Hypercholesterolemia
Classification & external resources

Cholesterol
ICD-10	E78.0
ICD-9	272.0
DiseasesDB	6226
eMedicine	med/1073
MeSH	D006937

Hypercholesterolemia (literally: high blood cholesterol) is the presence of high levels of cholesterol in the blood ^[1]. It is not a disease but a metabolic derangement that can be secondary to many diseases and can contribute to many forms of disease, most notably cardiovascular disease. It is closely related to the terms "hyperlipidemia" (elevated levels of lipids) and "hyperlipoproteinemia" (elevated levels of lipoproteins). Familial hypercholesterolemia is a rare genetic disorder that can occur in families, where sufferers cannot properly metabolise cholesterol. Image File history File links Cholesterol. ... Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... The International Statistical Classification of Diseases and Related Health Problems (commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following codes are used with International Statistical Classification of Diseases and Related Health Problems. ... // E00-E35 - Endocrine diseases (E00-E07) Disorders of thyroid gland (E00) Congenital iodine-deficiency syndrome (E01) Iodine-deficiency-related thyroid disorders and allied conditions (E02) Subclinical iodine-deficiency hypothyroidism (E03) Other hypothyroidism (E030) Congenital hypothyroidism with diffuse goitre (E031) Congenital hypothyroidism without goitre (E032) Hypothyroidism due to medicaments and other... The International Statistical Classification of Diseases and Related Health Problems (commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Disease Bold textDatabase is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... Medical Subject Headings (MeSH) is a huge controlled vocabulary (or metadata system) for the purpose of indexing journal articles and books in the life sciences. ... Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... It has been suggested that Refractory disease be merged into this article or section. ... Overview of the citric acid cycle The citric acid cycle, one of the central metabolic pathways in aerobic organisms. ... Cardiovascular disease refers to the class of diseases that involve the heart and/or blood vessels (arteries and veins). ... Hypercholesterolemia (literally: high blood cholesterol) is the presence of high levels of cholesterol in the blood. ... Figure 1: Basic lipid structure. ... Hyperlipoproteinemia is the presence of elevated levels of lipoprotein in the blood. ... A lipoprotein is a biochemical assembly that contains both proteins and lipids and may be structural or catalytic in function. ... In medicine, familial hypercholesterolemia is a rare disease characterised by very high LDL cholesterol and early cardiovascular disease running in families. ... A genetic disorder, or genetic disease, is a condition caused by abnormal expression of one or more genes resulting in a clinical phenotype. ...

Signs and symptoms

Elevated cholesterol does not lead to specific symptoms unless it has been longstanding. Some types of hypercholesterolemia lead to specific physical findings: xanthoma (thickening of tendons due to accumulation of cholesterol), xanthelasma palpabrum (yellowish patches around the eyelids) and arcus senilis (white discoloration of the peripheral cornea). Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... A xanthoma is a deposition of cholesterol-rich material in tendons and other body parts in various disease states: Tendon xanthomas (associated with familial hypercholesterolemia, cerebrotendineous xanthomatosis and phytosterolemia) Palmar xanthomas Eruptive xanthomas See also xanthelasma Categories: Stub | Sign (medicine) ... A tendon (or fatty) is a tough band of fibrous connective tissue that connects muscle to bone, or muscle to muscle and is designed to withstand tension. ... Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... Xanthelasma (or xanthelasma palpebrarum) are sharply demarcated yellowish collections of cholesterol underneath the skin, usually around the eyes. ... Arcus senilis (or Arcus senilis corneae. ...

Longstanding elevated hypercholesterolemia leads to accelerated atherosclerosis; this can express itself in a number of cardiovascular diseases: Cardiovascular disease refers to the class of diseases that involve the heart and/or blood vessels (arteries and veins). ...

