Hyperlipidemia Michele Ritter, M. D. Argy Resident – February, 2007 The story of lipids



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Hyperlipidemia

  • Michele Ritter, M.D.
  • Argy Resident – February, 2007

The story of lipids

  • Chylomicrons transport fats from the intestinal mucosa to the liver
  • In the liver, the chylomicrons release triglycerides and some cholesterol and become low-density lipoproteins (LDL).
  • LDL then carries fat and cholesterol to the body’s cells.
  • High-density lipoproteins (HDL) carry fat and cholesterol back to the liver for excretion.

The story of lipids (cont.)

  • When oxidized LDL cholesterol gets high, atheroma formation in the walls of arteries occurs, which causes atherosclerosis.
  • HDL cholesterol is able to go and remove cholesterol from the atheroma.
  • Atherogenic cholesterol → LDL, VLDL, IDL

Atherosclerosis

Causes of Hyperlipidemia

  • Diet
  • Hypothyroidism
  • Nephrotic syndrome
  • Anorexia nervosa
  • Obstructive liver disease
  • Obesity
  • Diabetes mellitus
  • Pregnancy
  • Obstructive liver disease
  • Acute heaptitis
  • Systemic lupus erythematousus
  • AIDS (protease inhibitors)

Dietary sources of Cholesterol

  • Type of Fat
  • Main Source
  • Effect on Cholesterol levels
  • Monounsaturated
  • Olives, olive oil, canola oil, peanut oil, cashews, almonds, peanuts and most other nuts; avocados
  • Lowers LDL, Raises HDL
  • Polyunsaturated
  • Corn, soybean, safflower and cottonseed oil; fish
  • Lowers LDL, Raises HDL
  • Saturated
  • Whole milk, butter, cheese, and ice cream; red meat; chocolate; coconuts, coconut milk, coconut oil , egg yolks, chicken skin
  • Raises both LDL and HDL
  • Trans
  • Most margarines; vegetable shortening; partially hydrogenated vegetable oil; deep-fried chips; many fast foods; most commercial baked goods
  • Raises LDL

Hereditary Causes of Hyperlipidemia

  • Familial Hypercholesterolemia
      • Codominant genetic disorder, coccurs in heterozygous form
      • Occurs in 1 in 500 individuals
      • Mutation in LDL receptor, resulting in elevated levels of LDL at birth and throughout life
      • High risk for atherosclerosis, tendon xanthomas (75% of patients), tuberous xanthomas and xanthelasmas of eyes.
  • Familial Combined Hyperlipidemia
      • Autosomal dominant
      • Increased secretions of VLDLs
  • Dysbetalipoproteinemia
      • Affects 1 in 10,000
      • Results in apo E2, a binding-defective form of apoE (which usually plays important role in catabolism of chylomicron and VLDL)
      • Increased risk for atherosclerosis, peripheral vascular disease
      • Tuberous xanthomas, striae palmaris

Checking lipids

  • Nonfasting 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)

When to check lipid panel

  • Two different Recommendations
    • Adult Treatment Panel (ATP III) of the National Cholesterol Education Program (NCEP)
        • Beginning at age 20: obtain a fasting (9 to 12 hour) serum lipid profile consisting of total cholesterol, LDL, HDL and triglycerides
        • Repeat testing every 5 years for acceptable values
    • United States Preventative Services Task Force
        • Women aged 45 years and older, and men ages 35 years and older undergo screening with a total and HDL cholesterol every 5 years.
        • If total cholesterol > 200 or HDL <40, then a fasting panel should be obtained
        • Cholesterol screening should begin at 20 years in patients with a history of multiple cardiovascular risk factors, diabetes, or family history of either elevated cholesteral levels or premature cardiovascular disease.

Goals for Lipids

  • LDL
    • < 100 →Optimal
    • 100-129 → Near optimal
    • 130-159 → Borderline
    • 160-189→ High
    • ≥ 190 → Very High
  • Total Cholesterol
    • < 200 → Desirable
    • 200-239 → Borderline
    • ≥240 → High
  • HDL
    • < 40 → Low
    • ≥ 60 → High
  • Serum Triglycerides
    • < 150 → normal
    • 150-199 → Borderline
    • 200-499 → High
    • ≥ 500 → Very High

Determining Cholesterol Goal (LDL!)

