ESTUDIO PANORÁMICO DE VIGILANCIA TECNOLÓGICA E INTELIGENCIA COMPETITIVA ALIMENTOS FUNCIONALES El contenido de la presente publicación es responsabilidad de sus autores… In NHANES III, 39% of women and 22% of men aged 65 to 74 years had a total cholesterol concentration above 240 mg/dL. Genetic studies indicate that Lp(a) concentration is highly heritable, and one study estimated that 98% of the variance in Lp(a) concentration could be explained by the Apolipoprotein (a) locus. In older Finnish men (mean age at entry 72 years), the death rate from CHD over 5 years of follow-up of men with the 4 allele was double that of men with the other apo E genotypes. A low-cholesterol diet had no effect on cardiovascular or overall mortality among a broad group of institutionalized individuals. Schematic overview of the Apo B containing lipoproteins. Heart Disease and Stroke Statistics—2007 Update. ISSN 2708-5546 www.revgacetaestudiantil.sld.cu 185 Los artículos de Gaceta Médica Estudiantil de la Universidad de Ciencias Médicas Guantánamo se comparten Physical findings directly related to dyslipidemia are relatively infrequent in elderly patients and include the development of yellowish nodules of fat, xanthomas or xanthelasmas, in the skin beneath eyes (xanthelamas palpebrarum), or overlying elbows, knees, and tendons. As a result, Lp(a) concentration is essentially constant across the life span. In the Framingham Offspring Study, apo E4 was a determinant of CHD risk independent of age, sex, hypertension, cigarette use, obesity, diabetes, or the concentrations of LDL-C and HDL-C. As obesity approaches epidemic proportions in western society, the prevalence of T2DM will likely increase proportionately. 128.199.151.20 Familial hypercholesterolemia is a genetic disorder caused by a defect on LDLR gene (chromosome 19), that encodes the LDL receptor protein, which normally removes LDL from the circulation The defect makes the body unable to remove low density lipoprotein (LDL, or "bad") cholesterol from the blood. For those aged 80 years and older, 33% of men and 22% of women have prevalent CHD. These lipoprotein particles contain TG, cholesterol, cholesterol esters, phospholipids, and apolipoproteins (apo). These dyslipidemic syndromes include the apoE4 genotype, elevated levels of Lp(a), and the atherogenic LDL pattern B phenotype. Among the subjects with diabetes, TG concentration was higher but HDL-C concentration did not differ across insulin quartiles; however, total and LDL-C concentrations were lower and white blood cell count higher in women with diabetes with high insulin concentrations. The decrease was greatest (approximately 13%) for people aged 70 years and older and least pronounced (approximately 7%) for the 20-to-39-year age range. Glucocorticoids raise HDL-C, TG, and LDL-C. Retinoids increase TG and LDL-C and also reduce HDL-C. Interferons can cause hypertriglyceridemia. Hepatic lipase stimulates HDL-C uptake by the hepatic scavenger class B type 1 receptor (SR-B1) (7). Some would also advocate increasing monounsaturated and polyunsaturated fat in the diet and increased intake of omega three oils. Randomized clinical trials are needed to determine the efficacy of aggressive nutritional intervention in older patients with hypocholesterolemia. It is well recognized that low total energy consumption is associated with inactivity, deconditioning, sarcopenia, and frailty. These analyses were not adjusted for medication usage or disease, and patients referred for assessment of their lipoprotein lipids may not be representative of the general population. Side effects include myositis, stomach upset, sun sensitivity, gallstones, irregular heartbeat, and liver damage. It is also becoming increasing clear that the measurement of structural markers of arterial vulnerability (carotid intimal-medial thickness, assessment of coronary artery calcium among others) and functional markers of arterial vulnerability (brachial artery reactivity assessment of endothelial function, arterial stiffness, and ankle-brachial blood pressure index [ABI]), similarly provide incremental benefit in predicting CVD risk in elderly people and help identify older individuals who might benefit from risk factor intervention. NUTRICIÓN Y DIETÉTICA CONTENIDO PROGRAMÁTICO UNIDAD 4: Nutrición infantil • 4.1.