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Rationale

Hypercholesterolemia is a common, important, and treatable cardiovascular risk factor. Its pathophysiology is increasingly understood, diagnostic tests are readily available, and treatment modalities range from diet and exercise to a multitude of pharmacotherapies. Competency in the evaluation and management of this problem helps develop skills in rational test selection, patient education, and design of cost-effective treatment strategies. It also draws attention to the importance of community health education and nutrition.

Prerequisites

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

  1. basic biochemistry of cholesterol and lipoprotein metabolism
  2. role of dyslipidemias in atherosclerosis
  3. basic patient education and communication skills

Specific Learning Objectives

  1. Knowledge: Students should be able to define and describe:
    1. the contribution of hypercholesterolemia to coronary heart disease (CHD) risk, including the importance of elevations in total cholesterol, LDL cholesterol, HDL cholesterol, ratio of total to HDL cholesterol, and lipoprotein subfractions
    2. the classification of dyslipidemias, including who to screen, and how often
    3. the available diagnostic studies and their use, particularly determinations of HDL, LDL and total cholesterol, as well as the need to test for other cardiovascular risk factors (see the Training Problem: Healthy Patient)
    4. the current National Cholesterol Education Program (NCEP) guidelines for treatment of hypercholesterolemia
    5. the therapeutic modalities for treatment of the common dyslipidemias, including diet, exercise, cessation of smoking, and use of statins, resins, and other agents; risks, benefits, expense, and how to choose a program
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease, including obtaining pertinent history for diagnosis of lipid disorders and presence of other cardiovascular risk factors, including:
      1. family history of early cardiovascular disease
      2. dietary fat, saturated fat and cholesterol intake
      3. smoking
      4. alcohol use
      5. presence of other CAD risk factors
      6. presence of symptoms of angina and peripheral vascular disease
      7. past history of established CAD
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including assessing for:
      1. blood pressure elevation
      2. xanthomata
      3. atherosclerotic fundoscopic changes
      4. carotid bruits
      5. S4, single S2
      6. femoral bruits
      7. diminished peripheral pulses
    3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest primary or secondary causes of dyslipidemia.
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment, based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests, when appropriate, should include:
        • lipoprotein fractions
        • TSH
        • serum glucose
    5. communication skills: Students should be able to:
      1. communicate the diagnosis, treatment plan and prognosis of the disease to patients and their families.
      2. tailor to the patient’s life-style and preferences, with emphasis on the patient’s role in treatment and maximizing compliance.
      3. address the lipid and cardiovascular risk problems in patient’s family and community as well as on an individual basis.
    6. basic procedural skills: None
    7. management skills: Students should develop an appropriate evaluation and treatment plan for patients including:
      1. design a cost-effective treatment plan that incorporates the NCEP recommendations, includes a program of dietary modification, attends to cost considerations, and takes into account the patient’s life-style
      2. provide a detailed patient education regarding diagnosis, prognosis and treatment plan
      3. monitoring response to therapy and compliance, including liver function in patients taking statin drugs, GI side effects in those taking resins, and renal function and glucose in those using niacin
      4. outline a plan of exercise and weight reduction
      5. accessing and utilizing appropriate information systems and resources to help delineate issues related to dyslipidemia
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. appreciate the importance of encouraging patients to assume responsibility for modifying their diet and increasing their exercise level
    2. appreciate the importance of treating asymptomatic patients at high risk for CAD as agressively as those with symptomatic disease