• Angina pectoris, leading to PTCA or CABG
• Myocardial infarction (heart attack)
• Transient ischemic attacks (TIAs)
• Cerebrovascular accidents/Strokes
• Peripheral artery disease (PAD)

Angioplasty is the mechanical dilation of an artery that have been obstructed, generally due to atheroma (the lesion of atherosclerosis). ... A coronary artery bypass graft (CABG) or heart bypass is a surgical procedure performed in patients with coronary artery disease (see atherosclerosis) for the relief of angina and possible improved heart muscle function. ... Acute myocardial infarction (AMI or MI), commonly known as a heart attack, is a disease state that occurs when the blood supply to a part of the heart is interrupted. ... Transient ischemic attacks (TIA) are caused by temporary disturbance of blood supply to a restricted area of brain and cause recurrent and brief (less than 24 hours) neurologic dysfunctions. ... A stroke or cerebrovascular accident (CVA) occurs when the blood supply to a part of the brain is suddenly interrupted by occlusion (an ischemic stroke- approximately 90% of strokes), by hemorrhage (a hemorrhagic stroke - less than 10% of strokes) or other causes. ... A stroke, also known as cerebrovascular accident (CVA),[1] is an acute neurological injury in which the blood supply to a part of the brain is interrupted. ... In medicine (vascular surgery), Peripheral artery occlusive disease (PAOD) is a collator for all disease caused by the obstruction of large peripheral arteries, which can result from atherosclerosis, inflammatory processes leading to stenosis, an embolism or thrombus formation. ...

Diagnosis

When measuring cholesterol, it is important to measure its subfractions before drawing a conclusion on the cause of the problem. The subfractions are LDL, HDL and VLDL. In the past, LDL and VLDL levels were rarely measured directly due to cost concerns. VLDL levels are reflected in the levels of triglycerides (generally about 45% of triglycerides is composed of VLDL). LDL was usually estimated as a calculated value from the other fractions (total cholesterol minus HDL and VLDL); this method is called the Friedewald calculation; specifically: LDL ~= Total Cholesterol - HDL - (0.2 x Triglycerides). Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... Low-density lipoprotein (LDL) is a class of lipoprotein particles that varies in size (18-25 nm in diameter) and contents (while carrying fatty acid molecules in blood and around the body). ... High-density lipoproteins (HDL) form a class of lipoproteins, varying somewhat in their size (8–11 nm in diameter), that carry cholesterol from the bodys tissues to the liver. ... Very Low Density Lipoprotein (VLDL) is a lipoprotein subclass. ... It has been suggested that Medium Chain Triglycerides be merged into this article or section. ...

Less expensive (and less accurate) laboratory methods and the Friedewald calculation have long been utilized because of the complexity, labor and expense of the electrophoretic methods developed in the 1970s to identify the different lipoprotein particles which transport cholesterol in the blood. As of 1980, the original methods, developed by research work in the mid-1970s cost about $5K, US 1980 dollars, per blood sample/person. Electrophoresis is the movement of an electrically charged substance under the influence of an electric field. ... A lipoprotein is a biochemical assembly that contains both proteins and lipids. ...

With time, more advanced laboratory analyses have been developed which do measure LDL and VLDL particle sizes and levels, and at far lower cost. These have partly been developed and become more popular as a result of the increasing clinical trial evidence that intentionally changing cholesterol transport patterns, including to certain abnormal values compared to most adults, often has a dramatic effect on reducing, even partially reversing, the atherosclerotic process. With ongoing research and advances in laboratory methods, the prices for more sophisticated analyses have markedly decreased, to less than $100, US 2004, by some labs, and with simultaneous increases in the accuracy of measurement for some of the methods. Atherosclerosis is a disease affecting the arterial blood vessel. ...

Screening

Screening for a disease refers to testing for a disease, such as hypercholesterolemia, in a patients who have no signs or symptoms of the disease. Screening, in medicine, is a strategy used to identify disease in an unsuspecting population. ...

In patients without any other risk factors, moderate hypercholesterolemia is often not treated. According to Framingham Heart Study, people with an age greater than 50 years have no increased overall mortality with either high or low serum cholesterol levels. There is, however, a correlation between falling cholesterol levels over the first 14 years and mortality over the following 18 years (11% overall and 14% CVD death rate increase per 1 mg/dL per year drop in cholesterol levels). This, however, does not mean that a decrease in serum levels is dangerous, as there has not yet been a recorded heart attack in the study in a person with a total cholesterol below 150 mg/dL. The Framingham Heart Study is a cardiovascular study based in Framingham, Massachusetts. ...

