Dyslipidemia

• Dyslipidemia

  A condition characterized by elevated serum levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non HDL-C)

  
• Elevations in levels of TC, LDL-C, and non–HDL-C are associated with risk of cardiovascular disease in adults, as are lower levels of HDL-C and, to a lesser extent, elevated triglyceride levels

  
• VLDL


  • Carries triglycerides to peripheral cells
  • High levels may be associated with increased CHD risk

  
• LDL

  • Carries cholesterol to cells
  • High levels linked to increased CHD risk
  • Primary target of cholesterol-reducing therapy
• HDL

  • Removes cholesterol from cells
  • High HDL considered protective against CHD
  • HDL >60 mg/dL decreases CHD risk
• Lipoprotein(a)

  • A complex of LDL and apolipoprotein(a)
  • Prevents LDL from being taken up by the Liver
  • Elevated Lp(a) is an independent risk factor for premature CHD

  
• Triglycerides

  • A neutral fat stored in adipose cells
  • Positively correlated with risk for CHD

  
• Familial hypercholesterolemia occurs in approximately 1 of every 200 to 500 persons in North America and Europe

  
• Recent estimates from the National Health and Nutrition Examination Survey (NHANES) indicate that 7.8% of children aged 8 to 17 years have elevated levels of TC (≥ 200 mg/dL), and 7.4% of adolescents aged 12 to 19 years have elevated LDL-C (≥ 130 mg/dL)

  
• High cholesterol reported in 35% of adults having cholesterol screening in United States in 2009

  
• Secondary causes of hyperlipidemia

  • Diet
  • Hypothyroidism
  • Nephrotic syndrome
  • Anorexia nervosa
  • Obstructive liver disease
  • Obesity
  • Pregnancy
  • DM
  • Acute hepatitis
  • Systemic lupus erythematousus
  • AIDS
  • Drugs: OCP, Thiazide,β blockers
  • Uremia
  • Alcoholi
• Familial hypercholesterolemia

  • Autosomal dominant
  • Abnormally of the LDL receptor
  • 0.2% of the general population
  • Premature CHD
  • 5% of MI survivors <60 years old
  • 1 in 500 individuals
  • High risk for atherosclerosis, tendon xanthoma,tuberous xanthomas and xanthelasmas of eyes

  
• Familial hypertriglyceridemia

  • Autosomal dominant
  • High VLDL production, decreased lipoprotein lipase activity
  • 1% of general population
  • Usually >30 years old
  • Usually after diabetes
  • May or may not have premature CHD
  • 5% of MI survivors <60 years old

  
• Familial combined hyperlipidemia


  • Autosomal dominant
  • LDL and VLDL, increased secretions of VLDLs
  • 0.5% of general population
  • Usually > 30 years old
  • Usually no xanthoma
  • Premature CHD
  • 15% of MI survivors <60 years old

  
• Dietary sources of cholesterol

  • Eggs
  • Meat
  • Dairy products
  • Seafood
• Non fasting lipid panel

  Measures HDL and total cholesterol

  
• Fasting lipid panel

  • Measures HDL, total cholesterol and triglycerides
  • LDL cholesterol is calculated: LDL cholesterol = total cholesterol – (HDL + triglycerides/5)

  
• Values of LDL cholesterol


  • <100 Optimal
  • 100-129 Near optimal
  • 130-159 Borderline
  • 160-189 High
  • ≥ 190 Very High

  
• Values of total cholesterol


  • <200 Desirable
  • 200-239 Borderline
  • ≥240 High

  
• Values of HDL cholesterol

  • <40 Low
  • ≥ 60 High

  
• Values of serum triglycerides

  • <150 Normal
  • 150-199 Borderline
  • 200-499 High
  • ≥ 500 Very High
• Screening recommendations

  • Men over 35 and woman 0ver 45
  • Anyone with atherosclerotic symptoms regardless of age
  • Anyone with diabetes regardless of age
  • Family history of premature CVD
  • Inflammatory diseases (lupus, rheumatoid arthritis, psoroasis)
  • Children of patients with severe dyslipidemia
  • HIV infection with HAART therapy
  • Clinical signs of hyperlipidemia
  • Erectile dysfunction
  • Chronic renal disease
  • Metabolic syndrome
• Management of dyslipidemia

  1. Determine lipoprotein levels

  2. Determine presence of major risk factors (other than LDL)

  3. 10 Year Risk assessment (according to Framingham point score)

  4. Initiate therapeutic lifestyle changes (TLC) if LDL is above goal

  5. Consider adding Drug Therapy

  
• Before giving drug LFT & CPK should be done
• The most effective drug in lowering LDL is statin
• The most effective drug in lowering TG is fibric acid or niacin
• The most effective drug in increasing HDL is niacin
• Follow up every 12 weeks to allow drug to take its effect
• Treatment of metabolic syndrome

  1. Treat underlying causes (overweight/obesity and physical inactivity)

  2. Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies
• When TG≥500 the risk of acute pancreatitis increased so it is so important to lower the level of TG
• Treatment of low HDL cholesterol

  First reach LDL goal, then Encourage weight management and increase physical activity
• Summary of 2013 AHA/ACC cholesterol treatment guidelines

  • Flowchart