You Need to Understand Your Cholesterol Numbers

What is Cholesterol?

Cholesterol is a waxy substance found in all cells of the body. It is essential for normal function. Cholesterol is also used by the body to make some hormones and other chemicals. About two thirds of the body’s cholesterol is made and stored in the liver. A high level of cholesterol in the blood is known as hypercholesterolemia. High blood cholesterol increases the chance of having a heart attack, stroke or chest pain. There are usually no symptoms of high cholesterol which is why everyone over the age of 20 should get their cholesterol checked every 5 years.

Once the results of the cholesterol test are available it is important to understand what these numbers mean. Cholesterol is carried through the blood stream on lipoproteins. There are three major categories of lipoproteins which are typically measured. These are HDL (high density lipoprotein), LDL (low density lipoprotein), VLDL (very low density lipoprotein).

Total Cholesterol (mg/dl)
Less Than 200	Good
200 to 239	Borderline High
240 and over	High

HDL are considered “good cholesterol” because they carry cholesterol from the body to the liver. This is good because the liver is responsible for removing cholesterol from the body. A high HDL will reduce your chances of heart disease.

HDL Cholesterol (mg/dl)
Less Than 40	Major heart disease risk
40 to 59	The higher the better
60 and above	Considered heart protective

LDL are considered “bad cholesterol” because they carry cholesterol from the liver out to the body. This is not a good thing because a high LDL is associated with an increased chance of premature heart disease and death.

LDL Cholesterol (mg/dl)
Less Than 100	Optimal
100 to 129	Near but above optimal
130 to 159	Borderline high
160 to 189	High
190 and above	Very High

VLDL are also considered to be bad because they carry triglycerides from the liver to the body. A high triglyceride level is also associated with heart disease.

Triglycerides (mg/dl)
Less than 150	Normal
150 to 199	Borderline high
200 to 499	High
Greater than 500	Very High

To get a handle on what your goal is for an ideal LDL cholesterol you need to know what your 10 year risk for heart disease. You can access the National Cholesterol Education Program’s 10 year risk calculator here. Once you know this number then find you LDL goal below.

LDL (mg/dl) Goal by Risk Level
High Risk – You have heart disease, diabetes OR a risk score of 20% or more.	Goal is less than 100
Moderate high risk – You have 2 or more risk factors and a risk score of 10 to 20%	Goal is les than 130
Moderate risk – You have 2 or more risk factors and a risk score less than 10%	Goal is less than 130
Low Risk – You have 0 or 1 risk factor	Goal is less than 160

Risk factors:

• Cigarette smoking,
• High blood pressure (140/90 or higher or on blood pressure medication)
• Low HDL (less than 140mg/dl)
• Family history of heart disease (in father or brother before age 55, in mother or sister before age 65)
• Male 45 years or older, female 55 years or older

Understanding your cholesterol numbers and how they affect your risk in development of heart disease is essential. With this information you can work with your doctor to develop a plan to improve your numbers and to reduce your risk. Medication may be needed to help you achieve your goal. In all cases, lifestyle changes will be required to achieve the maximum benefit and reduce your risks the most.

A great resource to help you make lifestyle changes to lower cholesterol can be found at the National Heart Lung and Blood institute website here. Your Guide to Lowering Cholesterol with Therapeutic Lifestyle Changes (TLC) You can print a free copy off the site or you can order a copy by calling 301-592-8573.

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Serotonin Syndrome – A Severe but Preventable Drug Reaction

On July 19, 2006 the Food and Drug Administration (FDA) issued a Public Health Advisory describing the possibility of developing life threatening serotonin syndrome if certain migraine medications are used in combination with some antidepressants.

Seroronin is a chemical found in many parts of the body including the brain, digestive tract and blood platelets. It functions in the brain to regulate mood, appetite, sleep, and memory.

Serotonin syndrome occurs when there is too much serotonin in the body. This can happen as a result of an interaction between two medications. It can also occur when starting a new medication that increases serotonin or after a dose increase of one of these medications. Serotonin syndrome can also occur from an interaction between a prescription medication and an over the counter medication or herbal supplement.

The symptoms of serotonin syndrome, which can occur within minutes to hours after adding a new medication or a dose increase of a current medication, may include:

• agitation
• coma
• diarrhea
• hallucinations
• increased and rapid changes in blood pressure
• increased body temperature
• increased heart rate
• loss of coordination
• nausea
• overactive reflexes
• restlessness
• vomiting

There are many medications in several different classes which can cause an increase in serotonin. The FDA public health advisory mentioned above refers to combining SSRI (selective serotonin reuptake inhibitors) or SNRI (selective serotonin/norepinephphrine reuptake inhibitors) antidepressants with “triptans” for migraines. Often these medications will be prescribed by two different doctors, each of which is not aware of the other medicaiton.

