DYSLIPIDEMIA

Ruth P. Anglo, MDDepartment of Family & Community Medicine

May 5,2012

Step 1: Determine and classify lipoprotein levels

ATP Classification of LDL, Total, and HDL Cholesterol

LDL Cholesterol

< 100 mg/dL Optimal

100-129 Near Optimal

130-159 Borderline High

160-189 High

>/= 190 Very High

Total Cholesterol<200 mg/dL Desirable

200-239 Borderline high>/= 240 High

HDL Cholesterol< 40 mg/dL Low

>/= 60 High

Step 2: Identify presence of clinical atherosclerotic disease

o Clinical CHDo Symptomatic coronary artery

diseaseo Peripheral artery diseaseo Abdominal aortic aneurysm

Step 3: Major Risk Factors

o Cigarette smokingo Hypertensiono Low HDL cholesterol (<40 mg/dL)o Family history of premature CHD male: <55 years; female: <65 years o Age: men >/=45 years;

women >/= 55 years

Step 4: Determine risk category

Risk Category

LDL Goal

Initiate TLC

Consider Drug

TherapyCHD or

CHDRisk Equivalents

<100 mg/dL >/= 100

mg/dL

>/= 130 mg/dL

100-129 mg/dL (optional)

2+ Risk Factors

<130 mg/dL

>/= 130 mg/dL

>/= 160 mg/dL

0-1 Risk Factors

<160 mg/dL

>/= 160 mg/dL

>/=190 mg/dL

Therapeutic Lifestyle Changes

o Weight managemento Increase physical activityo TLC diet

- Saturated fat < 7% of calories - Cholesterol < 200 mg/dL- Fiber 10-25 g/day

Model of Steps in Therapeutic Lifestyle Changes

Visit 1: Begin lifestyle therapies

6 weeks

Visit 2: Evaluate LDL response If goal not

reached,intensify LDL-lowering therapy

6 weeks

Visit 3: Evaluate LDL response If LDL goal not reached,

consideradding drug therapy

Q 4-6 weeks

Visit N: Monitor adherence to TLC

Progression of Drug Therapy in Primary Prevention

Initiate LDL-lowering therapy

6 weeks

If LDL goal not achieved,intensify LDL-lowering therapy

6 weeks

If LDL goal not reached, intensify drug therapy

Q 4-6 mos

Monitor response and adherence to therapy

Drugs Affecting Drug Metabolism

StatinsLDL 18-55% decreaseHDL 5-15% increaseTG 7-30% decrease

S/E: Increased liver enzymes, myopathyCI: Active or chronic liver disease

Fibric AcidsGemfibrozil, Clofibrate, Fenofibrate

LDL 5-20% decreaseHDL 10-20% increaseTG 20-50% decrease

SE: Dyspepsia, gallstones, myopathyCI: severe renal disease, severe hepatic dse

Bile Acid SequestrantsCholestyramine, Colestipol

LDL 15-30% decrreaseHDL 3-5% increaseTG no change or increase

SE: GI distress, constipationCI: Dysbetalipoprotenemia,

TG >200/>400 mg/dL

Nicotinic Acid

LDL 5-25% decreaseHDL 15-35% increaseTG 20-50% decrease

SE: Flushing, hyperglycemia, hyperuricemiaupper GI distress, hepatotoxicity

CI: Chronic liver dse, severe goutDM, hyperuricemia, PUD

Identify metabolic syndrome and treat, if present after 3 months of TLC:

Risk Factor Defining Level

Abdominal Obesity Men Women

Waist circumference >102 cm (>40 in) >88 cm (>35 in)

Triglyceride >/= 150mg/dL

HDL cholesterol Men Women

<40 mg/dL < 50 mg/dL

Blood pressure >/=130/>/=85mmHg

Fasting Glucose >/= 110 mg/dL

Treatment of Metabolic Syndrome

Treat underlying causes-Intensify weight management-Increase physical activity

Treat lipid & non-lipid risk factors-Treat hypertension-Use ASA for CHD patients -Treat elevated TG and/or low HDL

Treat elevated triglycerides:

ATP III Classification of Serum TG (mg/dL)

<150 Normal150-199 Borderline high200-499 High>/= 500 Very high

Treatment of elevated triglycerides (>/= 150mg/dL)

Primary aim of therapy is to reach LDL goalIntensify weight managementIncrease physical activityIf TG is >/=200mg/dL after LDL goal is reached,set secondary goal for non-HDL cholesterol 30mg/dL higher than LDL cholesterol

Comparison of LDL Cholesterol and Non-HDL Cholesterol GoalsRisk Category LDL

Goal(mg/dL)

Non-HDL Goal

CHD and CHD Risk Equivalent

<100 <130

Multiple Risk Factors and 10-year Risk <20%

<130 <160

0-1 Risk Factor <160 <190

Treatment of Low HDL Cholesterol (40 mg/dL)

Reach LDL goalIntensify weight management and increase physical activityIf TG 200-499 mg/dL,achieve non-HDL

goalIf TG < 200 mg/dL in CHD or CHD equivalent consider nicotinic acid or fibrate

Thank you!