The U.S. Preventive Services Task Force (USPSTF) has evaluated screening for hypercholesterolemia ^{[2] [3]}.

Classification

See also hyperlipoproteinemia for biochemical details Hyperlipoproteinemia is the presence of elevated levels of lipoprotein in the blood. ...

Fredrickson classification

Classically, hypercholesterolemia was categorized by lipoprotein electrophoresis and the Fredrickson classification. Newer methods, such as "lipoprotein subclass analysis" have offered significant improvements in understanding the connection with atherosclerosis progression and clinical consequences. A lipoprotein is a biochemical assembly that contains both proteins and lipids. ... Electrophoresis is the movement of an electrically charged substance under the influence of an electric field. ... Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of elevated or abnormal levels of lipids and/or lipoproteins in the blood. ...

If the hypercholesterolemia is hereditary (familial hypercholesterolemia), there is more often a family history of premature, earlier onset atherosclerosis, as well as familial occurrence of the signs mentioned above. In medicine, familial hypercholesterolemia is a rare disease characterised by very high LDL cholesterol and early cardiovascular disease running in families. ... In medicine, a family history consists of information about disorders that a patients direct blood relatives have suffered from. ...

Secondary causes

There are a number of secondary causes for high cholesterol:

• Diabetes mellitus and metabolic syndrome
• Kidney disease (nephrotic syndrome)
• Hypothyroidism
• Anorexia nervosa
• Zieve's syndrome
• Family history
• Diet: Saturated fat raises blood cholesterol levels. Although dietary cholesterol exerts some influence, the regulatory mechanism of the liver upon absorption of cholesterol decreases the effect of dietary cholesterol on total cholesterol levels. Thus it is mainly by limiting the amount of saturated fat in one's diet that helps lower total serum cholesterol.^{[citation needed]}
• Weight. Being overweight is a definite risk factor for heart disease. It also tends to increase your cholesterol. Losing weight can help lower your LDL and total cholesterol levels, as well as raise your HDL and lower your triglyceride levels.
• Physical Activity. Lack of physical activity is a risk factor for heart disease. Regular physical activity can also help lower LDL (bad) cholesterol and raise HDL (good) cholesterol levels. It also helps you lose weight.

All three of these activities done together can have a positive effect on one's blood cholesterol level. For the disease characterized by excretion of large amounts of severely diluted urine, see diabetes insipidus. ... Metabolic syndrome is a combination of medical disorders that affect a large number of people in a clustered fashion. ... It has been suggested that Renal anomalies and Renal plasma threshold be merged into this article or section. ... This article or section does not cite its references or sources. ... For the symphonic black metal band, see Anorexia Nervosa (band) Anorexia nervosa is a psychiatric diagnosis that describes an eating disorder characterised by low body weight and body image distortion. ... Zieves syndrome is an acute metabolic condition that can occur during withdrawal from prolonged alcohol abuse. ... Family history is the study of multiple generations of people who appear to be related. ... In the physical sciences, weight is a measurement of the gravitational force acting on an object. ...

Dietary influence

While part of the circulating cholesterol originates from diet, and restricting cholesterol intake may reduce blood cholesterol levels, there are various other links between the dietary pattern and cholesterol levels. The American Heart Association also compiles a list of the acceptable/unacceptable foods for those who are diagnosed with hypercholesterolemia.

Carbohydrates

Evidence is accumulating that eating more carbohydrates - especially simpler, more refined carbohydrates - increases levels of triglycerides in the blood, lowers HDL, and may shift the LDL particle distribution pattern into unhealthy atherogenic patterns. Thus a low fat diet, which often means a higher carbohydrate intake, may actually be an unhealthy change. Lactose is a disaccharide found in milk. ... Triglyceride (blue: fatty acid; red: glycerol backbone) Triglycerides are glycerides in which the glycerol is esterified with three fatty acids. ... An atheroma (plural: atheromata) is an abnormal inflammatory accumulation of macrophage white blood cells within the walls of arteries. ...

