Lipid Status

• Cholesterol levels should be less than 200 mg/dL, triglycerides less than 150 mg/dL, LDL less than 70 mg/dL or 100 mg/dL depending on your condition.

HDL should be greater than 50 mg/dL for women and greater than 40 mg/dL for men.

Find out if you need a Statin, Fibrate, or Cholesterol Absorption Inhibitor, Bile Acid Binding Resin, HDL raising medication (Niaspan).

• If your triglycerides are elevated, you should check with your doctor about the best lipid lowering agent for you. That could be a Fibrate, Lovaza (omega-3 acid ethyl esters) or Niaspan.

• Ask your doctor if you are a candidate for supplementation with omega 3 fatty acids (DHA & EPA).

• Lovaza (omega-3 acid ethyl esters) is a FDA approved omega 3 fatty acid product. Over the counter products are also available.

1 capsule of over the counter fish oil is equivalent to 300mg of EPA & DHA.

1 gram of a Lovaza (omega-3 acid ethyl esters) capsule has 840 mg of EPA and DHA.

• If you do not have coronary artery disease, you could benefit from 1-2 capsules of fish oil or 1 tablet of Lovaza a day (at least 500 mg of omega 3 fatty acids daily).
• If you do have coronary artery disease, you would benefit from 3-4 capsules of fish oil or 1-2 capsules of Lovaza a day (at least 1 gm of omega 3 fatty acids daily).

A serving of one oily fish per week may reduce cardiovascular risk by 15% in those individuals who never had a cardiac event.

Elevated LDL cholesterol is still the primary target for lipid lowering therapy. LDL cholesterol should be less than 100 mg/dL or less than 70 mg/dL in high risk individuals.

Triglyceride levels should be less than 150 mg/dL.

According to the American Heart Association Guidelines, if triglycerides are 200-499 mg/dL, non HDL goal should be less than 130 mg/dL.

If triglycerides are greater than 500 mg/dL, lowering triglycerides is the primary target.

(Buse JB, et al. Diabetes Care.2007; 30:162-172.)

HDL has been proposed to be a tertiary target after LDL goals (less than 100 mg/dL or 70 mg/dL) and triglyceride goals (less than 150 mg/dL) have been met. HDL levels should be greater than 40 mg/dL in men and greater than 50 mg/dL in women.

The American Heart Association proposes that HDL be a secondary target along with triglycerides with a goal of HDL levels being similar to that proposed by the American Heart Association.

Lowering LDL cholesterol using statins have shown 20-40% risk reduction for coronary heart disease.

In individuals with diabetes, controlling lipids leads to 36-44% risk reduction for CHD events (CARDS, CARE/LIPID, 4S)
Controlling lipids leads to 25-48% risk reduction for strokes (CARDS, 4S, HPS)

For every 10 mg/dL decrease in serum triglyceride level there was 1.4% decrease in the incidence of death, myocardial infarction, and recurrent acute coronary syndrome.

The lowest CHD risk was observed in the cohort with triglycerides less than 150 mg/dL and LDL cholesterol less than 70 mg/dL.

These individuals were on Pravastatin or Atorvastatin in the evaluation and infection therapy-thrombolysis in myocardial infarction study.

(Impact of Triglyceride Levels Beyond LDL Cholesterol After Acute Coronary Syndrome in the PROVE IT-TIMI 22 Trial Miller M. et al. Journal of American College of Cardiology 2008 Feb. 19;51(7)[724-730])

Every 1 mg/dL increase in HDL is associated with a 2-4% decrease in residual risk for coronary heart disease.
(Brown BG et. al. New England Journal Med. 2001;345:1583-1592)

Individuals with HDL cholesterol of less than 35 mg/dL had an 8-fold higher incidence of cardiovascular disease compared to those with HDL greater then 65 mg/dL.

(High Density Lipoprotein As A Therapeutic Target)

• 3 kg (about 6.7 lb) weight loss may lead to 1 mg/dL increase in HDL cholesterol.
• Diet rich in mono and poly unsaturated fatty acids may lead to 5% increase in HDL cholesterol.
• Tobacco cessation may lead to 5-10% increase in HDL cholesterol.
• Aerobic exercise may lead to 5-10% increase in HDL cholesterol.

The GISSI trial has shown that 4 months treatment with Omega 3 Fatty Acids (1 capsule a day with 850 mg of DHA and EPA) reduced sudden cardiac death by 45% and risk of death from any cause by 28%.

The JELIS study using a statin and EPA (1.8 gm per day) showed a 19 % reduction in cardiovascular events in those individuals with previous underlying coronary artery disease.

In the above two studies, individuals were maintained on statins, aspirin, beta blockers and angiotensin converting enzyme inhibitors.

(Review: Omega-3 Fatty Acids for Cardio protection. John H Lee et al. Mayo Clinic Proceedings: 2008;83: 324-332)