Clinical Manual for Management of the HIV-Infected ... - myCME.com

4–6 | Clinical Manual for Management of the HIV-Infected Adult/2006
♦
♦
♦
♦
Assess for CHD or CHD equivalents.
♦
♦
CHD includes a history of myocardial
infarction, unstable angina, stable angina, CHD
procedures, or evidence of clinically significant
myocardial ischemia.
CHD equivalents include diabetes, peripheral
vascular disease, carotid artery disease,
abdominal aortic aneurysm, transient ischemic
attacks, or 2 or more CHD risk factors with a
10-year risk of CHD >20% (see “Calculations
to Estimate the 10-Year Risk of Cardiac Events
for Men and Women”, below, or the online risk
calculator at http://hin.nhlbi.nih.gov/atpiii/
calculator.asp?usertype=prof).
Assess CHD risks. Major risk factors include
hypertension, diabetes, smoking, low HDL, age,
and family history of CHD.
Assess for causes of secondary dyslipidemias,
including diabetes, hypothyroidism, obstructive
liver diseases, chronic renal failure, and medications
such as corticosteroids or progestins.
Screen for other factors that contribute to
hyperlipidemia, including obesity, chronic
liver diseases, alcohol abuse, high-fat or highcarbohydrate
diet, and prothrombotic or
proinflammatory states.
Screen for health behaviors that increase CHD risk,
including smoking, high-fat diet, sedentary lifestyle,
and use of recreational drugs such as cocaine or
methamphetamine.
Review the patient’s family history for premature
CHD, obesity, diabetes, and lipid abnormalities.
Review the patient’s medications, with special
attention to ARVs known to increase LDL or TG
levels (particularly ritonavir and ritonavir-boosted
PIs) or decrease HDL.
O: Objective
Table 1. Low-Density Lipoprotein Cholesterol Goals and Thresholds for Treatment*
Risk Category Initiate Therapeutic
Lifestyle Changes
Lower risk: No CHD or CHD equivalents and
2 risk factors, with 10-year estimated
risk 2 risk factors and 10year
estimated risk 10-20%
LDL >160 mg/dL
(>4.1 mmol/L)
LDL >130 mg/dL
(>3.4 mmol/L)
LDL >130 mg/dL
(>3.4 mmol/L)
High risk: CHD or CHD equivalent LDL >100 mg/dL
(>2.6 mmol/L)
♦
♦
♦
Check vital signs, weight, and height. Calculate
body mass index (BMI). (See chapter Initial Physical
Examination for information on BMI.)
Perform a focused physical examination with
particular attention to signs of hyperlipidemia, such as
xanthelasma, and to the cardiovascular system.
Consider Drug Therapy LDL Goal*
>190 mg/dL
(>4.9 mmol/L)
(at 160-189 mg/dL, LDL drug
therapy is optional)
>160 mg/dL
(>4.1 mmol/L)
>130 mg/dL
(>3.4 mmol/L)
>100 mg/dL
(>2.6 mmol/L)