Ddx: Hyperlipidemia

Question 1

Ddx: Hyperlipidemia

Answer 1

Hyperlipidemia

Secondary dyslipidemis

Metabollic Syndrome

Question 2

Hyperlipidemia

Answer 2

Total cholesterol >200 mg/dL OR

low-density lipoprotein (LDL) cholesterol >130 mg/dL

High-density lipoprotein (HDL) cholesterol <40 mg/dL AND fasting triglycerides ≥150 mg/dL

Question 3

Tx:

Answer 3

Statins

The most recent American College of Cardiology/American Heart Association (ACC/AHA) cholesterol treatment guidelines discuss four high-risk groups that warrant treatment for hyperlipidemia. These include patients with established:

• Newly diagnosed atherosclerotic cardiovascular disease (ASCVD)
• Low-density lipoprotein (LDL) cholesterol level >190 mg/dL
• Patients with diabetes
• Patients with a 10-year risk of developing ASCVD of >7.5%.

High-intensity statin therapy: Atorvastatin, 40 mg to 80 mg/day, or rosuvastatin, 20 mg to 40 mg/day.

The 80-mg dose is best tolerated in younger patients and those without multiple medications or multiple comorbidities​.

The guidelines recommend high-intensity statin for patients with ASCVD who are younger than age 75 years.

The goal of high-intensity statin therapy is to lower the LDL cholesterol level by ≥50%, although routine follow-up of LDL cholesterol levels to guide therapy is not recommended.

Moderate-intensity statin therapy: Atorvastatin, 10 to 20 mg/day.

Fish oil: is high in omega-3 fatty acids and has been shown to be beneficial in lowering cholesterol. Fish oils work by decreasing secretion of triglycerides by the liver.

Gemfibrozil changes the hepatic metabolism of lipoproteins and is a logical choice for the patient with low HDL and elevated triglycerides.

Niacin was the first lipidlowering agent associated with decreased total mortality. It moderately decreases LDL, can increase HDL by 20% to 25%, and moderately decreases triglycerides.

Question 4

Tx Goals

Answer 4

Treatment Goals:

For patients with known CAD or diabetes, the treatment goal for LDL cholesterol is less than or equal to 70 mg/dL.

If the 10-year risk is greater than 20%, the LDL treatment goal should be less than or equal to 100 mg/dL.

If the risk is between 10% and 20%, the LDL treatment goal should be less than 130 mg/dL.

If the risk is less than 10%, the treatment goal should be less than 160 mg/dL.

Question 5

Secondary dyslipidemia

Answer 5

Even high-intensity statin therapy may be ineffective in the setting of untreated hypothyroidism, diabetes mellitus, obstructive liver disease, or nephrotic syndrome.

Question 6

Metabolic Syndrome

Answer 6

The clinical importance of identifying the metabolic syndrome is the increased risk for cardiovascular disease and type 2 diabetes mellitus. Persons with the metabolic syndrome should receive aggressive intervention focused on lifestyle modification to decrease weight, increase physical activity, and implement a nonatherogenic diet in addition to undergoing treatment for the significant metabolic abnormalities that define the syndrome.

The metabolic syndrome is frequently identified in patients with polycystic ovary syndrome and has also been associated with the development of other disorders, including fatty liver disease, obstructive sleep apnea, hyperuricemia, and gout.

Dx: The diagnosis of metabolic syndrome is made by the presence of three or more of the following five criteria:

Waist circumference: Men, >40 in (102 cm); Women, >35 in (88 cm)

Triglycerides: ≥150 mg/dL

High-density lipoprotein (HDL) cholesterol: Men, <40 mg/dL; Women, <50 mg/dL

Blood pressure: ≥130/85 mm Hg

Fasting glucose: ≥110 mg/dL