-Características del metabolismo del The NCEP III guidelines recognize small, dense LDL as a CVD risk factor. Current clinical trials question the added CHD preventive value of adding ezetimibe to statin therapy. The NCEP recommends that all patients older than 20 years of age undergo lipid testing at least every 5 years. Combination therapy of LDL-lowering drugs such as HMG-CoA reductase inhibitors with niacin, cholesterol absorption inhibitors (ezetimibe), or fibrates in combination with insulin sensitizers to reduce insulin resistance, glucose, and plasma triglyceride maybe required to achieve lipid-lowering targets (see “Management” later in the chapter.). The prevalence of obesity increases with aging, with a preferential accumulation of fat in visceral abdominal sites. To do this longitudinal studies are needed. The majority of studies report data on the relative risk of hypercholesterolemia for CHD morbidity and mortality. In the Honolulu Heart Study, persistence of low cholesterol concentrations over 20 years was associated with increased risk of death. However, many clinicians have taken a more aggressive therapeutic approach in older individuals in this category and have begun lipid-lowering therapy with statins to reduce LDL-C below 100 mg/dL. Can raise LDL in some patients. DISLIPOPROTEINEMIAS un defecto en algún paso en el metabolismo de las lipoproteínas trae aparejadas alteraciones en la concentración y calidad de las lipoproteínas plasmáticas. The results of the HHS, Veterans Affairs High Density Lipoprotein Intervention Trial (VA-HIT), the Bezafibrate Infarction Prevention Study (BIP), and the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) studies were inconsistent. However, because of both the high absolute risk in the elderly and the high attributable risk for CHD events, a given therapeutic treatment such as statin therapy will prevent a greater number of events in older than in younger people. In addition to the changes in the concentration of LDL, there are age-related changes in the LDL subclass population distribution that affect the atherogenicity and susceptibility of LDL to oxidation.   •  Accessibility Median survival was >11 years longer and 8 years longer, respectively, in men and women with optimal CHD risk factors. If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. Tratamiento nutricional. As discussed in the next section, an increasingly informed and proactive older population, and changes in professional opinion toward ever more aggressive therapy for hyperlipidemia are reflected in the large number of elderly people prescribed HMG-CoA reductase inhibitors (statins). The usefulness of blood-based biomarkers beyond a standard lipid panel (e.g., LDL particle size, insulin, high sensitivity CRP, homocysteine, apolipoproteins, etc.) Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). The pooled relative risk was 1.12. In older (>70 years) patients with diabetes, apo B concentration and the ratio of apo B to apo A-I predicted CHD events independent of LDL-C. Dislipoproteinemias . We advocate aggressive risk factor modification that includes therapeutic lifestyle changes and physical activity to modify obesity, as well as pharmacological interventions for each component of the metabolic syndrome as indicated. and (5) What role should the noninvasive measurements of atherosclerotic plaque or calcium score have in the assessment of cardiovascular risk and treatment? Without concomitant weight loss, the ratio of LDL-C to HDL-C may actually increase, not decrease when individuals are placed on diets low in saturated fat and cholesterol. Data from multiple sources including Grundy SM, Cleeman JI, Merz CN, et al. Endogenous TG is synthesized in the liver from carbohydrate and free fatty acid (FFA, derived from adipocyte hydrolysis by hormone-sensitive lipase) precursors assembled in the Golgi with apo B-100, E, C-II, C-III, and secreted as triglyceride-rich very low-density lipoproteins (VLDL-TG) (4). Such age-associated changes in dietary content would be expected to result in lower levels of total and LDL-C, a result that is opposite to the commonly observed age-associated increase in these parameters. Kardiologiia. Until there is greater uniformity and agreement on the components and cut points for the metabolic syndrome that define CVD risk, there is no clear rationale to cluster the vascular risk factors when prescribing treatment. heart palpitations. July 2020. The mechanism underlying the increased CHD in individuals carrying the 4 allele is not known with certainty, but is in part caused by changes in LDL and TG-rich remnant metabolism. Increased physical activity is often advocated as a means to reduce CVD risk factors. These studies did not control for differences in body composition and physical activity among age groups, factors which may elevate plasma-free fatty acid concentrations, glucose, and insulin concentrations in the older subjects and result in a raise in hepatic production of TG. The authors concluded that this U-shaped relationship may confound the association of cholesterol with CHD risk in the elderly. Thus most older individuals, particularly those at risk or with CVD, have already had multiple measurements of their lipid concentrations. This site uses cookies to provide, maintain and improve your experience. Familial dysbetalipoproteinemia (FD), or type III hyperlipoproteinemia (Fredrickson-Levy-Lees Classification) is a genetic lipid disorder characterized by increased accumulation of triglyceride-rich remnant lipoproteins. Dyslipoproteinemia, also referred to as dyslipidemia, encompasses a range of disorders of lipoprotein lipid metabolism that include both abnormally high and low lipoprotein concentrations, as well as abnormalities in the composition of these lipoprotein particles. The genetic locus for apolipoprotein (a) is polymorphic and there are a large number of genetically determined isoforms of Lp(a). There is an ongoing controversy as to the utility of the metabolic syndrome as a disease construct (also see the “Special Issues” section at the end of the chapter). The ATP III update emphasizes that therapeutic lifestyle changes, that is, diets low in saturated and trans fat, increased physical activity, and weight control are advocated for lowering cholesterol concentrations. Several investigators propose that the atherogenic LDL pattern B phenotype maybe the most common abnormality in lipoprotein metabolism that predisposes to CHD. http://www.lipidsonline.org/slides/. These studies demonstrate that treatment of hypercholesterolemia in high-risk older adults aged 65 to 80 years with statins reduces CHD death rates. These findings support the use of measurement of HDL-C along with total cholesterol to predict CHD risk in older individuals. Risk factors for atherosclerosis in diabetic old people in a medical office Age has a substantial effect on predicting absolute risk, and many elderly patients exceed thresholds for treatment solely based on their age. **If baseline LDL-C is <100 mg/dL, institution of an LDL-lowering drug is a therapeutic option on the basis of available clinical trial results. 10. This report recommends the calculation of the Framingham Risk Score (http://hp2010.nhlbihin.net/atpiii/riskcalc.htm) as the primary means of identifying older persons at increased risk for coronary events. This ratio can then be used to select drugs that target the patient's underlying metabolic abnormalities. Many cross-sectional studies have examined age-associated changes in lipoprotein concentrations in both men and women. †CHD includes history of myocardial infarction, unstable angina, stable angina, coronary artery procedures (angioplasty or bypass surgery), or evidence of clinically significant myocardial ischemia. These disorders of lipoprotein metabolism are more common than familial heterozygous hypercholesterolemia and familial multiple lipoprotein hyperlipidemia in both the general population and CHD patients, and may play major roles in the pathogenesis of CHD in older individuals. AccessMedicine is a subscription-based resource from McGraw Hill that features trusted medical content from the best minds in medicine. Resins may raise TG although this side effect appears to be less with colesevelam. For example, in NHANES III of 1988–1991, total cholesterol concentrations were on average 189 mg/dL in men aged 20 to 34 years and 221 mg/dL for men aged 55 to 64 years, but down to 205 mg/dL for men older than the age of 75 years. Historically, the lipoprotein particles in the plasma have been classified on the basis of their density or by their electrophoretic mobility. Dislipoproteinemia biasa. It is unclear whether these adverse results are restricted to this particular CETP inhibitor or to the entire class of CETP inhibitors. The foregoing arguments need to be viewed in the context of several secular changes. A large number of nutraceuticals and dietary supplements are also employed to improve lipoprotein profiles. We know of no definitive data demonstrating a lack of effectiveness among older individuals (>80 years). Knowledge of longitudinal changes in lipoproteins is limited because of the inherent difficulties in following cohorts of individuals over extended periods of time, and methodologies that limited widespread measurement of HDL-C and apolipoproteins prior to the mid-1970s. Despite impressive advances in our understanding of the pathogenesis of atherosclerosis, there are several ongoing questions to be resolved concerning the lipoprotein risk factors for CHD in the elderly population: (1) Do lipoprotein subfractions (Lp (a), LDL, HDL) predict CHD morbidity and mortality, as well as total mortality? The treatment of hyperlipidemia in T2DM is effective in reducing cardiovascular endpoints. The differences in obesity contribute the most to the difference in TG and HDL-C concentrations between older athletes and their sedentary counterparts, while the differences in maximal aerobic capacity (VO2 max) account for a small percentage of the variance in these lipoproteins. DISLIPOPROTEINEMIAS HIPERLIPEMIAS 2. (Data adapted from Carroll MD, Lacher DA, Sorlie PD, et al. There maybe a lag time (2 