart and Lung Center conducted was at a health fair on campus. "We did require that people call to register ahead of time and asked that they fast," says Kapeghian.
At all screening events, registered nurses are on hand to counsel participants. General written information about how to lower cholesterol is given to each participant while those with abnormal levels receive more specific information during the counseling time. "A short history is taken during the counseling after the testing for those who have abnormal results," says Kapeghian. This determines if other health factors put them at greater risk for a coronary event, such as lack of exercise, being overweight, diabetes, or high blood pressure.
The general message about cholesterol is relatively simple, says Luepker. "Cholesterol is involved in the disease process of heart attacks and strokes. The higher the blood cholesterol, the more likely you are to have those events," he says.
Everyone should be encouraged to eat a diet low in saturated fat with lots of fruits and vegetables, lean meat, fish, and poultry. However, the report from the expert panel recommends that people with elevated cholesterol eat a more therapeutic diet that rigorously restricts fat intake. If the more restrictive diet doesn’t have the desired effect after a few months, the report recommends placing the person on medications.
The new clinical practice guidelines on the prevention and management of high cholesterol in adults were developed because new and better research studies revealed that the old guidelines were outdated. "It is very clear that lowering cholesterol through drugs and/or diet for people who have had a heart attack already reduces future events and prolongs life. It also became apparent through a number of studies that the higher levels for treatment that were advocated in the previous report may not have been the best policy," says Luepker. The panel found that studies show lowering the LDL level can reduce the short-term risk for heart disease by as much as 40%.
The National Heart, Lung, and Blood Institute predicts that the new guidelines will expand the number of Americans being treated for high cholesterol. Dietary treatment should increase from 52 million to about 65 million, and those on cholesterol-lowering drugs should jump from 13 million to about 36 million.
"One of the messages of the new report is to treat more patients at lower levels to begin with than was recommended six or seven years ago because there are studies that show that it is beneficial," says Luepker. n
For more information about cholesterol screenings, contact:
• Nell Kapeghian, MSN, RN, Patient Care Services Programs Director, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ 08015. Telephone: (609) 893-1200, ext. 5258. E-mail: [email protected].
• Russell Luepker, MD, MS, Professor and Chairman, Division of Epidemiology, School of Public Health at the University of Minnesota in Minneapolis. E-mail: [email protected].
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