Dyslipidemia aka Hyperlipidemia aka Hypercholesterolemia

1. Dyslipidemia

2. Introduction
 Cardiovascular dse affects >70 mil Americans
- underlying dse largely preventable
 Increasingly aggressive approach in the treatment of
cholesterol
- NCEP ATP III guidelines

3. Epidemiology
 Total cholesterol & LDL Cholesterol increase
throughout life
- Atherogenic pattern characteristic of Western
society diets
 More than 50% of American adults 20y of age or older
have elevated total cholesterol
- 1/3 are aware of it

4.  Dyslipidemia – (aka hyperlipidemia, aka
hypercholesterolemia) is a disorder of elevated or
abnormal levels of lipids and/or lipoproteins in the
blood, characterized by high cholesterol, triglycerides
(TGs) or both, or low HDL levels.
- a complex disease caused by the interplay of
genetic, dietary and physiologic factors
- LDL ≥ 130mg/dl (borderline high or higher)
Diagnosis - by using fasting lipoprotein profiles and
measuring plasma levels (total cholesterol, TGs,
Lipoproteins)

5. Classification of Dyslipidemia
 Phenotype. Dyslipidemia is present in the body. You
can easily see that the type of lipid that has been
increased.
 Etiology. This classification tackles more on the reason
why the condition has happened. The reasons may
include genetic or secondary to another conditions.

6. LIPID METABOLISM (Normal Physiology)

8. Dyslipidemia Cause
 Primary Causes. (Familial) Overproduction and defective
clearance of the cholesterols TG and LDL is the result of the
mutations of single or multiple genes. The primary disorders
are the common dyslipidemia causes to the children,
although it may not affect in the most cases of adult
dyslipidemia.
 Secondary Causes. Adults are the most affected ones
when it comes to secondary causes. The causes contribute
a lot on how an adult will be affected with dyslipidemia. The
sedentary lifestyle is the most essential secondary cause.
The lifestyle includes excessive dietary intake of cholesterol,
trans fats and saturated fats. Trans fats are the fatty acids
that are either polyunsaturated or monounsaturated, in
which there are added hydrogen atoms. Trans fats are
usually used in a lot of processed foods.

9. Other secondary causes are:
 Alcohol overuse Cigarette smoking
 Inactivity
 Diabetes mellitus
 Hypertension & Obesity
 Chronic kidney disease
 Hypothyroidism, Liver disease
 Low HDL < 40mg/dl
 Age and Gender ( Men >45yo, Women >55yo )
 Other cholestatic liver diseases and primary biliary cirrhosis.
 Drugs like thiazides, retinoids, estrogens and glucocorticoids,
among others.

10.  Dyslipidemia Symptoms
 Dyslipidemia doesn’t have symptoms at all, but it can cause other
symptomatic vascular disease, like coronary artery disease.
 Eyelid xanthelasmas, tendinous xanthomas at the elbow, knee
tendons and Achilles and arcus cornea are caused by high levels of
LDL. Acute pancreatitis is caused by high levels of TGs.
 Patients that have familial hypercholesterolemia in homozygous form
can have the above findings with planar xanthomas. Patients that
have elevation of TGs in severe condition can expect having eruptive
xanthomas over their elbow, back, trunks, knees, buttocks, feet and
hands. Those with rare dysbetalipoproteinemia can expect having
palmar xanthomas and tuberous xanthomas.
 Retinal arteries and veins can have a creamy white appearance due
to the severe hypertriglyceridemia. You can also have a milky
appearance in your blood plasma when you have high lipid levels.
You can expect symptoms like paresthesias, confusion and dypsnea.

14. Determining Goal
 Identify presence of clinical atherosclerotic dse (high
risk)
 Determine presence of major risk factors
 Cigarette smoking
 HTN (BP≥ 140/90 or uncontrolled or on meds)
 Low HDL (<40mg/dl)
 Family history of premature CHD
 Age ( men ≥ 45 , women ≥ 55)
 Determine Framingham risk

19. Dyslipidemia Treatment
A. Non-Pharmacologic Treatment
 Therapeutic Lifestyle Change- diet plans include foods that are low
in cholesterol and calories and trans-fat free. Foods that are sugary
and fried must be avoided. Dairy products and red meat are taken in
moderation. In order to lower their cholesterol level, it is
recommended that patients should eat fish, vegetables, nuts and
fruits.
-eat in smaller portions and avoid their cravings.
- 3 months trial for all patients
 Smoking Cessation
 Physical Activity
 Weight Loss
 Dietary Modification
 -Reduce saturated and “trans” fats
 Increase Fiber (25g/day) and complex carbohydrates

