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cules Total cholesterol equals the sum of these three components: Total cholesterol = HDL cholesterol + VLDL cholesterol + LDL cholesterol Most clinical laboratories measure the total cholesterol, the total triglycerides, and the amount of cholesterol found in the HDL fraction, which is easily precipitated from serum Most triglyceride is found in VLDL particles, which contain five times as much triglyceride by weight as cholesterol The amount of cholesterol found in the VLDL fraction can be estimated by dividing the triglyceride by 5: Triglycerides VLDL cholesterol = --------------------------5 Because the triglyceride level is used as a proxy for the amount of VLDL, this formula works only in fasting samples and when the triglyceride level is less than 400 mg/ dL At higher triglyceride levels, LDL and VLDL cholesterol levels can be determined after ultracentrifugation or by direct chemical measurement The total cholesterol is reasonably stable over time; however, measurements of HDL and especially triglycerides may vary considerably because of analytic error in the laboratory and biologic variation in a patient s lipid level Thus, the LDL should always be estimated as the mean of at least two determinations; if those two estimates differ by more than 10%, a third lipid profile is obtained The LDL is estimated as follows: Triglycerides Total HDL LDL = cholesterol cholesterol (mg/dL) --------------------------cholesterol (mg/dL) (mg/dL) 5 When using SI units, the formula becomes Triglycerides Total HDL LDL = cholesterol cholesterol (mmol/L) --------------------------cholesterol (mmol/L) (mmol/L) 22 Understanding the relationships of the different lipid fractions leads to a more accurate understanding of a patient s lipid-related coronary risk than the total cholesterol Two persons with the same total cholesterol of 275 mg/dL may have very different lipid profiles One may have an HDL cholesterol of 110 mg/dL with a triglyceride of 150 mg/dL, giving an estimated LDL cholesterol of 135 mg/dL; the other may have an HDL cholesterol of 25 mg/ dL with a triglyceride of 200 mg/dL and an LDL cholesterol of 210 mg/dL The second would have more than a tenfold higher CHD risk than the first, assuming no differences in other factors Because of high HDL cholesterol levels in women, many with apparently high total cholesterol levels have favorable lipid profiles Thus, evaluation of the lipid fractions is essential before therapy is initiated Some authorities use the ratio of the total to HDL cholesterol as an indicator of lipid-related coronary risk: the lower this ratio is, the better (In the example above, the first person would have a ratio of 275 110 = 25, while the second would have a much less favorable ratio of 275 25 = 11) Although ratios are useful predictors within populations of patients, they may obscure important information in individual patients (A total cholesterol of 300 mg/dL and an HDL of 60 mg/dL result in the.

FIGURE 4-4

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same ratio of 5 as a total cholesterol of 150 mg/dL with an HDL of 30 mg/dL) Moreover, the total cholesterol-toHDL cholesterol ratio will magnify the importance of variations in HDL measurement There is no true normal range for serum lipids In Western populations, cholesterol values are about 20% higher than in Asian populations and exceed 300 mg/dL in nearly 5% of adults About 10% of adults have LDL cholesterol levels above 200 mg/dL Total and LDL cholesterol levels tend to rise with age in persons who are otherwise in good health Declines are seen in acute illness, and lipid studies in such patients are of little value with the exception of the serum triglyceride level in a patient with pancreatitis Cholesterol levels (even when expressed as an age-matched percentile rank, such as the highest 20%) do not remain constant over time, especially from childhood through adolescence and young adulthood Thus, children and young adults with relatively high cholesterol may have lower levels later in life, whereas those with low cholesterol may show increases

Fenoldopam (Corlopam) Nicardipine (Cardene) Enalaprilat (Vasotec) Furosemide (Lasix) Hydralazine (Apresoline) Diazoxide (Hyperstat)

Reflex tachycardia, hypotension, intraocular pressure Hypotension, tachycardia, headache Excessive hypotension Hypokalemia, hypotension Tachycardia, headache, GI

5 mg/h; may increase by 1 25 mg/h every 15 minutes to 15 mg/h 125 mg every 6 hours 10 80 mg 5 20 mg intravenously or intramuscularly (less desirable); may repeat after 20 minutes 50 150 mg repeated at intervals of 5 15 minutes, or 15 30 mg/ min by intravenous infusion to a maximum of 600 mg 05 5 mg/min

May precipitate myocardial ischemia Additive with diuretics; may be continued orally Adjunct to vasodilator Avoid in coronary artery disease, dissection Rarely used except in pregnancy Avoid in coronary artery disease and dissection Use with -blocker and diuretic Mostly obsolete

Excessive hypotension, tachycardia, myocardial ischemia, headache, nausea, vomiting, hyperglycemia Necrosis with extravasation Hypotension, ileus, urinary retention, respiratory arrest Liberates histamine; use caution in allergic individuals Excessive hypotension, tachycardia, headache, angina, myocardial infarction, stroke Sedation

Trimethaphan (Arfonad)

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