Special
Considerations
Alcohol
Although alcohol does cause a rise in HDL cholesterol, it is not certain that this effect affords any protection against atherosclerosis. Because of the well known adverse effects, it is not recommended for the prevention of coronary heart disease.
Hypertension
Beta blockers raise triglycerides and lower HDL levels. Lipids levels should be monitored and lipid lowering therapy instituted when needed.
Hormonal
Replacement Therapy
Data suggests that the incidence of CHD is dramatically reduced by post-menopausal hormonal replacement therapy (HRT). This is especially true in women who have had hysterectomies and who, therefore, do not need to have a concomitant progestin added.
Antioxidants
Antioxidant therapy may be useful in preventing atherosclerosis. By inhibiting the oxidation of LDL, chemotactic factors are not secreted thus preventing the migration of monocytes to the vessel wall and subsequent inflammatory reaction. Vitamin E and possibly C may be useful in this regard. Beta Carotene should be avoided as it has recently been shown that it does not bestow protection and actually may increase the risk of cancer in cigarette smokers.
Homocysteine
High plasma levels of the amino acid homocysteine have been found to be an independent risk factor for the development of coronary heart disease. Homocysteine levels can be reduced by the ingestion of folic acid, vitamin B6 and vitamin B12. Although there are no prospective randomized trials demonstrating that homocysteine modification using vitamin supplementation reduces heart disease, this therapy may be of value in high risk patients.
Elderly
Because the elderly are especially vulnerable to the side effects of drugs and have survived for years without them, a conservative approach should be taken. Additionally, one must remember that it takes several years before seeing a favorable effect of lipid lowering therapy in primary prevention. One still should strongly consider cholesterol lowering drugs in elderly patients with known atherosclerosis.
