– VERY HIGH LDLs (190 mg / dl)
People with very high LDL usually have a genetic form of hypercholesterolemia: monogenic family hypercholesterolemia, familial defect of apolipoprotein B, and polygenic hypercholesterolemia. The early detection of these disorders by determining cholesterol in young adults is necessary to prevent premature coronary disease. Cholesterol testing in relatives is important to identify affected family members. These disorders often require a combination therapy (statin + bile acid sequestrant or ezetemiba and omega 3) to achieve an adequate reduction of LDLs.
– ELEVATED TRIGLYCERIDES
Recent meta-analyzes of several prospective studies indicate that elevated triglycerides are also an independent risk factor for coronary heart disease.
Factors that contribute to high triglycerides (higher than normal) in the general population include obesity and overweight, physical inactivity, smoking, excessive alcohol, a diet rich in carbohydrates (> 60% of calories), some diseases (type 2 diabetes, chronic renal failure, nephrotic syndrome), some drugs (corticosteroids, estrogens, high doses of b-blocking drugs), and genetic disorders (combined familial hyperlipidemia, familial hypertriglyceridemia, and familial dysbetalipoproteinemia).
In clinical practice, elevated plasma triglycerides are observed more frequently in people with the metabolic syndrome, although other secondary or genetic factors can also influence:
-Normal triglycerides: <150 mg / dL.
-Marginally elevated triglycerides: 150-199 mg / dL.
-High triglycerides: 200-499 mg / dL.
-Very high triglycerides: 500 mg / dL.
The finding that triglycerides are an independent risk factor for coronary disease suggests that some lipoproteins rich in triglycerides are atherogenic. The latter are partially degraded VLDLs, often called remnant lipoproteins. In clinical practice, VLDLs are the most easily determinable measure of atherogenic remnant lipoproteins.
The sum of LDLs + VLDLs (also called non-HDL cholesterol = total cholesterol – HDL cholesterol) is identified as a secondary treatment target in people with high triglycerides (200 mg / dL). The treatment strategy for elevated triglycerides depends on the causes of their elevation and their severity. For a person with high or marginally high triglycerides, the primary goal of treatment is to achieve the desirable values of the LDLs.
When triglycerides are marginally high (150-199 mg / dL), weight reduction and increased physical activity should be emphasized. For high triglycerides (200-499 mg / dL), non-HDL cholesterol becomes a secondary treatment target. Next to weight reduction and increased physical activity, drug treatment should be considered in people at high risk to achieve the desired levels of non-HDL cholesterol.
In some very rare cases, in which triglycerides are very high (500 mg / dl), the primary object of treatment should be the prevention of acute pancreatitis by reducing triglycerides. The treatment consists of a diet very low in fat (less than 15% of calories), reduced body weight, increased physical activity and a triglyceride reducing drug.
Cholesterol associated with HDL is a powerful predictor of coronary heart disease, it is defined categorically with low HLDs <40 mg / dL, an increase with respect to the values admitted in previous versions that were <35 mg / dL, some HDLs Lowers modify the objectives of LDL-reducing therapy and are used as a risk factor to estimate the risk of coronary heart disease in the following 10 years.
Low HDLs have several causes, many of which are associated with insulin resistance, that is, high triglycerides, overweight and obesity, physical inactivity and type 2 diabetes. Other associated causes are tobacco abuse, too much carbohydrate intake high (> 60% of calories) and some drugs (eg, b-blockers, anabolic steroids, progestins).
There are no drugs available that selectively increase HDLs, except the intake of omega 3 at high doses, 3 grs. once a day. Despite the above, attention should be paid to low HDLs and treatment, in all people with low HDLs, the primary objective of treatment are the LDLs, following the recommendations, indicated above to achieve this objective.
Secondly, once adequate LDLs have been achieved, attention should be focused on weight reduction and increased physical activity (particularly if the metabolic syndrome is present). When low HDLs are associated with high triglycerides (200 -499 mg / dL), the second priority is to achieve the appropriate levels of non-HDL cholesterol as indicated above.
Finally, if triglycerides are <200 mg / dL (low HDLs in isolation), the use of drugs that increase HDLs (fibrates or nicotinic acid, omega 3, ezetemiba) may be considered, even if only partially.
If you have suffered a previous infarction LDL-cholesterol, should always keep below 100mg / dl.In general, men have a higher risk of coronary heart disease than women. Middle-aged men in particular show a higher prevalence of the most important risk factors and have a greater predisposition towards abdominal obsesity and metabolic syndrome. A significant fraction of all infarcts occurs in middle-aged men. For these men, who have an appreciable risk of coronary heart disease, intensive reductive therapy of LDLs is necessary.
In women, the onset of coronary heart disease is delayed by 10-15 years compared to men. Thus, most heart attacks in women take place after 65 years of age. All risk factors contribute to coronary disease in women and more premature infarcts (<65 years) occur in those in which they show multiple risk factors and metabolic syndrome.
Contrary to the belief that women’s estrogens confer a protective effect against coronary disease, recent clinical studies on the prevention of coronary heart disease by hormone replacement therapy in post-menopausal women, raise serious doubts about this . By contrast, the favorable effects of statins in women show that cholesterol-lowering therapy is preferable to hormone replacement therapy.