1. Fair, Joan ANP, Phd
  2. Fletcher, Barbara J. RN, MN, FAAN

Article Content

A dream is just a dream, a goal is a dream with a plan and a deadline. - -Harvey MacKay


With the new millennium, it is appropriate to look back over the past decade, to examine where we have come from and to set our sights on where we are going. Despite considerable research and health education, coronary artery disease remains as the leading cause of death for adult Americans. Is is now well accepted that abnormal blood lipids lead to increased cardiovascular morbidity and mortality and that correction of abnormal blood lipids improves these outcomes. In 1990, the Secretary of Health and Human Services published national health objectives, goals for the year 2000. Among the prevention objectives were goals to reduce the mean serum cholesterol among adults to <200 mg/dL and the prevalence of cholesterol levels >240 mg/dL to <20% of the population. 1 It is estimated that currently more than 38 million adults in the United States have cholesterol levels >240 mg/dL and that more than 4 million persons will require medications for cholesterol lowering. 2 Clearly, health care agencies and nurses must be highly engaged in the management of hyperlipidemia if the year 2000 goals are to be achieved.


Although the data are just being accumulated to tell how far we have come in achieving these national goals, some recent studies suggest we are just beginning. In a recent survey of nurses and nursing students, only 12% were able to identify ideal low-density lipoprotein (LDL) levels (the basis for initiating treatment). Furthermore, 74% of nurses felt ill prepared to counsel patients regarding lipid-lowering drug therapies. 3 Record reviews of coronary care admissions and coronary heart disease (CHD) out-patient visits indicate that documentation of cholesterol levels and prescriptions for treatment are poor. For example, LDL cholesterol was documented in <50% of CHD patients, and among those who were eligible for drug therapy based on LDL levels, therapy was prescribed in approximately 50% of patients. 4,5 These data suggest that hyperlipidemia may be undetected as well as undertreated among those who would most benefit from treatment. Nurses are particularly well suited to participate in the management of hyperlipidemia, particularly because treatment strategies include the modification of lifestyle factors such as diet and exercise. The nursing perspective views the patient, the environment, and the pathology. Thus, one of the goals of this issue of the The Journal of Cardiovascular Nursing (14:2) is to provide nurses with up-to-date knowledge to increase their active participation in the management of hyperlipidemia.


The scientific community continues to unravel the connections between lifestyle and genes and their relationships to the development of disease. There is continuing discussion and debate about the causes of hyperlipidemia: is hyperlipidemia lifestyle or genetics? Supporting arguments for both exist in research literature as well as within this issue. In a recent study, investigators from the Southeast United States and Southeast Brazil compared coronary risk factors in adult children of parents with coronary artery disease and currently enrolled in cardiac rehabilitation programs. 6 More of the Brazilian adult children reported not adhering to a low-fat diet, having a lower high-density lipoprotein (HDL) cholesterol level, and currently smoking. More of the adult children in the United States reported adhering to a low-fat diet, having elevated total cholesterol, and currently exercising. The authors concluded that coronary risk factors differed significantly in this sample of young adults with a heredity factor for coronary heart disease and that these differences may reflect geographic, social, or economic factors. Thus, these data appear to emphasize the influence of lifestyle and behavior on coronary risk factors over the familial factor. Despite the outcome of this genetic versus lifestyle debate, one must invoke the wisdom that humans do have control of their lifestyles and behavior and that may or may not include a decision in favor of compliance with pharmacologic intervention for abnormal blood lipids.


In the first article in this issue, Holm emphasizes the role of the National Cholesterol Education Program and the American Heart Association in increasing the clinician's awareness of the "need to treat" and promoting public education of risks associated with elevated cholesterol. However, cholesterol-lowering strategies remain underused. Although diet and lifestyle changes are generally the first line of treatment, it is well accepted that most individuals will require pharmacologic intervention. Whether this is because of lack of strict long-term adherence remains a question. Beneficial results of lipid-lowering agents in both primary and secondary prevention are nicely depicted in Tables 1 and 2. Holm cautions, however, that these data are from large clinical trials and not individually based and that the level of lipid lowering must be evaluated in each individual patient, especially with respect to cost utility and cost-effectiveness.


Next Gylys provides a review of the pharmaceutical agents used for hyperlipidemia. This department contribution will assist the reader in using the information in Holm's article in clinical practice. Compliance with lipid-lowering drugs can be facilitated by nurses who play a major role in patient management by evaluating and minimizing barriers and side effects related to such regimens.


Gulanick and Cofer emphasize the interrelationship of the many risk factors for cardiovascular disease and how difficult it is to isolate the effect of a specific risk factor on the lipid profile. Specifically, risk factors addressed include physical inactivity, obesity, cigarette smoking, age, elevated blood glucose, and hypertension. The effects of various antihypertensive agents on lipids are portrayed. In addition, this article provides three easy-to-read exhibits: (1) factors to consider when reviewing data on the effects of risk factors on lipids, (2) research design factors to consider when reviewing data on the effect of risk factors on lipids, and (3) predominant effects of cardiac risk factors and their treatment on lipids.


