The
content of the Dermatology Series is provided by:
Dr. Chan Loi Yuen and Dr. Tang Yuk Ming, William
Specialist in Dermatology & Venereology
皮膚科病例研究之內容誠蒙陳來源醫生及鄧旭明醫生提供。
Online Clinical Case Study (February 2003)
A 40 year old 70 kg asymptomatic businessman has a routine fasting blood checkup revealing Total Cholesterol of 6.4 mmol/l and Triglyceride of 2.0 mmol/l; HDLC of 1.0 mmol/l; LDLC of 4.5mmol/l. He comes to your clinic for advice and requests drugs for treatment of his lipid disorders in order to prevent heart attack. His BP is normal and he is a smoker, and he never drinks alcohol.
The
content of the Office Cardiology Series is provided by:
Dr. Cham Kam Tim
M.B.,B.S.(H.K.), M.R.C.P.(U.K.), F.H.K.A.M., F.H.K.C.P, Specialist
in Cardiology
Dr. Wong Shou Pang, Alexander
F.R.C.P., F.H.K.A.M.(Med.), F.H.K.C.P., Specialist in Cardiology
Dr. Li Siu Lung, Steven
M.B.,B.S.(H.K.), M.R.C.P.(U.K.), F.H.K.A.M., F.H.K.C.P., F.R.C.P.(Glasg.),
Specialist in Cardiology
臨床心臟科個案研究之內容誠蒙陳鑑添醫生、王壽鵬醫生及李少隆醫生提供。
Answers
The NCEP (National Cholesterol Education Program) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) has published its latest guidelines recently. (JAMA; May; 2001; 285(19),2486-2497); http://nhlbi.nih.gov/guidelines/cholesterol. These guidelines provide a very comprehensive overview of lipid management in various patient subsets and serve as our excellent reference. However, it must be remembered that individual judgement for each particular patient must be exercised in our clinical setting.
The first patient is a case of PRIMARY prevention, which is frequently encountered by our family physicians. We need to assess the Absolute Global Risks for each patient and target our therapy to ALL remediable risks factors.
| 1. | What other major risk factors for coronary artery diseases will you need to assess? |
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Major CAD Risk Factors Exclusive of Elevated LDL-C:
NB. HDLC >= 1.55 mmol/l or 60mg/dL is a Negative risk factors and remove one risk factor from the total count. NB. In the ATP III Guidelines; DM is regarded as a CAD Risk Equivalent because it confers a high risk of new CHD within 10 years. Other CAD Equivalents include:
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| 2. |
What further blood tests will you perform for this gentleman? |
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We should recheck his full lipid profiles (TC, TG, HDLC, LDLC), FBS with a 12 hrs fasting period to reconfirm the blood test result. DM has also to be ruled out by checking the fasting sugar level. Appropriate blood tests to detect secondary causes will be required if clinically indicated. Secondary causes of dyslipidemia include Type II DM; Hypothyroid; obstructive liver diseases; renal diseases; alcoholism; drug induced - betablockers; steroids and etc. |
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| 3. | In the absence of all other risk factors, will you start drug therapy for him right away? If not, what is your plan for management? |
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No. As this is a case of primary prevention, there is no urgency to try pharmacological treatment. We should try therapeutic life styles changes (TLC) measures first. We can measure his BMI and try aggressive diet treatment therapy and exercise to maintain an ideal body wt. He must be advised to stop smoking and his lipid profile should be rechecked few months later. For patients with 0 to 1 other risk factors; lipid drugs can be started if LDLC >= 4.9 mmol/l or 190 mg/dL. The aim is to keep LDLC goal of < 4.1 mmol/l or 130 mg/dL either by lifestyles measures +/- drugs. For patients with 2+ risk factors, the LDLC should be kept < 3.4 mmol/l or 160 mg/dL. |
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| He also has a 43 year old male friend; a chronic smoker; who had a PTCA done for his IHD one year ago in the UK. He remained very well now and returned to HK and had a fasting TC of 6.5 mmol/l, TG of 1.5 mmol/l, HDLC of 0.9mmol/l . | |
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| 4. | What is his LDLC level? How would you manage this patient? |
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LDLC is approximately 4.9 mmol/l (Friedewald equation: LDLC = TC - HDLC - (TG/2.2) mmol/l; if TG < 4 mmol/l) This patient has definite evidence of IHD with intervention done; and he is warranted more aggressive treatment as compared with the first case (Secondary Prevention). Life styles modification measures should be instituted (smoking cessation; dietary measures; body wt control, etc.) and be reinforced serially. Probable secondary factors should also be checked and managed accordingly. It is also warranted to try drug treatment for his high LDLC level. Drug treatment is usually indicated if LDLC >= 3.4 mmol/l or 130 mg/dL with a target goal of < 2.6 mmol/l or 100 mg/dL. |
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| 5. | Will you start antihyperlipidemic drug treatment right away? And which drugs will you use? |
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Yes, a good choice will be the class of HMGCoA inhibitors that has been proven to improve mortality for secondary prevention cases. Fasting lipid levels can be rechecked 8-12 weeks later for readjustment of dose. The target LDLC level should be reduced to less than 2.6 mmol/l. We need to monitor the LFT and beware of side effects like myopathy. (AVOID drug interaction like HMGCoA and Fibrates; HMGCoA and Nicotinic acids which increase the chance of muscular side-effects.) In case of recurrent angina or difficulty in attaining the target treatment goal; it is strongly recommended to refer these patients for specialty care. |
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A 45 year old Chinese male presented with an asymptomatic rash on the dorsum of his left hand for six months. There were no precipitating factors such as insect bite, trauma or drug. He enjoyed good general health. Physical examination revealed a non-scaly erythematous annule with raised active border and central clearing. The lesion measured four cm in diameter. Examination was otherwise normal.
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