Dyslipidemia: women's health adviser.(Clinical Rounds)

While cardiovascular disease mortality in men has dropped since the early 1980s, women have not been so lucky. After a substantial drop in the early 1990s, women's rates of death from cardiovascular disease have increased steadily. Yet most women still believe that cancer--particularly breast cancer--is their greatest health risk.

This erroneous perception increases a woman's chances of developing heart disease: Women who don't see the disease as a threat don't take steps to prevent it. Ob.gyns. are in a key position to interrupt that cycle of ignorance, according to "Management of Dyslipidemia," a new monograph developed by the American College of Obstetricians and Gynecologists (Clinical Updates in Women's Health Care 11[1]:1-78, 2003).

Screening

Current guidelines from the National Cholesterol Education Program recommend performing a fasting lipid profile for every woman every 5 years, beginning at age 20. The results of this test--combined with age, smoking status, blood pressure, and family history--are the basis of formulating the patient's 10-year Framingham cardiovascular disease risk. (See the ACOG monograph for details on how to calculate risk.)

Screening also includes a thorough history and exam, with questions about a family history of heart disease and the patient's smoking status. The physical exam should include the peripheral pulses, the presence of bruits, blood pressure, height, weight, and a cardiac auscultation. It's especially important to measure the patient's abdominal girth. A waist circumference of 35 inches or greater and a body mass index of 25 or higher indicate an increased risk of coronary heart disease in women.

The total cholesterol level is not as important as the LDL cholesterol level, since LDL cholesterol is the most atherogenic lipoprotein. And while a high LDL cholesterol level (optimal is less than 100 mg/dL) is a significant risk factor, so is a low HDL cholesterol level (less than 50 mg/dL). High triglyceride levels (above 150 mg/dL) are also of concern.

While most dyslipidemia is related to unhealthy lifestyle, secondary causes include diabetes, hypothyroidism, pregnancy, hormone status, and obesity. To rule out secondary causes, lab tests should include assessment of fasting blood glucose, liver function, thyroid function, estrogen status, and a urinalysis.