yr) between the initiation of therapy and the reduction of morbidity and mortality from CHD, Cost for elderly persons on fixed incomes with limited insurance, The presence of other multiple comorbid diseases might limit life span or the quality of life, Polypharmacy and risk of drug side effects. Factors associated with survival to age 85 years included female gender, lower total cholesterol, lower systolic blood pressure, better glucose tolerance, not smoking, and higher education levels. Not only is this more closely linked to CVD, but increasing clinical trial data tie improvements in LDL-C to those in CHD clinical endpoints (see below). rcsp Revista Cubana de Salud Pública Rev Cubana Salud Pública 0864-3466 1561-3127 Centro Nacional de Información de Ciencias Médicas 00003 00003 Investigación Valores de riesgo vascular de indicadores metabólicos en adolescentes y ancianos de La Habana Vascular Risk Values of Metabolic Indicators in Adolescents and Elderlies from Havana 0000-0003-1941-0440 Hernández Hernández Héctor 1 . In these four groups the LDL apo B fractional catabolic rate decreased with age, whereas the LDL production rate did not change with age. Serious side effects for these sequestrants include fecal impaction and a variety of GI symptoms; medications may also lead to a deficiency of fat-soluble vitamins and loss of calcium in the urine. These diseases may either suppress hepatic cholesterol synthesis or accelerate cholesterol catabolism. cold sweats. In that study, there was no significant effect of treatment on declining physical function. This chapter reviews the epidemiology and mechanisms underlying age-associated changes in lipoprotein lipid concentrations, evidence that hyperlipidemia is a risk factor for coronary heart disease (CHD) in the elderly population, and controversies regarding the screening and treatment of hyperlipidemia in elderly patients. Lack of evidence that primary or secondary prevention decreases CHD morbidity and mortality in individuals older than age 80 yr. Most, but not all studies, demonstrate an association between LDL pattern B and increased risk for prevalent CHD and subclincal manifestations of atherosclerosis detected by assessment of carotid intima media thickness. There are contradictory reports of the effects of statins and estrogen replacement therapy on Lp(a) concentrations. The primary dyslipoproteinemias can be caused by biochemical defects resulting from single-gene mutations or can be caused by polygenetic or multifactorial causes. These findings suggest that lipoprotein particle size is associated with longevity. In this situation, individuals with the highest or lowest cholesterol levels are at increased risk for CHD, as compared to those with intermediate levels. ‡CHD risk equivalents include clinical manifestations of noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease [transient ischemic attacks or stroke of carotid origin or >50% obstruction of a carotid artery]), diabetes, and 2+ risk factors with 10-yr risk for hard CHD >20%. Part of this program was the Lipid Research Clinics Prevalence Study, a standardized series of cross-sectional surveys of various North American populations designed to determine the prevalence of dyslipidemias and to describe the distributions of lipids and lipoproteins in major ethnic and social groups. Subjects with LDL patterns B and A had differential lipoprotein lipid responses to dietary interventions, exercise, weight loss, and therapy with statins, nicotinic acid, bile acid-binding resins, and fibrates. Data represent values for all races combined. The prevalence of individuals with a predominance of small, dense apo B-enriched LDL particles increases with age. The primary clinical manifestations of dyslipoproteinemia are those related to symptomatic CVD. These biomarkers provide incremental benefit in predicting CVD risk beyond the routine measures that are included in the Framingham Risk score. Drug class of choice for high TG, low HDL. Until that time, measurement of apo B concentrations and the LDL-C to apo B ratio can be used as surrogate markers for LDL particle size. Age, environmental factors, diet, and other lifestyle factors affect the phenotypic expression of both the single-gene and polygenetic disorders. The secular decline in cholesterol concentration maybe accelerating. In the St. Thomas’ Atherosclerosis Regression Study (STARS) comparing usual care, intervention with lipid-lowering diet and lipid lowering diet + cholestyramine, small dense LDL was significantly reduced in the groups showing regression, and dense LDL concentration during the trial was the best predictor of arteriographic outcome with those with the lowest treated levels of dense LDL having the greatest regression. Antiretroviral therapy for human immunodeficiency virus (HIV), particularly protease