Microsoft word - patient information.doc

There is quite a bit of talk about cholesterol these days. You may have seen recent
news articles about this issue. In the early 1990s, the American Heart Association, in
conjunction with the National Institute of Heath, provided guidelines called the
National Cholesterol Education Program II, also known as NCEP II. In 2003, the
American Heart Association provided newer, stricter guidelines, called NCEP III.
If interested, you can access most of this information at their website at:
You might be asking, why did the American Heart Association & the National
Institute of Health develop stricter guidelines? That’s a good question. First, within
the past decade, there has been increasing scientific evidence that cholesterol
reduction can provide both primary and secondary prevention in terms of heart
a. Primary prevention is prevention which helps prevent the problem from
developing. For example: if you maintain your car properly, that will help
prevent your car from getting in an accident (such as by making sure that
the breaks work). Granted, if you maintain your vehicle, that won’t guarantee
that you will never have an accident -- but it will help.
b. In contrast, secondary prevention helps prevent a problem from getting worse.
For example: if you wear your seatbelt, that won’t prevent an accident, but
if you get in an accident, it will help prevent serious injury.
Until the mid-1990s, there was evidence that cholesterol treatment would help people
who already had heart disease -- but there was less evidence that cholesterol treatment
would help PREVENT heart disease. Over the past several years, there has been
overwhelming evidence that cholesterol treatment can help PREVENT heart disease -
- and also help those with established heart disease. Finally, until the early 1990s
there were few medications that could safely and effectively lower cholesterol.
Newer medications have become widely available, and these newer medications now
have a proven track record for safety and efficacy. Thus, the American Heart
Association and the National Institute for Health have developed stricter guidelines
because: (a) there is more evidence that treatment is effective and (b) there are better
treatment options available.
So what is cholesterol, anyway? Cholesterol is manufactured in your liver. Cholesterol is found in every part of your body, and cholesterol is necessary for the proper growth of children. Your total cholesterol level is made up of LDL, HDL, and triglycerides. LDL (also called bad cholesterol) is the kind that can easily get stuck in your blood vessel walls, build up and cause heart attacks. It is believed that HDL (also called good cholesterol) helps clear away the LDL (bad cholesterol) so that it doesn't build up. Triglycerides are fats in the blood that increase after you eat. Triglycerides are less clearly related to coronary disease. The primary numbers which we monitor are the TOTAL cholesterol, the LDL cholesterol, and the HDL cholesterol. Under most circumstances, as a "rough approximation", your LDL is usually about two-thirds of your TOTAL cholesterol. For example: if your TOTAL cholesterol is 240, your LDL is usually around 160. At one time, you might have been told that cholesterol should be "less than 200". In recent years, we have found that "one size doesn't fit all". We have different "goals" for different people depending on their overall medical condition. Remember, cholesterol is only one of many risk factors for coronary disease. Thus, if you have few other risk factors for heart disease, then an elevation in cholesterol is not as worrisome. In contrast, if you have other conditions which might increase your risk for heart disease, then any increases in your cholesterol are more potentially serious. And of course, if your have established heart disease, your cholesterol is extremely important. The major “cholesterol goals” are as follows: a. NCEP III still has different goals for different people. If someone has established heart disease, that person should still pursue a “goal” LDL of less than 100. NOTE: IF someone has had a stroke or peripheral vascular disease, that person’s “goal” LDL is still < 100. The new feature: if someone has diabetes, even if that person does NOT have established heart disease, that person should also pursue an LDL < 100. b. If someone does NOT have heart disease, NCEP III places their “goals” based on a person’s overall 10-year risk for heart disease. 1. If that person’s estimated 10-year risk is over 20%, we would recommend that individual to pursue a goal LDL < 100. 2. If an individual’s estimated 10-year risk is 10 to 20%, we recommend that individual to pursue a goal LDL < 130. 3. All other indivudals should pursue a goal LDL < 160.
A person’s estimated 10-year risk for heart disease is found in APPENDIX A.
This is taken directly from Journal of the American Medical Association (JAMA),
Vol 285, #19, May 16, 2001, p. 2497
c. A final major change: under NCEP II, if your HDL was < 35, this was considered
an additional risk factor for heart disease. Under NCEP III, an HDL < 40 is
considered a risk factor for heart disease.
The "first-line" efforts include: diet, exercise, and cessation of smoking. (Smoking
will decrease your HDL). These measures have few "downsides". Thus, we usually
want to give "non-medication" a trial before starting medication. Once exception: if
you have just sustained a heart attack, we usually start medication when you go home
from the hospital. Since all medications have some expense and some potential for
side effects, we usually reserve medication as a "second-line".
However, despite diet & exercise, many people can not reach even a "minimal" goal
without medication. The more common medications are listed below with "Trade
Name” followed by the generic name in parentheses:
1. HMG-CoA-Reductase inhibitors: This class of medications blocks the formation
of cholesterol in the liver. These medications are generally well-tolerated,
although somewhat expensive. We need to watch your liver function, and we will
be calling you for frequent labs. These medications include:
a. Zocor (Simvastatin)
b. Mevacor (Lovastatin)
c. Pravachol (Pravastatin)
d. Lescol (Fluvastatin)
e. Lipitor (Atorvastatin)
f. Crestor
2. Niacin: this medication can cause flushing and GI upset. In addition, Niacin can
elevations in blood sugar and problems with liver enzymes. Still, many people
have taken it quite successfully. Niacin is available over-the-counter, and it is
considerably cheaper than ALL of the other agents. Even though it is over-the-
counter, you still need regular check-ups if you take Niacin!
3. Fibric Acid derivatives: these medications primarily lowers triglycerides, but
also raises HDL and lowers LDL. These medications are generally well-tolerated,
but we need to monitor your liver enzymes. These medications can interact with
the HMG-CoA Reductase inhibitors (listed in #1) above, causing a rare muscle

problem called rhabdomyolysis. Under very limited circumstances, we
sometimes combine these medications. The two most common medications in
this categlory include:
a. Gemfibrozil (LOPID)
b. Fenofibrate (TRICOR)
4. Bile Acid Sequestrants: these agents block the absorption of cholesterol from
the gut. These medications do not cause liver problems, but these medications
are prone to "bloating and gas". These medications can interfere with the
absorption of other medications.
a. Colestid (Colestipol)
b. Questran (Cholestyramine)
5. Vytorin: this is a new medication which combines both Zetia and Zocor to lower
Both the Triglycerides and the LDL cholesterol


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