Hyperlipidemia

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Clinical-manifestations 5 Laboratory 6 Management 7 More General Terms 8 Additional Terms 9 References

More Specific Terms

• hypercholesterolemia
• hypertriglyceridemia
• lecithin-cholesterol acyltransferase [LCAT] deficiency (Norum disease)

Introduction

• Hyperlipidemia: Excessive quantity of fat ( cholesterol &/or triglycerides) in the blood.

Etiology

• primary hyperlipidemia

• genetic disorders of lipoprotein metabolism

• secondary hyperlipidemia

• excess dietary intact of fat, calories, alcohol
• concurrent illnesses

• obesity*
• hypothyroidism
• nephrotic syndrome
• uremia
• cholestasis, obstructive liver disease

• primary biliary cirrhosis
• alcoholism [1]

• diabetes mellitus type 2 ( insulin resistance)*
• renal failure*

• pharmacologic agents

• corticosteroids
• thiazide diuretics
• beta-blockers*
• estrogens, oral contraceptives
• alcohol
• amiodarone
• cyclosporine
• retinoids*
• antiretroviral protease inhibitors

• smoking [1]
• combinations of 1,2,3, & 4

• * increased serum triglycerides & decreased HDL cholesterol

Clinical-manifestations

• generally asymptomatic until symptoms secondary to atherosclerosis occur

• angina pectoris
• claudication
• symptoms of TIA or stroke

• elevation of triglyceride > 1000 mg/dL may cause symptoms of pancreatitis
• xanthomas may occur on extensor tendons
• periorbital xanthelasmas may occur in familial cases

Laboratory

• fasting lipid panel

• non HDL cholesterol = total cholesterol - HDL cholesterol

• useful for serum triglycerides > 200 mg/dL
• target = target LDL cholesterol + 30 [1]

• see management for goals of therapy

• laboratory tests that have no impact on mortality [1]

• serum C-reactive protein
• serum lipoprotein<a>
• serum apolipoprotein B
• serum homocysteine

Management

• goals of therapy

• target LDL cholesterol depends upon

• presence of CAD: < 100 mg/dL
• 2 or more cardiovascular risk factors: < 130 mg/dL
• < 2 cardiovascular risk factors: < 160 mg/dL [1]

• no target for treating low HDL cholesterol [1]

• diet is primary therapy

• total fat < 30% of calories, < 10% saturated fat
• limit carbohydrates [1]
• cholesterol < 300 mg/day
• lower LDL & HDL cholesterol
• may not affect HDL cholesterol / total cholesterol [2]
• plant-based diet may have additional benefit [2]
• Mediterranean-style diet, fish-oil (2.2 g/day of w-3 polyunsaturated fat) & red yeast rice- extract (2.4-3.6 g/day) as effective as 40 mg simvastatin/day in lowering LDL cholesterol [4]
• limit alcohol consumption

• aerobic exercise - 20 to 30 minutes 3 times/week
• pharmacologic agents

• hypercholesterolemia

• HMG CoA reductase inhibitors (first choice) [1]

• beneficial effects on LDL cholesterol, HDL cholesterol, serum triglycerides

• bile acid sequestrant

• affect (lowers) mainly LDL cholesterol
• cholestyramine ( Questran) 4 g QD - TID

• nicotinic acid 1-3 g TID

• beneficial effects on LDL cholesterol, HDL cholesterol, serum triglycerides
• better for hypertriglyceridemia than statins [1]

• Probucol ( Lorelco) 500 mg PO BID
• estrogen replacement therapy

• hypertriglyceridemia

• fibrates are 1st line

• gemfibrozil ( Lopid) 600 mg PO BID

• nicotinic acid (second choice)
• statins

More General Terms

• lipid disorder (dyslipidemia)
• chronic metabolic disease

Additional Terms

• hypercholesterolemia
• hyperlipoproteinemia (HLP)

References

1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
2. Journal Watch 25(12):97, 2005 Gardner CD, Coulston A, Chatterjee L, Rigby A, Spiller G, Farquhar JW. The effect of a plant-based diet on plasma lipids in hypercholesterolemic adults: a randomized trial. Ann Intern Med. 2005 May 3;142(9):725-33. Summary for patients in: Ann Intern Med. 2005 May 3;142(9):I35. PMID: [1]
3. Prescriber's Letter 14(1): 2007 Intensive LDL Reduction: What's the Evidence? Detail-Document#: [2] (subscription needed) [3]
4. Becker DJ et al. Simvastatin vs therapeutic lifestyle changes and supplements: Randomized primary prevention trial. Mayo Clin Proc 2008 Jul; 83:758. PMID: [4]
5. National Guideline Clearinghouse
   - Disorders of lipid metabolism. Evidence-based nutrition practice guideline. ngc-guideline: [5]
   - Drug treatment for hyperlipidaemias. ngc-guideline: [6]
   - Treatment of hyperlipidaemia: aims and selection. (Finnish Medical Society Duodecim) ngc-guideline: [7]
   - Screening and management of hyperlipidemia. (Michigan Quality Improvement Consortium) ngc-guideline: [8]

hyperlipidemia