inhibitors, can cause dyslipidemia characterized by elevated TG and LDL-C and other metabolic abnormalities (lipodystrophy syndrome) that increase risk for atherosclerosis. High risk: CHD† or CHD risk equivalents‡ (10-yr risk >20%), ≥100 mg/dL** (<100 mg/dL: consider drug options)*, Moderately high risk: 2+ risk factors‡ (10-yr risk 10–20%)††, ≥130 mg/dL (100–129 mg/dL; consider drug options)§§, Moderate risk: 2+ risk factors¶¶(10-yr risk <10%)††, ≥190 mg/dL (160–189 mg/dL: LDL-lowering drug optional). In the Framingham Offspring Study, postmenopausal women had 16% higher values of total cholesterol, 62% higher TG, 23% higher LDL-C, and smaller LDL particles than premenopausal women. Extensive drug–drug interactions (consult pharmacist). Future advances in pharmacogenetics and therapeutics are likely to produce novel therapies for T2DM and the metabolic syndrome. By 2002, roughly 27% of the 41 million Medicare beneficiaries (11 million individuals) used the drugs. In data pooled from 19 cohort studies, men and women with cholesterol concentrations <160 mg/dL were at a 40% to 50% higher risk for noncardiovascular deaths that occurred more than 5 years after baseline measurement than individuals with cholesterol concentrations of 200–239 mg/dL. Weight loss and aerobic exercise results in improved lipoprotein concentrations (as well as glucose tolerance and blood pressure) in middle-aged and older women and men, whereas aerobic training without weight loss yields substantially less beneficial effects. Fenofibrate effectively lowers triglyceride and raises HDL-C in persons with hypertriglyceridemia, but we do not recommend combined therapy with statins because of the increased risk for myopathy in elderly patients. Others have reported changes in the distribution of energy consumed in older adults with a larger relative contribution of calories consumed at breakfast and snacks, with fewer calories consumed at lunch and dinner. Individuals with the highest baseline cholesterol concentrations show the greatest improvements with weight loss and AHA diet interventions. Type 2 diabetes is commonly associated with dyslipidemia, characterized by hypertriglyceridemia, reduced HDL-C, a predominance of small-dense LDL particles, increased concentrations of apo B, and the accumulation of cholesterol-rich remnant particles, especially postprandially. These findings raise questions about whether it is advisable to lower cholesterol concentrations below 180 mg/dL (4.65 mmol/L) in elderly people. Unfortunately, there are no firm guidelines for the evaluation of patients with hypocholesterolemia. The prevalence of hypocholesterolemia (typically defined as total cholesterol concentrations <160 mg/dL, sixth percentile Multiple Risk Factor Intervention Trial (MRFIT)], increases with age. Age-associated changes in dietary content are reviewed in Chapter 38. The phenotypic expression of the pattern is affected by age, visceral obesity, diet, sedentary lifestyle, and the presence of type 2 diabetes. Definitive evidence supporting treatment for those 80 years old and older is limited, and the ATP III recommends using good clinical judgment. Dislipoproteinemias. These changes are associated with hyperinsulinemia, which predisposes older adults to develop glucose intolerance, type 2 diabetes, and other metabolic risk factors for CHD. 2005;294:1773–1781.). Introduction. This leads to increased clearance of LDL and VLDL remnants from the circulation. The plasma lipids and lipoprotein levels are under the control of a number of genetic and environmental influences. There are a number of studies that demonstrate that LDL-C concentrations are in part determined by the apo E gene locus. Concentrations are expressed as arithmetic means for LDL cholesterol and geometric means for triglycerides. In addition to contributing to the . However, if there is excess VLDL-TG production or dietary fat intake, CETP exchanges cholesterol from HDL with TG from VLDL, raising the TG and lowering the cholesterol composition of HDL (9). Avoid use with cyclosporine, gemfibrozil; increased transaminases when used in combination with statin. However, some studies have found lower HDL-C concentrations in postmenopausal women. 