  • Look at JNC 7 Risk Factors
      • Cigarette smoking
      • Hypertension (BP ≥140/90 or on anti-hypertensives)
      • Low HDL cholesterol (< 40 mg/dL)
      • Family History of premature coronary heart disease (CHD) (CHD in first-degree male relative <55 or CHD in first-degree female relative < 65)
      • Age (men ≥ 45, women ≥ 55)

Determining Goal LDL

  • CHD and CHD Risk Equivalents:

LDL Goals

  • 0-1 Risk Factors:
      • LDL goal is 160
      • If LDL ≥ 160: Initiate TLC (therapeutic lifestyle changes)
      • If LDL ≥ 190: Initiate pharmaceutical treatment
  • 2 + Risk Factors
      • LDL goal is 130
      • If LDL ≥ 130: Initiate TLC
      • If LDL ≥ 160: Initiate pharmaceutical treatment
  • CHD or CHD Risk Equivalent
      • LDL goal is 100 (or 70)
      • If LDL ≥ 100: Initiate TLC and pharmaceutical treatment

Treatment of Hyperlipidemia

  • Lifestyle modification
    • Low-cholesterol diet
    • Exercise

Medications for Hyperlipidemia

  • Drug Class
  • Agents
  • Effects (% change)
  • Side Effects
  • HMG CoA reductase inhibitors
  • Lovastatin
  • Pravastatin
  • LDL (18-55), HDL (5-15)
  •  Triglycerides (7-30)
  • Myopathy, increased liver enzymes
  • Cholesterol absorption inhibitor
  • Ezetimibe
  •  LDL( 14-18),  HDL (1-3)
  • Triglyceride (2)
  • Headache, GI distress
  • Nicotinic Acid
  • LDL (15-30),  HDL (15-35)
  •  Triglyceride (20-50)
  • Flushing, Hyperglycemia,
  • Hyperuricemia, GI distress, hepatotoxicity
  • Fibric Acids
  • Gemfibrozil
  • Fenofibrate
  • LDL (5-20), HDL (10-20)
  • Triglyceride (20-50)
  • Dyspepsia, gallstones, myopathy
  • Bile Acid sequestrants
  • Cholestyramine
  • GI distress, constipation, decreased absorption of other drugs

Case # 1

  • A 55-year-old woman without symptoms of CAD seeks assessment and advice for routine health maintenance. Her blood pressure is 135/85 mm Hg. She does not smoke or have diabetes and has been postmenopausal for 3 years. Her BMI is 24. Lipoprotein analysis shows a total cholesterol level of 240 mg/dL, an HDL level of 55 mg/dL, a triglyceride level of 85 mg/dL and a LDL level is 180 mg/dL. The patient has no family history of premature CAD.

Case # 1 (cont.)

  • What is the goal LDL in this woman?
  • What would you do if exercise/diet change do not improve cholesterol after 3 months?
  • How would your management change if she complained of claudication with walking?

Case # 2

  • A 40- year-old man without significant past medical history comes in for a routine annual exam. He has no complaints but is worried because his father had a “heart attack” at the age of 45. He is a current smoker and has a 23-pack year history of tobacco use. A fasting lipid panel reveals a LDL 170 mg/dL and an HDL of 35 mg/dL. Serum Triglycerides were 140 mg/dL. Serum chemistries including liver panel are all normal.

Case # 2 (cont.)

  • What is this patient’s goal LDL?
  • Would you start medication, and if so, what?

Case # 3

  • A 65 year-old woman with medical history of Type II diabetes, obesity, and hypertension comes to your office for the first time. She has been told her cholesterol was elevated in the past and states that she has been following a “low cholesterol diet” for the past 6 months after seeing a dietician. She had a normal exercise stress test last year prior to knee replacement surgery and has never had symptoms of CHD. A fasting lipid profile was performed and revealed a LDL 130, HDL 30 and a total triglyceride of 300. Her Hgba1c is 6.5%.

Case # 3 (cont.)

  • What is this patient’s goal LDL?
  • What medication would you consider starting in this patient?
  • What labs would you want to monitor in this patient?

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