CM 1- Lipid Disorders
•

Risk Factors for ASVD
Prior CHD, Smoking, Peripheral vascular disease, HTN, Stroke, Diabetes, Age (>50), Obesity, Gender (Males),
Physical Inactivity, Family history
Dyslipidemia (Low HDL, High LDL, high triglycerides, lipoprotein a high, small LDL particles, Apolipoprotein Blow, TC/HDL ratio)
Classes of Lipoproteins
Cholesterol Metabolism
Dyslipidemias
Hereditary
• Familial Hypercholesterolemia
• Homozygous 1/1 million
• Heterozygous 1/500
• Familial Hypertriglyceridemia 1/500
• Familial Combined Hyperlipidemia 1/200
• Tangier Disease – rare
Clinical Presentation in FH
 Xanthelasma; Corneal arcus; Achilles tendon, Tendon, Tuberous, and Plantar xanthomas
Treatment with statins decreases the rates of MI in FH patients, reduces mortality
CM 1- Lipid Disorders
Basic Lifestyle Therapy for FH Patients
Patients with familial hypercholesterolemias (FH) shouls be counseled regarding the following lifestyle
modifications:
 Therapeutic lifestyle changes and dietary adjuncts
 Reduced intakes of saturated fats and cholesterol: total fat 25-35% of energy intake, saturated fatty acids 7%,
dietary cholesterol 200 mg/day
 Use of plant stanol or sterol esters 2g/day
 Use of soluble fiber 10-20g/day
 Physical activity and caloric intake to achieve and maintain a healthy body weight
 Limitation of alcohol consumption
 Emphatic recommendation to avoid use of any tobacco products
 Clinicians are encouraged to refer patients to registered dietitians or other qualified nutritionists for medical
nutrition therapy
Acquired
• Obesity
• Diabetes
• Thyroid disorders
• Renal disorders
• Liver disorders
• Alcoholism
• Estrogens
• Cushing’s syndrome
Elevated LDL
• Research in humans and experimental animal models has demonstrated that elevated LDL is a major causal risk
factor for development of CHD.
• Elevated LDL cholesterol is the primary target of lipid lowering therapy.
• How much is too much?
NCEP-ATP III Guidelines
LDL cholesterol
<100
100-129
130-159
160-189
>190
optimal
near optimal
borderline high
high
very high
Total cholesterol
<200
200-239
>240
desirable
borderline high
high
HDL Cholesterol
<40
low
>60
High (desirable)
CM 1- Lipid Disorders
Categories of Risk Factors
• Major, independent risk factors
• Smoking
• Hypertension
• Low HDL (< 40)
• Positive family history
• Age > 45 for M, age > 55 for F
• Elevated LDL
• Life-habit risk factors
• Obesity (BMI  30)
• Physical inactivity
• Atherogenic diet
• Emerging risk factors
• Lipoprotein (a)
• Homocysteine
• Prothrombotic factors
• Proinflammatory factors
• Impaired fasting glucose
• Subclinical atherosclerosis
ATP Screening recommendations
• Age 20- Initial fasting lipid profile
• Rescreen every 5 years if :
• LDL <160 with 0-1 risk factors
• LDL<130 with >2 risk factors
• Rescreen every 1-2 years if :
• LDL >160 with 0-1risk factors
• LDL >130 with >2 risk factors
• LDL >100 with CHD or CHD risk equivalent
Risk assessment
Count major risk factors
• For patients with multiple (2+) risk factors
• Perform 10-year risk assessment
• For patients with 0–1 risk factor
• 10 year risk assessment not required
• Most patients have 10-year risk <10%
Risk Category
CHD or equivalent
2+ risk factors
0 or 1 risk factors
10 year risk of
coronary event
>20%
10-20%
<10%
Major risk factors (exclusive of LDL cholesterol) that modify LDL Goals
• Cigarette smoking
• Hypertension (BP 140/90 mmHg or on
antihypertensive medication)
• Low HDL cholesterol (<40 mg/dL)†
• Family history of premature CHD
• CHD in male first degree relative <55 years
• CHD in female first degree relative <65 years
• Age (men 45 years; women 55 years)
• †HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the
total count.