2 Métodos: estudio descriptivo, de corte transversal. The restriction of saturated fats, trans-unsaturated fats, and the inclusion of increased dietary fiber are recommended to improve lipids. These alleles encode 3 common isoforms, E2, E3, E4, that determine the six common apo E genotypes E2/2, 2/3, 2/4, 3/3, 4/3, and 4/4. The prevalence of metabolic syndrome increases with age. [Cholesterol is also synthesized endogenously from acetate precursors, regulated by the enzyme HMG-CoA reductase. Early detection and treatment of hyperlipidemia is critical for primary and secondary prevention of CHD in the elderly. In a subgroup of men aged 71 to 93 years from the Honolulu Heart Study, the age-adjusted incidence rates of coronary heart disease exhibited a significant U-shaped relationship with both total cholesterol and LDL. vomiting and nausea. There is considerable controversy concerning the management of hyperlipidemia in older individuals who have no risk factors other than their age. In women, the relative risk for all-cause mortality was 1.5 and the risk for CHD mortality was 3.1 (HDL-C < 45 mg/dL vs. > 69 mg/dL). Age-associated increases in adiposity, decreased fitness, decreased number or function of the LDL receptor, and hormonal changes associated with menopause act in concert with polygenetic factors to raise LDL-C concentrations in older age. Millions of older individuals with prevalent CHD, CHD equivalents (diabetes, stroke, peripheral vascular disease, chronic kidney disease), or with multiple risk factors for CHD events also are candidates for cholesterol lowering-drugs. Statins are very safe: 95% of patients can tolerate them; 5% cannot. [Article in Russian] Ninguna Categoria Subido por Paula Chamba Lineamientos para el cuidado nutricional Kajian tentang pecahan lipoprotein dalam amalan klinikal digunakan untuk menonjolkan dislipoproteinemia. As a result, a majority of older individuals could be classified as having undesirable lipoprotein lipid concentrations and are candidates for lifestyle intervention and potentially for pharmacological therapy if their concentrations exceed treatment cut points. However, this also results in an increased synthesis of cholesterol by the liver, thereby partially negating the LDL-C-lowering effects of the sequestrants. Estimation of lifetime risk may provide a more useful conceptual framework for the primary prevention of CVD. General Discussion. 20–80 mg/day, take with evening meal, take bid if >20 mg/day. It inhibits the peripheral mobilization of free fatty acids, thus reducing hepatic synthesis of TG and the secretion of VLDL, reducing the number of LDL particles. Full text. A “J”-shaped relationship between cholesterol and mortality is reported in some studies, suggesting that hypocholesterolemic individuals are at increased risk of death. Therefore statins are effective in treating patients who have an elevation of both LDL-C and TG. Described originally in 1988 by Reaven to include insulin resistance, glucose intolerance, hyperinsulinemia, increased TG, decreased HDL-C, and hypertension, many now consider inflammation, microalbuminuria, small dense LDL particles, dysfibrinolysis and coagulopathy, nonalcoholic fatty liver disease, and central adiposity to components of the syndrome. The ATP III guidelines for pharmacological treatment in people at low risk have not changed the LDL concentration at which drug therapy should be considered, i.e., ≥160 mg/dL. Diets reduced in saturated fat and cholesterol and increased in fiber and complex carbohydrate content, weight loss, and regular aerobic exercise (Therapeutic Lifestyle Changes) are widely advocated for the initial treatment of hyperlipidemia. Please try again later or contact an administrator at OnlineCustomer_Service@email.mheducation.com. In a cohort of 5732 subjects aged 70 to 82 years enrolled in the prospective study of pravastatin in the elderly at risk PROSPER study, Lp(a) concentration was associated with a small increased risk of vascular disease over a period of 3 years. Furthermore, as discussed in the Management section of this chapter, the number of subjects who have to be treated to prevent one death or the inverse of the attributable risk is substantially lower in older than in younger adults. The decline in average LDL-C concentration was observed across all age groups, but was most pronounced for tests performed on older patients. Unidad de Bioquimica y Nutrición, INCIENSA Apartado 4,Tres Rios,Cartago. Affected individuals may also develop the buildup . These guidelines are based on experimental and epidemiologic data that energy expenditure and metabolic responses to exercise training reduce lipoprotein lipid, insulin-glucose, and blood pressure associated CVD risk, and directly affect CVD mortality. This suggests that there are impressive long-term benefits from optimal control of CVD risk factors. Cholesterol and Coronary Heart Disease. There are a number of limitations to applying the Framingham Risk Score to older adults. Recipients may need to check their spam filters or confirm that the address is safe. The major classes of lipoproteins comprise subpopulations of lipoproteins that differ in composition, metabolic function, and atherogenic potential. However, different statins have differential effect on the LDL subclass distribution. There have been substantial changes in lipoprotein lipid concentrations in the U.S. population over the past four decades (Figure 