Trans fats

An increasing number of researchers are suggesting that a major dietary risk factor for cardiovascular diseases is trans fatty acids, not saturated fats, as had been suggested by the Framingham Heart Study, and in the US the FDA plans revised food labeling to include listing trans fat quantities, by 2007.^{[citation needed]} A trans fatty acid (commonly shortened to trans fat) is an unsaturated fatty acid molecule that contains a trans double bond between carbon atoms, which makes the molecule less kinked compared to cis fat. Research suggests a correlation between diets high in trans fats and diseases like atherosclerosis and coronary... Saturated fat is fat that consists of triglycerides containing only saturated fatty acids. ...

Treatment

Clinical Evidence has summarized treatment for both primary prevention ^[4] and secondary prevention ^[5]. Two factors to consider when choosing therapy are the patient's risk of coronary disease and their lipoprotein pattern.

Risk of coronary disease. To calculated the benefit of treatment, there are two online calculators that can estimate baseline risk ^{[6] [7]}. Combining the baseline risk with the relative risk reduction of a treatment can lead to the absolute risk reduction of number needed to treat. For example, one of the calculators projects that a patient had a 10% risk of coronary disease over ten years. As noted below, the relative risk reduction of a statin is 30%. Thus, after 4-7 years of treatment with a statin, a patient's risk will drop to 7%. This equates to an absolute risk reduction of 3%, or a number needed to treat of 33. Thirty three such patients must be treated for 4-7 years for one to benefit.

Lipoprotein patterns. (See hyperlipoproteinemia for details) The treatment depends on the type of hypercholesterolemia. Clinical trials, starting in the 1970s, have repeatedly and increasingly found that normal cholesterol values do not necessarily reflect healthy cholesterol values. This has increasingly lead to the newer concept of dyslipidemia, despite normo-cholesterolemia. Thus there has been increasing recognition of the importance of "lipoprotein subclass analysis" as an important approach to better understand and change the connection between cholesterol transport and atherosclerosis progression. Fredrickson Types IIa and IIb can be treated with diet, statins (most prominently rosuvastatin, atorvastatin, simvastatin, or pravastatin), cholesterol absorption inhibitors (ezetimibe), fibrates (gemfibrozil, bezafibrate, fenofibrate or ciprofibrate), vitamin B3 (nicotinic acid), bile acid sequestrants (colestipol, cholestyramine), LDL apheresis and in hereditary severe cases liver transplantation. The treatment is made more complex when elevated levels of asymmetric dimethylarginine (ADMA) are present in endothelial blood, since ADMA down-regulates the production of endothelial nitric oxide production and hence aggravates the extent of oxidized LDL^{[citation needed]}.

