Hyperlipidemia Management in the Retail Clinic

December 8th 2016

High cholesterol is significant risk factor for cardiovascular disease, along with high blood pressure and smoking.

High cholesterol is significant risk factor for cardiovascular disease, along with high blood pressure and smoking. Each is modifiable, and with adequate treatment, the risk of cardiovascular morbidity and mortality improves.

One in every 4 deaths in the United States today is from cardiovascular disease, and more than 610,000 individuals per year in the United States die from cardiovascular disease, according to the CDC. In addition, coronary heart disease kills more than 370,000 yearly in the United States, with male deaths predominating. Heart attacks also are experienced by 735,000 American annually, and one-third of those have had a prior heart attack.1

The retail health clinic setting provides a unique opportunity to identify patients with hyperlipidemia and related cardiovascular risk factors. Major impacts can be made through early identification of risk factors and individualized counseling. Hyperlipidemia is an elevation of total cholesterol (TC) or non—high-density-lipoprotein (HDL) cholesterol (TC minus HDL-cholesterol). The newer classification system of dyslipidemia incorporates the role of decreased HDL cholesterol, or isolated hypertriglyceridemia, as pathogenic. Other classifications include mixed or combined dyslipidemia in TC or low-density-lipoprotein (LDL) cholesterol and in triglycerides.

Low levels of HDL cholesterol can be caused by abdominal obesity with insulin resistance, elevated triglycerides, smoking, or genetic factors. The closely interwoven lifestyle elements of sedentary behaviors and high dietary intake of saturated or trans fats are the most often seen secondary causes. Medical condition causes include diabetes, hypothyroidism, renal disease, or liver disease. Medications, too, can alter lipid profiles (eg, some beta-blockers, thiazide diuretics, oral estrogens, atypical antipsychotics, and glucocorticoids).

Abnormal lipid metabolism, primar- ily of LDL cholesterol, contributes to the development of hypercholesterolemia because it’s the major risk factor for the development of atherosclerosis. Dietary excesses of trans fat or saturated fat trigger familial hypercholesterolemia. Other types of familial combined or dyslipidemia states may trigger increased liver very-low-density lipoprotein production in insulin-resistant states of abdominal obesity or type 2 diabetes.

It is currently thought that atherosclerosis develops as apolipoproteins are deposited in the subendothelial space. Reactive oxygen species modify the surface phospholipids and nonesterified cholesterol of the small LDL particle. Macrophages, through scavenger receptors, take up circulating LDL particles. Isoprostanes form as a result of LDL oxidation, a product of arachidonic acid. Isoprostane levels are elevated in atherosclerotic lesions. Elevated plasma levels of oxidized LDL have a strong association with coronary heart disease (CHD). There are multiple pathways that oxidize LDL, promote atherosclerosis and damage the endothelium, induce growth factors, and recruit macrophages and monocytes. Vasoconstriction, with the high levels of oxidized LDL, lowers the release of vasodilator nitric oxide from damaged endothelial walls and raises platelet aggregation and thromboxane release. Smooth muscle then proliferates.

The hypercholesterolemia increase of oxidized LDL cholesterol within macrophages becomes foam cells. The rupture of this cell type leads to further damage of the blood vessel walls with the release of the oxygen free radicles, oxidized LDL, and intracellular enzymes. The Clinical Laboratory Improvement Amendments waived point-of-care devices used in the biometric screening; they are not diag- nostic instruments and do not constitute a complete evaluation. With high risk identified, referral for diagnostic laboratory evaluation is indicated. A physical exam may show signs of hypercholesterolemia, like arcus cornea, xanthomas, or eyelid xanthelasmas. Additional testing may include thyroid, renal, cardiac, and diabetes investigations.

Lifestyle changes are the first-line therapy for lipid management. Attention to body mass index (BMI), with the goal of less than 25%, is recommended through dietary modification and weight loss as indicated, smoking cessation, and exercise. Oral statin therapy may be prescribed to attain goals. When indicated, niacin, cholesterol absorption inhibitors, or bile acid sequestrants may be added.