CM 1- Lipid Disorders
CHD Risk Equivalents
• Risk for major coronary events equal to that in established CHD
• 10-year risk for hard CHD >20%
• Hard CHD = myocardial infarction + coronary death
• Carry a risk of a major coronary event equal to that of known established CHD
• Peripheral arterial disease
• Abdominal aortic aneurysm
• Symptomatic carotid artery disease
• Diabetes
Three Categories of Risk that Modify LDL-Cholesterol goals
Risk Category
LDL Goal (mg/dL)
CHD and CHD risk equivalents
<100
Multiple (2+) risk factors
<130
Zero to one risk factor
<160
Primary Prevention
• Seeks to prevent development of a disease
• First approach is lifestyle change
• Reduced saturated fat and cholesterol intake
• Weight control
• Exercise
• Smoking cessation
• Fruit, vegetables, fiber, omega-3
• Second approach includes lipid lowering agents
Secondary Prevention
• Reduces further events in patients with an established disease
• LDL-lowering drugs have been shown to
• Reduce overall mortality
• Reduce coronary mortality
• Reduce coronary events
• Reduce stroke
Acquired Dyslipidemias
• Prior to initiating lipid lowering agents check for
• Diabetes
• Hypothyroidism
• Liver disease
• Renal failure
• Medications such as estrogens, anabolic steroids, corticosteroids
Lab Evaluation
• Fasting lipid panel - (12-14 hr fast)
• Thyroid panel
• Creatinine
• Glucose
• Hepatic panel- baseline and after 1 month of therapy
• Urine for protein
• CK if they c/o myalgias or muscle weakness after initiation of therapy
CM 1- Lipid Disorders
Lipid Lowering Agents
• Cholesterol Absorption inhibitors- ezetimbe (Zetia)
• Interferes with transport across the intestinal brush border
• Fibrates-gemfibrozil (Lopid)
• lowers VLDL and triglycerides
• Bile sequestration- cholestyramine
• lowers LDL, but may raise triglycerides
• Nicotinic acid- Niacin
•
raises HDL and lowers LDL and triglycerides
• Statins- HMG-CoA reductase inhibitors (Pravachol, Lipitor, Crestor, Zocor)
• lower LDL, raise HDL and lower triglycerides
Questions
1. Which of the following is NOT a risk factor for ASVD?
A. HTN
B. Stroke
C. Diabetes
D. Elevated LDL
E. Elevated HDL
2. The primary target of medical lipid therapy is to
A. Lower LDL
B. Increase HDL
C. Lower triglycerides
D. Increase lipoprotein(a)
E. Control blood pressure
3. Most acute coronary events are caused by
A. Cholesterol emboli
B. Plaque rupture and thrombus formation
C. Coronary artery vasospasm
D. Hypertension
E. Diabetes
4. HDL cholesterol actually protects against heart disease
A. True
B. False
5. Which of the following is as big a risk factor for a major cardiac event as known coronary disease itself?
A. Elevated LDL
B. Low HDL
C. Smoking
D. Diabetes
E. Obesity
6. Lifestyle changes recommended for reducing risk of heart disease include all of the following except
A. Exercise
B. Reduced intake of saturated fat
C. Low carb diets
D. Increased fiber intake
E. Smoking cessation
CM 1- Lipid Disorders
7. Diabetes is most closely associated with
A. low LDL
B. normal HDL
C. hypertriglyceridemia
D. lipoprotein (a)
E. increased deep vein thrombosis
8. Diabetes increases risk for
A. Coronary disease
B. Stroke
C. Renal disease
D. Peripheral vascular disease
E. All of the above
9. Hypertriglyceridemia increases risk for
A. Diabetes
B. Heart disease
C. Pancreatitis
D. Insulin resistance
E. All of the above
10. The best initial approach to hypertriglyceridemia is
A. Weight loss
B. One or two glasses of wine per day
C. One aspirin per day
D. Reduced fat intake
E. Medical therapy
11. All of the following can be causes of hyperlipidemia except
A. Diabetes
B. Hypothyroidism
C. Emphysema
D. Liver disease
E. Renal disease
12. Certain medications such as anabolic steroids can lower HDL levels
A. True
B. False
13. Increased HDL is associated with
A. Stroke
B. Peripheral vascular disease
C. MI
D. Longevity
E. Hypertriglyceridemia