Treatment of Hyperlipidemia in Women:
New Data and Controversies
Valerie Spotts, RN, BSN

J.T. is a 40-year-old woman with type II diabetes and hyperlipidemia, currently taking a statin. She wants to get pregnant. R.M. is a 50-year-old overweight woman with hypertension who would like to start hormone replacement therapy (HRT). C.D. is a 76-year-old woman admitted to the hospital with an acute myocardial infarction.

What do these women have in common? Hyperlipidemia is a risk factor or an existing condition that puts them at risk for coronary heart disease (CHD). The most recent guidelines for the management of hyperlipidemia, Adult Treatment Panel III (ATP III), were published in May 2001.¹ Although the guidelines state that an LDL-C < 100 mg/dL is optimal for all adults, goals of treatment vary if the patient has CHD and/or at her risk factors. (See “Adult Treatment Panel III Guidelines for Lipid Goals.”)Lowering LDL-C is achieved through diet, exercise, weight loss, and medications (primarily HMG-CoA reductase inhibitors, more commonly known as statins).

Can we apply these guidelines and current research as we care for each of these women?

Case #1

Forty-year-old J.T. has had type II diabetes for five years and has taken a statin for two years. Her current LDL-C is 110 mg/dL. She wants to become pregnant and needs recommendations about her medications.

Case #1 Discussion

1. Statins are contraindicated during pregnancy and breastfeeding, so her statin needs to be discontinued before conception. Because statins interfere with the synthesis of cholesterol, fetal harm or death may result if they are given during pregnancy.
2. Diabetes is now considered a CHD equivalent, which means the risk of a coronary event is equal to the risk of someone without diabetes but with known CHD.¹ Also, J.T’s LDL-C is not at goal (<100 mg/dL). Options during pregnancy include intensifying diet therapy and/or starting a nonsystemic agent like a bile acid sequestrant (prevents absorption of bile acids in the digestive system), e.g., cholestyramine, colestipol, or colesevelam, which are rated pregnancy category B.²

Case #2

R.M. is 50 years old and comes to your clinic for a health maintenance exam. Hot flashes and sweating are making it hard for her to sleep. She’d like to start HRT to control her vasomotor symptoms. R.M. is overweight and hypertensive, and she has a sedentary lifestyle. Results of a recent CHD profile are total cholesterol 208 mg/dL, LDL-C 165 mg/dL, HDL-C 22 mg/dL, and triglycerides 349 mg/dL.

Case #2 Discussion

1. Assess for other CHD risk factors like smoking and family history of premature heart disease.
2. Evaluate her for metabolic syndrome. (See “Identifying the Metabolic Syndrome.”) Measure her waist, as this is a better indicator than either weight or body mass index. A waist measurement over 35 inches for a woman is associated with the metabolic syndrome. Abdominal fat is metabolically active and contributes to an elevated triglyceride level and low HDL-C level. She needs counseling for a low-cholesterol, low saturated fat, and weight reduction diet.
3. Hypertension needs aggressive control. ACE inhibitors are often the preferred treatment, especially if diabetes is present. However, according to recent data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial study, starting with a diuretic would be appropriate, then adding an ACE inhibitor if needed to control her BP or if she develops microalbuminuria.³
4. Sedentary lifestyle is a risk factor for CHD and type II diabetes. Increasing R.M.’s activity will have many benefits, including blood pressure control, improvement in lipid levels, weight loss, and decreased risk of diabetes. Patients often feel they have no time to exercise, so the challenge is to help them integrate it into their day. Suggestions may include taking a short walk during work breaks, parking farther from buildings, and using the stairs instead of elevators.
5. R.M. is interested in HRT. Past studies, as well as the recently reported Women’s Health Initiative, have failed to demonstrate a benefit of HRT in preventing cardiovascular disease.⁴ Despite improvement in the lipid profile, randomized studies have shown an increase in cardiovascular disease CVD in women treated with a combination of estrogen and progestin. Options include assessing the frequency and severity of the symptoms and helping R.M. decide if the benefits outweigh the risks of CVD. If HRT is started it should be continued only as long as the vasomotor symptoms are intolerable.