110-1). The age-related rise in LDL was attributed to an acquired defect in the LDL receptor function. Fibrates are indicated in the treatment of patients with high TG and low HDL-C. Bile acid resins are generally considered second-line agents for the treatment of hypercholesterolemia. Scope Note. Thus, some clinicians will place older patients on statins hoping for the secondary (pleiotropic) benefits despite a lack of convincing evidence that the therapy will be efficacious. Given the high prevalence of physical inactivity, hypertension and type 2 diabetes (T2DM) in the elderly, the geriatrician must have a firm understanding of the pathogenesis and treatment of disorders of lipoprotein metabolism in the geriatric population. Heart Protection Collaborative Group. Conversely, secular changes resulting in an increased prevalence of obesity may worsen the manifestations of the metabolic syndrome, i.e., raise TG concentration, lower HDL-C concentration, and shift the distribution of HDL and LDL lipoprotein particle distribution toward smaller, denser, more atherogenic particles, worsen insulin resistance, and raise blood pressure. The HDL-C concentration then remains fairly constant until the sixth or seventh decade of life, at which point there maybe an increase in the HDL-C concentration. swelling in the legs, ankles, feet, stomach, and veins of the neck. Familial combined hyperlipidemia might not be phenotypically manifest until after puberty, and is usually clinically and biochemically diagnosed in the fourth decade. Example: jdoe@example.com. Similarly, in the Helsinki Heart Study (HHS), the subset of subjects having an elevated TG concentration and low HDL-C, that is, patients who presumably had LDL pattern B, received substantial clinical benefit from gemfibrozil. The evidence supporting elevated levels of LDL-C as a risk factor for CHD in the elderly population, particularly elderly women, is mixed. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. To reduce LDL-C, the American Heart Association and the American Diabetes Association recommend the following dietary composition: saturated fats should be <7% of energy intake; dietary cholesterol should be <200 mg/day; intake of trans-unsaturated fatty acids should be <1% of energy intake; total energy intake should be adjusted to achieve body-weight goals; total dietary fat should be moderated (25–35% of total calories) and should consist mainly of monounsaturated or polyunsaturated fat; dietary fiber should be >14 g per calories consumed; salt intake should be 1200 to 2300 mg/day; and alcohol intake should be moderate (limited to 1 drink per day in women and 2 drinks in men). The latter is mediated by the peroxisome proliferator-activated receptor (PPAR)-α and by an increase in lipoprotein lipase, a key enzyme in the clearance of TG-enriched particles. Niacin is the most effective drug available for raising HDL-C. 1 gm/d can raise HDL by 25%. Fibrates also increase HDL-C and apo A-I. The Atherosclerosis Risk in Communities (ARIC) study showed that over a 10-year period, Lp (a) along with LDL-C, HDL-C, HDL3-C, and TG concentrations were independent predictors of CHD events in middle-aged subjects, whereas apo B, apo A-I, and HDL2-C were not. Over the past several years, National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) consensus guidelines have made the target lipoprotein concentrations more stringent for individuals with CVD. Hepatic lipase hydrolyzes HDL TG and phospholipid, converting HDL2 back to smaller HDL3 particles, reducing the efficient clearance of cholesterol from cells. However, the NCEP, World Health Organization, and International Diabetes Federation criteria define multiple phenotypes based on cutoffs for blood pressure, glucose, waist circumference, HDL, and TG levels. The increase in the proportion of adults using lipid-lowering medication, particularly in older age groups, likely contributed to the decreases in total and LDL-C concentration, while the heightened prevalence of obesity in the U.S. population probably contributed to the increase in plasma TG levels. Another confounder in the association between cholesterol levels and CHD outcomes in the elderly person is that cholesterol levels measured at a given time may not accurately reflect the lifelong average exposure to plasma cholesterol, leading to spurious conclusions. However, these numbers severely understate the burden of CHD in the older adult population because much of the disease is clinically silent. In Swedish men aged 77 years who participated in the Uppsala Longitudinal Study of adult men, men in the first, second, and third quartiles of apo A-I values had a relative risk of subsequent death of 10.2, 5.0, and 3.0 compared to the quartile with the highest apo A-1 concentration. Apolipoprotein E is a constituent of chylomicrons, VLDL, and