Multiple clinical trials, each, by design, examining only one of multiple relevant issues, have increasingly examined the connection between these issues and atherosclerosis clinical consequences. Some of the better recent randomized human outcome trials include ASTEROID, ASCOT-LLA, REVERSAL, PROVE-IT, CARDS, Heart Protection Study, HOPE, PROGRESS, COPERNICUS, and especially a newer research approach utilizing a synthetically produced and IV administered human HDL, the Apo A-I Milano Trial^{[citation needed]}. The number needed to treat (NNT) is an epidemiological measure that indicates how many patients would require treatment with a form of medication to reduce the expected number of cases of a defined endpoint by one. ... Lovastatin, the first statin to be marketed The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic agents, used as pharmaceuticals to lower cholesterol levels in people at risk for cardiovascular disease because of hypercholesterolemia. ... Lovastatin, the first statin to be marketed The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic agents, used as pharmaceuticals to lower cholesterol levels in people at risk for cardiovascular disease because of hypercholesterolemia. ... The number needed to treat (NNT) is an epidemiological measure that indicates how many patients would require treatment with a form of medication to reduce the expected number of cases of a defined endpoint by one. ... Hyperlipoproteinemia is the presence of elevated levels of lipoprotein in the blood. ... Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... Hypercholesterolemia (literally: high blood cholesterol) is the presence of high levels of cholesterol in the blood. ... Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of elevated or abnormal levels of lipids and/or lipoproteins in the blood. ... Measuring body weight on a scale Dieting is the practice of eating (and drinking) in a regulated fashion to achieve a particular, short-term objective. ... Lovastatin, the first statin to be marketed The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic agents, used as pharmaceuticals to lower cholesterol levels in people at risk for cardiovascular disease because of hypercholesterolemia. ... Rosuvastatin is a member of the drug class of statins, used to treat hypercholesterolemia and related conditions, and to prevent cardiovascular disease. ... Atorvastatin (INN) (IPA: ) is a member of the drug class known as statins, used for lowering cholesterol and thereby reducing cardiovascular disease. ... Simvastatin (INN) (IPA: ) is a hypolipidemic drug belonging to the class of pharmaceuticals called statins. It is used to control hypercholesterolemia (elevated cholesterol levels) and to prevent cardiovascular disease. ... Categories: Stub | Hypolipidemic agents ... Zetia Logo Ezetimibe (IPA: ) (Zetia®, Ezemibe®, Ezetrol®) is an anti-hyperlipidemic medication. ... In pharmacology, the fibrates are a class of amphipathic carboxylic acids. ... Gemfibrozil is the generic name for a oral lipid lowering drug. ... Bezafibrate (Bezalip® and various other brand names) is a fibrate drug used for the treatment of hyperlipidaemia. ... Fenofibrate is a drug of the fibrate class. ... Niacin, also known as nicotinic acid or vitamin B3, is a water-soluble vitamin whose derivatives such as NADH play essential roles in energy metabolism in the living cell. ... In pharmacology, bile acid sequestrants a group of medication used for binding bile in the gastrointestinal tract. ... Cholestyramine (Questran®, Questran Light®, Cholybar®) is a bile acid sequestrant, which binds bile in the gastrointestinal tract to prevent its reabsorption. ... In medicine, LDL apheresis is a form of apheresis, resembling dialysis, to eliminate the cholesterol-containing particle low-density lipoprotein (LDL) from the bloodstream. ... Molecular structure of ADMA Asymmetric dimethylarginine (ADMA) is a naturally occurring chemical found in blood plasma. ... Molecular structure of ADMA Asymmetric dimethylarginine (ADMA) is a naturally occurring chemical found in blood plasma. ... The endothelium is the layer of thin, flat cells that lines the interior surface of blood vessels, forming an interface between circulating blood in the lumen and the rest of the vessel wall. ... R-phrases , , , , S-phrases , , , Supplementary data page Structure and properties n, εr, etc. ... Low-density lipoprotein (LDL) refers to a class and range of lipoprotein particles, varying somewhat in their size and contents, which carry cholesterol in the blood and around the body, for use by various cells. ... The ASTEROID trial was a clinical trial published in 2006 that shows the effects of statins (drugs that inhibit the enzyme HMG-CoA reductase) on atherosclerosis. ... The Heart Protection Study is a large randomized controlled trial by the Medical Research Council (MRC) in the United Kingdom. ... High-density lipoproteins (HDL) form a class of lipoproteins, varying somewhat in their size (8–11 nm in diameter), that carry cholesterol from the bodys tissues to the liver. ...

Diet

On the other hand, and though less dramatic than the many cardiovascular procedures, some people, especially with newer and more sophisticated information, are changing their eating and especially food supplement patterns, many of the supplements still being prescription agents. Though generally not aware of the internal changes in their cholesterol transport patterns, recent trials have demonstrated increasing success with some of these strategies; see the LDL, HDL and IVUS sections. Cholesterol is a sterol (a combination steroid and alcohol) and a lipid found in the cell membranes of all body tissues, and transported in the blood plasma of all animals. ... Low-density lipoprotein (LDL) is a class of lipoprotein particles that varies in size (18-25 nm in diameter) and contents (while carrying fatty acid molecules in blood and around the body). ... High-density lipoproteins (HDL) form a class of lipoproteins, varying somewhat in their size (8–11 nm in diameter), that carry cholesterol from the bodys tissues to the liver. ... Intravascular ultrasound (IVUS) is an medical imaging methodology using (a) specially designed long thin complex manufactured catheters attached to (b) computerized ultrasound equipment. ...

