shelly hyperlipidemia

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Hyperlipidemia Michele Ritter, M.D.  Argy Resident   February, 2007

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  • HyperlipidemiaMichele Ritter, M.D.Argy Resident February, 2007

  • The story of lipidsChylomicrons transport fats from the intestinal mucosa to the liverIn the liver, the chylomicrons release triglycerides and some cholesterol and become low-density lipoproteins (LDL).LDL then carries fat and cholesterol to the bodys 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 HyperlipidemiaDietHypothyroidismNephrotic syndromeAnorexia nervosaObstructive liver diseaseObesityDiabetes mellitusPregnancyObstructive liver diseaseAcute heaptitisSystemic lupus erythematoususAIDS (protease inhibitors)

  • Dietary sources of Cholesterol

  • Hereditary Causes of HyperlipidemiaFamilial HypercholesterolemiaCodominant genetic disorder, coccurs in heterozygous formOccurs in 1 in 500 individualsMutation in LDL receptor, resulting in elevated levels of LDL at birth and throughout lifeHigh risk for atherosclerosis, tendon xanthomas (75% of patients), tuberous xanthomas and xanthelasmas of eyes. Familial Combined HyperlipidemiaAutosomal dominantIncreased secretions of VLDLsDysbetalipoproteinemiaAffects 1 in 10,000Results 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 diseaseTuberous xanthomas, striae palmaris

  • Checking lipidsNonfasting lipid panelmeasures HDL and total cholesterolFasting lipid panelMeasures HDL, total cholesterol and triglyceridesLDL cholesterol is calculated:LDL cholesterol = total cholesterol (HDL + triglycerides/5)

  • When to check lipid panelTwo different RecommendationsAdult 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 triglyceridesRepeat testing every 5 years for acceptable valuesUnited States Preventative Services Task ForceWomen 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
  • Goals for LipidsLDL< 100 Optimal100-129 Near optimal130-159 Borderline160-189 High 190 Very HighTotal Cholesterol< 200 Desirable200-239 Borderline 240 HighHDL< 40 Low 60 HighSerum Triglycerides< 150 normal150-199 Borderline200-499 High 500 Very High

  • Determining Cholesterol Goal(LDL!)Look at JNC 7 Risk FactorsCigarette smokingHypertension (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
  • Determining Goal LDLCHD and CHD Risk Equivalents:Peripheral Vascular DiseaseCerebral Vascular AccidentDiabetes Mellitus

  • LDL Goals0-1 Risk Factors:LDL goal is 160 If LDL 160: Initiate TLC (therapeutic lifestyle changes) If LDL 190: Initiate pharmaceutical treatment2 + Risk FactorsLDL goal is 130If LDL 130: Initiate TLCIf LDL 160: Initiate pharmaceutical treatmentCHD or CHD Risk EquivalentLDL goal is 100 (or 70)If LDL 100: Initiate TLC and pharmaceutical treatment

  • Treatment of HyperlipidemiaLifestyle modificationLow-cholesterol dietExercise

  • Medications for Hyperlipidemia

  • Case # 1A 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 # 2A 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 patients goal LDL?Would you start medication, and if so, what?

  • Case # 3A 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 patients goal LDL?What medication would you consider starting in this patient?What labs would you want to monitor in this patient?