HDL, and modulates the metabolism of the apo B-containing lipoproteins. Apunte: Obesidad para aprobar Fisiopatologia y Dietoterapia I de Nutricion UNC en Universidad Nacional de Cordoba. Therapy with gemfibrozil increased HDL-C and reduced the risk of stroke in older men with prevalent CHD. However, as a result of age-associated increases in the CHD death rate in men with “normal” cholesterol, the attributable risk for CHD in the upper versus lowest quintile increased progressively with age, from 0.7% for men aged 35 to 39 years compared to 1.9% for men aged 55 to 59 years. In that study, the earlier in life that the patients exhibited hypocholesterolemia, the greater the risk of death. However, some investigators suggest that the attributable risk is a more useful parameter for making clinical decisions regarding treatment of hypercholesterolemia in the elderly. Lp(a) concentration was higher in subjects who developed CHD, but added only a small predictive value to that provided by LDL-C, HDL-C, and TG, and was not a predictor in black men. Furthermore, glucose toxicity affects coronary risk in older people with diabetes, and hyperglycemia is associated with a heightened incidence of silent ischemia during exercise stress testing. This decline in cholesterol concentration could have a significant impact on CVD morbidity and mortality. Second, given secular increases in the use of hypolipidemic drugs for both the primary and secondary prevention of CHD in middle-aged and older individuals, an increasing number of older patients presenting to the geriatrician will already be on lipid-lowering medications. However, most patients with T2DM have elevated TG and low HDL-C, lipoprotein lipids that are only modestly affected by statins. Although the relative risk (RR) for CHD death for individuals with hypercholesterolemia declines with aging, because of age-associated increases in the absolute death rate from CHD, the attributable risk (AR) for CHD in the upper versus lowest quintile increased progressively with age. Trends in serum lipids and lipoproteins of adults, 1960–2002. In 1997, fewer than 12% of the 38 million Medicare beneficiaries (4.4 million persons) used at least one statin. (2) Should the interpretation of a given lipoprotein concentration take into account the age of the patient? ARTÍCULO ORIGINAL . Pada individu yang sehat, IDL terdiri dari sekitar 31 persen triasilgliserol, 22 persen fosfolipid, dan 18 persen protein. 1-Hypolipoproteinemia : DefectName No chylomicrons ,VLDL , LDL are . Thus, pharmacologic interventions to decrease morbidity and mortality from CHD maybe more cost-effective in older compared to younger people. In men in the Baltimore Longitudinal Study of Aging (BLSA), total caloric intake, cholesterol intake, the percent of calories obtained from fat, and the percent of calories obtained from saturated fat declined with age. The importance of patient-specific attributable risk.   •  Privacy Policy In obese individuals, moderate weight loss in combination with aerobic exercise will decrease total cholesterol and LDL-C concentrations by 10% to 15%, increase HDL-C by 15%, improve glucose tolerance, and lower blood pressure. Such studies, in a variety of populations, have revealed correlations of low cholesterol with nutritional and functional status, as well as mini-mental examination scores. A joint statement in 2005 from the American Diabetes Association and the European Association for the Study of Diabetes noted that the metabolic syndrome is imprecisely defined, there is a lack of consensus on the underlying pathophysiology, and there is little evidence that the metabolic syndrome denotes greater CVD risk per se than the sum of its parts (low HDL-C, hypertension, glucose intolerance, hypertriglyceridemia, increased waist circumference). The fibrates decrease the production of VLDL and increase the clearance of triglyceride-rich lipoproteins. Xanthomas are lipid deposits in the skin and tendons that occur secondary to a lipid abnormality. Their use is beyond the scope of this chapter. §§For moderately high-risk persons, when LDL-C concentration is 100 to 129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C concentration <100 mg/dL is a therapeutic option on the basis of available clinical trial results. This document was uploaded by user and they confirmed that they have the permission to share it. However, until large-scale clinical trials comparing the effect of the different statins on morbidity and mortality in older individuals with different LDL subclass distributions and apolipoprotein profiles are performed, we will not know if the theoretical advantages of those medications particularly effective in decreasing dense LDL subfraction concentration result in improved clinical outcomes.

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