Case #3

C.D. is 76 years old and is admitted to your telemetry unit with an acute myocardial infarction (AMI). She has a history of hypertension, but otherwise has been healthy. Her medications include: aspirin 160 mg daily and hydrochlorothiazide 25 mg daily. In the hospital, she is started on 75 mg clopidogrel daily, metoprolol 25 mg twice daily, and ramipril 5 mg daily. The results of her CHD profile, drawn on the third day of hospitalization are total cholesterol 198 mg/dl, LDL-C 125 mg/dL, HDL-C 30 mg/dL, and triglycerides 88 mg/dL. Will she need treatment for lipids, and if she does will it begin before discharge or wait until a follow-up visit in four to six weeks?

Case #3 Discussion

1. Factors you need to consider when evaluating a patient’s lipid profile are whether the blood was drawn after fasting and how long after a coronary event it was drawn. Cholesterol levels decline in the first 24 hours following a coronary event.⁵ Levels drawn after this time are falsely low and can lead to inadequate treatment. The levels may remain falsely low for four to six weeks; so even at a return appointment, you may not be able to assess the true lipid values. The LDL-C goal for this women is < 100 mg/dL. ATP III guidelines state that drug therapy is optional for LDL 100-129 mg/dL.¹ However, given the fact that C.D.’s blood was drawn three days after the event, her LDL-C would have probably been > 130 mg/dL at admission.
2. The decision is made to start CD on lovastatin (an HMG-CoA reductase inhibitor) 10 mg daily. Should this start in the hospital? Recent revisions to the guidelines for non-ST elevated MI (NSTEMI) have included recommendations to begin lipid lowering therapy in the hospital.⁶ There are many benefits to this approach. Treatment at the time of the event has been shown to increase long-term adherence, decrease the risk of death and MI, and prevent patients from “falling through the cracks” in the transition from inpatient to outpatient care.
3. C.D. is elderly. Will statin therapy benefit her? The benefits of statin therapy include a reduction in major coronary events, CHD mortality, need for coronary procedures, stroke, and total mortality. She does not appear to have any other comorbid conditions that would shorten her life span. Much of the available data comes from studies of people 65 years or younger. However the recently published PROSPER trial demonstrated that treatment with a statin in the elderly (ages 70 to 82 years) reduced the mortality from CHD by 24%.⁷
4. Teaching patients about their medications and monitoring for adverse effects is an important part of nursing care. You would assess C.D.’s liver function tests before therapy starts, six to 12 weeks after treatment begins, and every six to 12 months thereafter because serum transaminase levels rise markedly in about 21% of patients. Other important side effects to watch for are myopathies: mylagia, mysositis, and rhabdomyolysis. You would instruct C.D. to report any symptoms of muscle weakness or pain and dark or brown colored urine. This would prompt stopping the statin and checking creatine/phosphokinase levels.

Since 1984, more women than men have died of cardiovascular disease, thus highlighting the importance of continued research into the most effective treatments for women.⁸ Recent research has widened our knowledge base. To improve outcomes for women with CHD, nurses must incorporate current research results into their practice.

Valerie Spotts, RN, BSN, is an educational nurse coordinator with the University of Michigan.

References

1. 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). JAMA. 2001;285(19);2486-2497.

2. Colesevelam package insert. Version 4 (10/23/00). Sankyo Pharma Inc., website. Available at: www.welchol.com. Accessed August 13, 2003.

3. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. (2002). Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitors or calcium channel blocker vs diuretic. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 288(23);2981-2997.

4. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-333.

5. Rosenson R.S. Myocardial injury: the acute phase response and lipoprotein metabolism. J Am Coll Cardio. 1993;22(3):933-940.

6. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction — summary article. J Am Coll Cardio. 2002;407(7):1366-1374.

7. Shephard J, Blauw GJ, Murphy MB, Bollen ELEM, Buckley BM, Cobbe SM, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet. 2002; 360;1623-1630.

8. Heart disease and stroke statistics update. American Heart Association website. Available at: http://www.american heart.org/presenter.jhtml?identifier=1928. Accessed August 13, 2003.