Hyperlipidemia Case Study

John, a 41-year-old African American man, presents at the retail clinic with a promotion voucher for a biometric screening. He relates that he is in good health and needs his cholesterol testing done to reduce his monthly insurance rates. He reports that he has never had his cholesterol checked. However, although his health history is unremark- able, his family history notes cardiac deaths generally in males younger than age 55. He does some exercise, “shoot- ing hoops” on the weekends; drinks 3 to 5 beers a week; and smokes part of a cigar 2 to 3 times a year.

DISCUSSION QUESTION:What additional information would you want to know about John’s health history?

ANSWER:Clarification of the family his- tory of cardiac events is most import- ant for first-degree relatives (ie, parents or siblings). It is worth noting that this profile reports his medical history for cholesterol or diabetes and his history of smoking, exercise pattern, and med- ication use.

DISCUSSION QUESTION:What constitutes biometric risk factor evaluation?

ANSWER:Lipid measurement, prefer- ably fasting of the TC, LDL either by estimated or direct, triglycerides, HDL cholesterol, and non—HDL cholesterol. Other portions of a biometric evalu- ation often include fasting glucose, height, weight, BMI, girth measure- ment at the umbilicus, and resting blood pressure and heart rates.

John’s screening shows the following:

• resting blood pressure of 130/80 mm Hg

• pulse of 87

• height of 71 inches

• weight of 196 lb, girth of 38 inches

• BMI of 27.3%

• fasting TC of 242

• LDL cholesterol of 253, triglycerides of 275

• HDL cholesterol of 42

• non—HDL cholesterol of 200

• glucose of 99

DISCUSSION QUESTION:What is your initial diagnosis for John’s presentation?

ANSWER:Overweight, with a BMI of 27.3%, and dyslipidemia are diagnosed. The fasting glucose is at the upper limit of normal.

DISCUSSION QUESTION:What key messages would you share with John regarding his efforts to modify his hyperlipidemia and lifestyle risk factors?

ANSWER:Review his findings with him and compare those findings with established goals in all areas. Reflective listening techniques promote John’s ownership of his present health status. After reviewing strategies he’s tried in the past, fostering his selection and commitment toward personal goals for dietary modification, increasing exercise, and not smoking the occasional cigar, John relates that he will grill food more often, eat more nonfried vegetables, and lose 10 pounds in the next 6 months. He committed to adding a 20-minute treadmill run at the gym 2 times each week. He has also agreed to follow up with his family’s primary care physician for additional evaluation.

Summary

Because there is a strong link between hyperlipidemia and the development of CHD, screening for hyperlipidemia in the retail clinic is an opportunity for significant health promotion. Lowering of LDL cholesterol in moderate- and high-risk patients leads to a reduction of cardiovascular events. Screening is recommended to begin at age 20, with no upper age limit identified. Fasting lipid panels every 5 years, along with screening for cardiovascular risk factors of hypertension, diabetes, obesity, smoking, and premature cardiovascular disease in first-degree relatives younger than 55 years is helpful. Lipid screening includes TC, non—HDL cholesterol, and HDL cholesterol with risk factor assessment. With the identification of personal risk, appropriate primary prevention strategies and, when indicated, appropriate referral for treatment may be initiated. Special opportunity exists in the retail clinic for individuals, and families often come together for their biometric screening to promote healthier lifestyles for all affected family members.

Recommended Reading

Raal FJ, Santos RD. Homozygous familial hypercholesterolemia: current perspectives on diagnosis and treatment.Atherosclerosis. 2012;232(2):262- 268 doi: 10.1016/j.atherosclerosis.2012. 02.019. American College of Cardiology/ American Heart Association. ASC- VD risk estimator. ACC website. tools .acc.org/ASCVD-Risk-Estimator/. Accessed October 15, 2016.

Marjorie Rachide, FNP-BC, MSN, is a Clinic Manager, Atlanta, GA, Market with The Health Care Clinics at Walgreens. She is a graduate of East Carolina University, Greenville, NC.

Reference:

1. CDC. Heart disease facts. CDC web- site. cdc.gov/heartdisease/facts.htm. Accessed October 2, 2016.

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