|Increased LDL cholesterol level||Increased triglyceride level||Decreased HDL cholesterol level|
Hypothyroidism Nephrotic syndrome Obstructive liver disease
Alcoholism Hypothyroidism Obesity Renal insufficiency
Cigarette smoking Hypertriglyceridemia Menopause Obesity Uremia
|Advanced age (especially more than 80 years) in patients (women more than men)|
|Small body frame and frailty|
|Multisystem disease (e.g., chronic renal insufficiency, especially due to diabetes)|
|Fibrates (especially gemfibrozil, but other fibrates too)|
|Nicotinic acid (rarely)|
|Macrolides (azithromycin, clarithromycin, erythromycin)|
|Azole antifungals (itraconazole, ketoconazole)|
|Calcium antagonists (mibefradil, diltiazem, verapamil)|
|Protease inhibitors (amprenavir, indinavir, nelfinavir, ritonavir, saquinavir)|
|Large quantities of grapefruit juice (usually more than 1 quart per day)|
|Alcohol abuse (independently predisposes to myopathy)|
NOTE: This does not represent a complete list.
|Drug class||Total cholesterol levels||LDL levels||HDL levels||Triglycerides|
|Bile acid binding resins||20%||10% to 20%||3% to 5%||Neutral or|
|Nicotinic acid||25%||10% to 25%||15% to 35%||20% to 50%|
|Fibric acid analogs||15%||5% to 15%||14% to 20%||20% to 50%|
|HMG-CoA reductase inhibitors||15% to 30%||20% to 60%||5% to 15%||10% to 40%|
All patients must be prescribed lifestyle changes and this should be continued even if drug therapy is started.
If BP <15/10 mm Hg above goal (130/80 mm Hg), then ACE inhibitors (ACEi's) or Angiotensin Receptor Blockers (ARBs) alone may be used to initiate therapy. The doses can be gradually increased, as needed to the highest dose range to achieve the blood pressure goal;
If this does not allow for optimal control, add a small dose of a thiazide diuretic.
If the patient has a blood pressure of >15/10 mm Hg above the goal (<130/80 mm Hg), begin therapy with a combination of an ACEi or ARB and a thiazide diuretic, increasing the dosage of the former, as needed, to the high-dose range to achieve the blood pressure goal.
In both the above cases, if blood pressure is still not controlled, add a calcium channel blocker (CCB); a nondihydropyridine CCB is recommended for those with proteinuria of >300 mg/day. Non-dihydropyridine CCBs, verapamil, diltiazem have been shown to reduce both CV mortality, proteinuria and diabetic nephropathy progression independent of an ACE inhibitor.
Beta blockers may be substituted for calcium channel blockers if the patient has angina, heart failure, or arrhythmia necessitating their use. The newer highly selective beta blockers with proven efficacy to reduce CV events and the lowest side effect profile are preferred.
The use of a beta blocker with a nondihydropyridine CCB should be avoided in the elderly and those with conduction abnormalities. Otherwise, such combinations are safe and particularly effective for lowering blood pressure.
If the blood pressure is still not at the optimal level, add a long acting alpha blocker at bedtime.
Most patients will require multi-drug therapy to achieve and maintain their BP at the optimal levels.
Raised blood pressure (systolic and /or diatolic) increased levels of insulin resistance / hyperinsulinemia atherogenic dyslipidemia raised levels of LDL-C and apo-B Endothelial dysfunction increased prothomboitic and procoagulant state raised pro-inflammatory status decrease in levels of antiatherogenic levels of adiponectin premature atherosclerosis (leading to early onset CHD and stroke) Raised levels of serum uric acid sleep apnoea syndrome and related polycystic ovary syndrome microalbuminuria is an integral component of the cardiometabolic syndrome, and patients with this syndrome have a propensity to develop type 2 diabetes.
These medications should preferably not be used if weight loss is the aim. Moroever, some of these medications lead to lethargy and drowsiness and may make increased physical activity difficult. Some of these medications are given in Table.
|Antidepressants||Serotonin reuptake inhibitors, tricyclic antidepressants, monamine oxidase inhibitors, eg., amitryptiline, imipramine, doxepin, desipramine, trazodone, lithium, etc.,|
|Antiepileptics||Valproate, carabamazepine, gabapentin, lithium|
|Antipsychotics||Atypical neuroleptic agents: clozapine, olanzapine, risperidone etc.,|
|Steroids and other hormones||Estrogens, progesterone, hormonal contraceptives, corticosteroids|
|Diabetes medications||Insulin, sulfonylureas, glitazones|
|Antihypertensive Agents||a- and ß-adrenergic receptor blockers|
|Serotonin and histamine inhibitors|
NOTE: This is not a complete list.
NOTE: This system does not take diabetes into its point consideration as all people with diabetes are considered to be in the high risk category.
People with diabetes and ASCVD are always considered to be in the high risk category.