Dyslipidaemia

Question 1

How is Hypercholesteraemia defined?

Answer 1

Serum level elevation of total Cholesterol (>5.2mmol/l)

or low-density Lipoprotein Cholesterol (LDL-C) or Non- high – density lipoprotein Cholesterol (Total Cholesterol - HDL-C)

Question 2

How is Hypertriglyceridaemia defined?

Answer 2

fasting plasma triglyceride level ≥2.3 mmol/L (≥200 mg/dL)

Question 3

What is the epidemiology of Hypercholesterolaemia?

Answer 3

50% of people in UK have high enough levels to be at risk of CHD

Question 4

What is the prevelence of Hypertriglyceridaemia?

Answer 4

• In Patients with T2DM/ insulin resistance/ metabolic syndrome or central obesity (90 percentile for triglyceride 2.8 in US)
• About 20% of population in US high

Question 5

What is the aetiology of Hypercholesterolaemia

Answer 5

• Primary
  
  • Mostly idiopathic/unknown
• There are some genetic conditions e.g. familial hypercholesterolaemia
• Secondary
  
  • Hypothyroidism, nephrotic syndrome, cholestatic liver disease, anorexia nervosa.

Question 6

What ist the aetiology of Hypertriglyceridaemia?

Answer 6

• Primary
  
  • Inherited genetic conditions (e.g. familial hypertriglyceridemia)
• Secondary
  
  • Obesity, T2DM, metabolic syndrome, Hypothyroidism, Kidney disease (Nephrotic syndrome and Dialysis), Liver disease, alcohol, CF and HIV
  • Drugs ß-blocker, thiazides, oestrogens

Question 7

What are risk factors for the development of Hypercholesterolaemia?

Answer 7

• Genetic predisposition (primary)
• Lifestyle
  
  • sedentary lifestyle, too little exercise
  • Diet with excessive consumption of saturated Fat, trans-fatty acids and total cholesterol
  • Low HDL: Smoking + abdominal obesity
• Insulin resistance and T2DM
• Obesity
• Hypothyroidism
• Cholestatic liver disease
• Anorexia nervosa

Question 8

What are risk factors for the development of Hypertriglyceridaemia?

Answer 8

• Obesity
• Insulin Resistance/T2DM
• Nephrotic syndrome/ other renal disease
• Diet: high saturated fat and carbohydrate
• Liver disease
• Hypothyroidism
• Excessive alcohol consumption

Question 9

What are symtoms of Hypercholesterolaemia?

Answer 9

• Normally Asymptomatic with presence of risk factors:
• Might show symptoms of CHD complications
• Enquire about other CVS risk factors:
  
  • Diabetes
  • Family history
  • Smoking
  • Hypertension

Question 10

What are symptoms of Hypertriglyceridaemia?

Answer 10

symptomatic, do routine blood test especially in patients with presence of risk factors

Question 11

What are signs for the presence of Hypercholesterolaemia?

Answer 11

Usually no signs

Might see lipid deposits

• Tendon Xanthoma
• Xanthelasma
• Corneal arcus

Signs of complications

• Decrease in peripheral pulses, carotid bruit other CVS signs

Question 12

What are signs of Hypertriglyceridaemia?

Answer 12

• Lipaemia retinalis
  
  • milchig-weißge gefäße in fundoskopie
• Eruptive xanthomas

Question 13

What are eruptive xanthomas?

Answer 13

Small yellowish papules, frequently surrounded by an erythematous base, that appear predominantly on the buttocks, elbows, and other pressure-sensitive areas

Question 14

What are the investigations you would do in a person with Hypercholesterolaemia/Hypertriglyceridaemia

Answer 14

• Hypercholesterolaemia
  
  • Lipid profile (Total Cholesterole, HDL, LDL, TGC)
• Hypertriglyceridaemia
  
  • Fasting triglycerides
  • Fasting glucose
• • For Both
    
    • U&E
    • LFT
    • TFT

Question 15

What is the conservative management for Hypercholesterolaemia/ Hypertriglyceridaemia?

Answer 15

• Treat Secondary cause
• Exercise, lose weight, stop smoking, control BP, control diabetes, reduce alcohol,
• dietary modification (low saturated fat, total fat and refined carbohydrates)

Question 16

What is the medical management of Hypercholesteraemia?

Answer 16

Statins

• 2nd line:
• Ezetimibe (cholesterol absorption inhibitors)
• PCSK9 inhibitors

Question 17

What is the medical management for Hypertriglyceridaemia

Answer 17

Statins

• 2nd line fibrates

Question 18

What are the possible complications of Hypertriglyceridaemia?

Answer 18

• Coronary events
• Acute Pancreatitis

Question 19

What are possible complications of Hypercholesterolaemia?

Answer 19

Atherosclerosis –> Risk factor for:

• Cerebrovascular disease
• Coronary Heart disease
• Peripheral artery disease

E.g. myocardial infarction, ischaemic cardiomyopathy, sudden cardiac death, ischaemic stroke, erectile dysfunction, claudication, and acute limb ischaemia

Question 20

What is the prognosis for a patient with Hypercholesterolaemia or Hypertriglyceridaemia ?

Answer 20

Improved since statin therapy (majorify without adverse events)

• Significantly better if measurements taken to lower Triglycerides

Question 21

What is the MOA of statins?

Answer 21

HMG-CoA reductase inhibitors –>

1. reduce hepatic cholesterol synthesis (due to inhibiting the rate limiting step
2. Cause upregulation of hepatic LDL recpetors –> increased LDL recycling leading to

Question 22

What are the effects of statins on the lipid profile?

Answer 22

• Lowering LDL
• Increaseing HDL
• Lowering Triglycerides

Question 23

What are contra-indications for the use of statins?

Answer 23

Akute liver disease

Pregnancy, Breastfeeding

Muscle disorder

Question 24

What are non-muscular side-effects of Statins?

Answer 24

• Common: Headache and GI side effects (fatulaence, constipation, diarrhoea)
• Other:
• Increase in LFT

Question 25

What are the muscular side effects of statins?

Answer 25

• Myalgia (check CK levels, continue treatment if CK levels normal)
• Statin-associated myopathy –> Discontinue treatment!
  
  • Muscle pain and weakness
  • Myositis with increased CK
  • Progression into break down of skeletal muscle –> leading to increase in myoglobulinuria –>AKI