Diet controversies are discussed by Winston, St. Jeor, and Ashley. The presence or absence of evidence for very low-fat diets, transunsaturated fatty acids, omega-3 fatty acids, dietary alterations of homocysteine levels, antioxidant drugs, and phytochemicals and their effect on blood lipids are all addressed with supporting data.


Hayman meticulously examines the debate over environment versus genetics. Data from twin populations and family units are presented in detail. Collective results emphasize the importance of both genetic and environmental influences on adverse lipid levels as well as implications for clinical practice and future research. Family-based approaches to assessment and management of abnormal blood lipids are recommended, even though current systems of health care delivery are not organized to facilitate such approaches. Table 1 presents a summary of genes affecting LDL cholesterol including those implicated in familial syndromes. Additional readings are suggested for those interested in the genetic and environmental effect on abnormal blood lipids.


Allen addresses the opportunities available for nurse case managers in the management of abnormal blood lipids. She provides more than adequate data supporting both the lack of treatment and inadequate treatment of lipids in primary and secondary prevention populations. By identifying and addressing barriers to treatment, nurses can institute more effective and economical strategies for management of lipid disorders, thus facilitating the narrowing of the huge gap between knowledge of effective strategies and actual effective treatment. Future challenges will include creating cost-effective analysis models, strategies to address reimbursement issues, and modifying graduate training programs for preparation of nurse case managers specializing in lipid control.


Berra examines hyperlipidemia among women. Heart disease is the primary killer of middle-aged women. Despite this fact, coronary risk factors including hyperlipidemia are less aggressively acknowledged and treated in women than in men. Berra provides an excellent overview of gender differences related to the development of cardiovascular disease among women. Special emphasis is given to the role of hormones, triglycerides, and diabetes that can influence dyslipidemia in women.


Lamendola reviews the evidence linking elevated triglyceride levels to the development of cardiovascular disease. For several years, researchers have vacillated when considering whether elevated triglycerides is an independent predicator of CHD. As Lamendola discusses, elevated triglyceride levels are linked with many other risk factors, most importantly, low HDL, insulin resistance, and syndrome X. Evaluation of the etiology of elevated triglyceride levels is an important consideration in the overall management of hyperlipidemia. Patients with mixed dyslipidemias (elevated cholesterol and triglyceride levels) require complex evaluations and treatments. Clearly, the era of managing only total cholesterol is past.


Recognizing the multifactoral nature and causalities associated with coronary disease, Hughes reviews several of the new and emerging risk factors now linked to the development of CHD. The evidence linking factors such as lipoprotein (a), LDL particle size, hyperhomocysteinemia, infectious and inflammatory factors, and iron stores are presented, and the interrelationships with lipid factors and potential treatment strategies are discussed. As pointed out by this author, information technology has expanded so rapidly that patients are often aware of these newer risk factors just as health care professionals are learning of them. This chapter ensures that nurses will be up to date.


Although the prevention of CHD remains only a dream, we have a plan and a deadline to achieve these health goals. Every nurse reading this issue is encouraged to consider his or her own practice and develop a personal plan to ensure that the lack of detection and treatment of hyperlipidemia is indeed a problem of past decades. Meeting this goal will require the participation and active involvement of nurses. A national organization, such as the Lipid Nurse Task Force, whose mission is dedicated to promoting the role of nurses in the prevention and management of coronary risk, is a vital resource for nurses. We encourage your active participation and support of the task force.


-Joan Fair, ANP, PhD


Research Project Director; Stanford Center for Researche in Disease Prevention; Stanford University School of Medicine; Stanford, California


-Barbara J. Fletcher, RN, MN, FAAN


Clinical Associate Professor; Department of Nursing; College of Health; University of North Florida; Jacksonville, Florida


Issue Editors




1. Department of Health and Human Services. Healthy People 2000. Washington, DC: Department of Health and Human Services; 1990. [Context Link]


2. American Heart Association. Heart and Stroke Statistical Update. Dallas, Tex: AHA National Center; 1998. [Context Link]


3. Lenatsch G. Knowledge, attitudes, treatment pratices, and health behaviors of nurses regarding blood cholesterol. J Cont Ed Nurs. 1990;30:13-19. [Context Link]


4. Sueta CA, Chowdhury M, Boccuzzi SJ, et al. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease. Am J Cardiol. 1999;83:1303-1307. [Context Link]


5. Frolkis JP, Zyzanski SJ, Schwartz JM, Suhan PS. Physician noncompliance with the 1993 National Cholesterol Education Program (NCEP-ATPII) guidelines. Circulation. 1998;98:851-855. [Context Link]


6. Bueno N, Fletcher B, Fletcher G, et al. Comparison of coronary risk factors in adult children of parents with coronary heart disease enrolled in cardiac rehabilitation programs in Southeast Brazil and Southeast United States. Presented at the World Congress of Cardiac Rehabilitation, Rio de Janeiro, 1998. [Context Link]