Medications

Many primary physicians and heart specialists will initially prescribe medication in combination with diet and exercise. According to various resources, statins are the most commonly used and effective forms of medication for the treatment of high cholesterol. The U.S. Preventive Services Task Force (USPSTF) estimated that after 5 to 7 years of treatment, statins can reduce the risk of coronary heart disease events is decreased by approximately 30% ^{[2] [3]}. More recently, a meta-analysis reported an almost identical reduction of 29.2% in low risk patients treated for 4.3 years ^[8]. Lovastatin, the first statin to be marketed The statins form a class of hypolipidemic agents. ... Lovastatin, the first statin to be marketed The statins form a class of hypolipidemic agents. ... A meta-analysis is a statistical practice of combining the results of a number of studies. ...

Alternative medicine

A survey released in May 2004 by the National Center for Complementary and Alternative Medicine focused on who used complementary and alternative medicine (CAM), what was used, and why it was used in the United States by adults age 18 years and over during 2002. According to this survey, CAM was used to treat cholesterol by 1.1% of U.S. adults who used CAM during 2002 ([1] table 3 on page 9). Consistent with previous studies, this study found that the majority of individuals (i.e., 54.9%) used CAM in conjunction with conventional medicine (page 6). The National Center for Complementary and Alternative Medicine or NCCAM, a division of the National Institutes of Health within the Department of Health and Human Services of the United States federal government, was established in October, 1991, as the Office of Alternative Medicine, which was re-established as the NCCAM... It has been suggested that this article or section be merged into Alternative medicine. ... See drugs, medication, and pharmacology for substances that treat patients. ...

Clinical Practice Guidelines

Various clinical practice guidelines have addressed the treatment of hypercholesterolemia. The American College of Physicians has addressed hypercholesterolemia in patients with diabetes ^[9]. Their recommendations are: The American College of Physicians (ACP) is a national organization of doctors of internal medicine (internists) -- physicians who specialize in the prevention, detection and treatment of illnesses in adults. ... This article is about the disease that features high blood sugar. ...

• Recommendation 1: Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes.
• Recommendation 2: Statins should be used for primary prevention against macrovascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors.
• Recommendation 3: Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin.
• Recommendation 4: For those patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances.

References

1. ^ Durrington P (2003). "Dyslipidaemia". Lancet 362 (9385): 717-31. PMID 12957096. 
2. ^ ^{a b} Pignone M, Phillips C, Atkins D, Teutsch S, Mulrow C, Lohr K (2001). "Screening and treating adults for lipid disorders". Am J Prev Med 20 (3 Suppl): 77-89. DOI:10.1016/S0749-3797(01)00255-0. PMID 11306236. 
3. ^ ^{a b} U.S. Preventive Services Task Force. Screening for Lipid Disorders: Recommendations and Rationale. Retrieved on Feb 26, 2007.
4. ^ Pignone M. "Primary prevention: dyslipidaemia". Clin Evid: 142-50. PMID 16620402. 
5. ^ Gami A. "Secondary prevention of ischaemic cardiac events". Clin Evid: 195-228. PMID 16973010. 
6. ^ Pignone MP; Sheridan SL. med-decisions.com. Retrieved on Feb 26, 2007.
7. ^ National Cholesterol Education Program. 10-year CVD Risk Calculator (Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (Myocardial Infarction and Coronary Death) Version). Retrieved on Feb 26, 2007.
8. ^ Thavendiranathan P, Bagai A, Brookhart M, Choudhry N (2006). "Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials". Arch Intern Med 166 (21): 2307-13. PMID 17130382. 
9. ^ Snow V, Aronson M, Hornbake E, Mottur-Pilson C, Weiss K (2004). "Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians". Ann Intern Med 140 (8): 644-9. PMID 15096336. 

A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ...

See also

• Familial hypercholesterolemia