Here is a list of medications which could contribute to or cause serotonin syndrome. (list is not complete)

• SSRIs – citalopram (Celexa®), escitalopram (Lexapro®), fluoxetine (Prozac®, Symbiax®, Serafem®), fluvoxamine (Luvox®), paroxetine (Paxil®), sertraline (Zoloft®)
• SNRIs – duloxetine (Cymbalta®), desvenlafaxine (Pristiq®), venlafaxine (Effexor®)
• TCAs – amitriptyline (Elavil®), clomipramine (Anafranil®), desipramine (Norpramin®), doxepin (Sinequan®), imipramine (Tofranil®), nortriptyline (Pamelor®)
• MAOIs – isocarboxazid (Marplan®), phenelzine (Nardil®), tranylcypromine (Parnate®)
• Other antidepressants – buproprion (Wellbutrin®, Zyban®), trazodone (Desyrel®)
• Triptans – almotriptan (Axert®), eletriptan (Relpax®), frovatriptan (Frova®), naratriptan (Amerge®), sumatriptan (Imitrex®), zolmitriptan (Zomig®)
• Dopamine agonists – amantadine, bromocriptine (Parlodel®), levodopa (Simemet®)
• Supplements/Herbals – St. John’s Wort, panax ginseng, L-tryptophan
• Street drugs – cocaine, ecstasy, LSD “acid”
• Other medications – dextromethorphan (Robitussin DM®), lithium, buspirone (Buspar®), amphetamines (Ritalin®, Concerta®, Adderal®), linezolid (Zyvox®), tramadol (Ultram®, Ultracet®), meperidine (Demerol®), sibutramine (Meridia®)

Treatment of serotonin syndrome should be supervised by a doctor. Often the medications involved will be discontinued and patients may need to be admitted to the hospital for 24 hours for close observation. Treatment may also include IV fluids, drugs that block serotonin such as cyproheptadine (Periactin®). Muscle relaxants such as diazepam (Valium®) or lorazepam (Ativan®) may be used to decrease agitation and muscle stiffness. Symptoms can improve within 24 hours with treatment.

In conclusion there are many medications with the potential to interact and cause serotonin syndrome. Many health professionals may not be aware of this potential problem or may not be aware of the range of medications which may be involved. This condition can be prevented with good communication between health professionals and patients and with education of possible side effects and interactions.

Here is an article by the National Institutes of Health http://www.nlm.nih.gov/medlineplus/ency/article/007272.htm

Here is a brief review in CMAJ http://www.cmaj.ca/cgi/content/full/168/11/1439

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You Have PreHypertension – Now What?

So you visit the doctor’s office for what you think is just another routine physical. They take your blood pressure which has always been normal. Then you are told you have prehypertension. “What in the world is this?” you wonder. You have heard of high blood pressure (aka hypertension) but this is a new term for you. What do you do now?

Blood pressure is the force of the blood pushing on the walls of the arteries as it moves through the body. The National Institutes of Health (NIH) defines normal blood pressure as less than 120/80. The top number is systolic (pressure when the heart contracts) and the bottom number is diastolic (pressure when the heart relaxes).

Prehypertension is when blood pressure falls between hypertension and normal. It is defined as systolic blood pressure of 120–139 OR diastolic blood pressure of 80-89. A blood pressure higher than this is considered hypertension.

A blood pressure that is too high makes the heart work too hard and contributes to hardening of the arteries (atherosclerosis). It also increases the risk of heart disease, kidney failure and stroke. In the past blood pressure in the 120-139/80-89 rang was considered borderline high. This term has been changed to prehypertension in order to emphasize the significance of these numbers. Any blood pressure reading above 120/80 raises your risks and the risks increase as blood pressure increases. The term prehypertension has been adopted to highlight this is a significant condition that needs to be taken seriously and a person with prehypertension should explore possible lifestyle changes.

If left untreated, prehypertension will worsen and become hypertension. Also, both prehypertension and hypertension have no symptoms. The only way to detect either is through blood pressure monitoring. It is routine for doctors to check your blood pressure at each visit. It is also a good idea to check it yourself with a good home blood pressure monitor and track it using a blood pressure log.

If you are diagnosed with prehypertension (or hypertension) there are things you can do to keep it under control. These include:

• Eat a healthy diet – Follow the Dietary Approaches to Stop Hypertension (DASH) diet. This includes fruits, vegetables, whole grains, and low-fat dairy.
• Maintain a healthy weight – Even a small weight loss of 5 to 10 pounds can improve your blood pressure
• Increase activity – regular physical activity is essential to lower blood pressure and maintain a healthy weight. I recently heard someone say “The less you do, the less you will be able to do as you age.”
• Reduce sodium in your diet – It is recommended to keep sodium intake to less than 2400 mg per day.
• Limit alcohol – No alcohol is best but no more than one drink daily for women and two drinks daily for men.

In conclusion, prehypertension is an indicator of increased health risk and usually worsen to hypertension. If this happens you will likely need prescription medications to control your blood pressure. Lifestyle modifications can lower blood pressure and prevent or delay progression to hypertension. Home blood pressure monitoring can play a role in helping you keep your blood pressure under control. Taking prehypertension seriously may prevent or delay the use of blood pressure medications to control your blood pressure.

For more information about lifestyle modifications you can read our previous post in September 2009. http://pharmerdon.wordpress.com/2008/09/

For more information on home blood pressure monitoring you can read our previous post form October 2008. http://pharmerdon.wordpress.com/2008/10/

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