20.  Diet remains cornerstone of therapy
 LDL lowering of 25%
 Exercise to increase HDL
 Cardioprotective affect
 Non-prescription agents
 Garlic (-6%)
 Soy protien (-9%)
 Vitamin E reduces efficacy of statins and niacin

21.  Regular Exercise- regular exercises help the patients
in losing weight, improve the functions of their lungs
and heart and to stabilize their blood pressure.
Exercise routines are adjusted to fit in the patient’s
ability level. If the patient is physically able, they are
encouraged to take walk regularly and ride bicycles.
Other activities like Pilates, Yoga, Workout classes and
weightlifting are also suggested.
*If TLC are not effective or pts. are at high CV risk or
extremely elevated LDL ( >200mg/dl ) then, TLC is
applied concurrently with Pharmacologic Tx

23. Lipid lowering drugs
B. Pharmacologic Treatment
Omega-3 fatty acids (fish oil)

24. Statin
 Synthesis of LDL cholesterol
 LDL lowering 10-70%
 Other benefits
 Reduce plasma viscosity
 Decrease platelet aggregation
 Decrease C-reactive protein levels
Adverse effect
- Elevated LFT – obtain LFT at baseline, routine monitoring is
necessary
- Rhabdomyolysis w/ acute renal failure and or myopathy –
baseline CPK and recheck CPK if symptoms suggest myopathy;
patient should be instructed to report unexplained muscle pain,
tenderness, weakness, brown urine; d/c if CPK is markedly elevated
or myopathy is suspected

25. Bile Acid Sequestrants
 Rarely used
 Bind bile acids in the intestinal lumen
 Increased clearance of cholesterol from blood
 Poorly tolerated (GI effects, Constipation, aggravate GI
conditions – IBS, Crohn’s)
 Mild LDL lowering
 Increase HDL

26. Nicotinic acid (Niacin)
 Modifies plasma lipoproteins and lipids favorably
 Effects on lipids
 LDL: dec 14%
 HDL: inc 25%
 TGs: dec 30%
 Preferred agent for patients with low HDL in whom therapeutic lifestyle
changes have already been tried
 Niacin 500-1000mg PO QHS
 Pre-treat w/ ASA 325mg PO 1-2hrs before dose to avoid ADRs (flushing,
pruritus, Gi distress)
Adverse Effect
- Flushing – taking aspirin 30 mins before aspirin, taking niacin at bedtime w/
food, avoid hot beverages, spicy foods and hot shower at time of
administration
- Hyperglycemia – caution w/ diabetes
- Upper GI Distress
- Hepatotoxic – monitor LFT 6-12 weeks

27. Fibrates
 Regulate genes that control lipid metabolism
 Indicated for hypertriglyceridemia with low LDL
 GI disturbances
Adverse Effect
- Gallstones – increase fluid intake, d/c if gallstones are found
- Myopathy – baseline CPK
- - Increase hepatic transaminase – monitor LFT every 3
months

28. Fish Oil
 Omega-3 fatty acids
 Decrease triglycerides by 20-50%
 1-4g PO QD
 Chill capsules to increase palatability
Long-term intake results in increased HDL

29. Cholesterol absorption
inhibitor
 MOA – intestinal absorption of cholesterol

30.  Dyslipidemia in Diabetes
Diabetics with dyslipidemia are diagnosed to have low HDL
cholesterol and too many triglycerides. Patients of type 2
diabetes have higher risk of having this condition. The risk
factors are having high blood glucose, being obese, and
resistant to insulin. And with the combination of these two
conditions, there is a consequence of having poor control of
their diabetes. Those diabetics with no dyslipidemia can
develop one for no apparent reasons like kidney diseases and
hypothyroidism. Patients with dyslipidemia can develop
diabetes in the future, according to studies. Female patients
that have diabetes can have higher risk of cardiac disease
because of this form.

31. There are no great limits to growth because
there are no limits of human intelligence,
imagination, and wonder.
Ronald Reagan

32. Thank you.