At my school, the outpatient medicine rotation students take a break from the clinic once a week for class. Today we had a dazzling presentation on cholesterol management. Really! Every slide had blockbuster stuff. Some pearls that I can recall, off the top of my head:
How low is too low? Aside from low LDL potentially causing myelination problems in children, there's really nothing but benefits the lower you take your (LDL and total) cholesterol. Right now the guidelines are to keep LDL below 160 if there are no other cardiac risk factors, but it's really a compromise so that we don't start the whole nation on meds.
Fish oil gets no love from the press or drug companies, but it's great for raising HDL. In clinic I've noticed it's good for skin, too. Maybe also schizophrenia.
Via the 4S study, from the perspective of mortality and cholesterol medical management, a patient with newly diagnosed diabetes should be treated as aggressively as a patient who's already had a heart attack.
Women's cholesterol rises more or less linearly through their adult life. There's no change in the increase during menopause. Cholesterol in men, on the other hand, plateaus and actually starts to decline after midlife. No one knows why.
Zetia! It's fun to say, and it works well in combination with statins.
At the end of the lecture, I asked the presenter if he had seen a recent report on seasonal variations in cholesterol, and if so, would he start factoring that into his management strategies.
He replied that he was already taking seasonal variation into account, because
he wrote the report I was citing. I love it when that happens.
The skinny on his data: total cholesterol is, on average, 4 points higher in men, 5-6 in women, in winter. There's greater variation in hypercholesterolemic patients, though. This variation is largely due to seasonal changes in plasma volume (even as we lose weight in the winter, we retain more water in the blood).
So, if a doctor starts a patient on cholesterol-lowering regimen in January, and checks the lipid panel again at a 6 month follow-up, the successful decline could be artificially inflated. Likewise, one shouldn't get discouraged by what appears as meager progress from June to December.
Note: Hat tip to
Medpundit with bringing the cholesterol variation report to my attention originally, and I should add that any transcription or interpretation errors in this post are my own, and not the fault of today's lecturer.
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