Dyslipidaemia Flashcards
What is dyslipidaemia?
Abnormal lipid and/or lipoprotein levels in the blood. It includes elevated cholesterol, triglycerides, or lipoproteins.
Effect of dyslipidaemia? What other conditions can it cause?
Increase CVD risk, endothelial dysfunction and atherogenesis.
Two pathways of lipid metabolism?
- Exogenous pathway (where dietary lipids are absorbed and transported to tissues)
- Endogenous pathway (where lipids are synthesized and delivered to tissues via VLDL)
Exogenous pathway
triglycerides and cholesterol absorbed from the diet are transported by chylomicrons to peripheral tissues. After getting rid of the triglycerides, the remaining chylomicron remnant is cleared by the liver via the LDL receptor (LDLR).
Endogenous pathway
Delivers cholesterol and lipids to tissues via very low-density lipoproteins
(VLDL).
Two classes of dyslipidaemia
Primary and secondary dyslipidaemia
What is primary dyslipidaemia caused by?
Caused by genetic predisposition and dietary factors.
What is secondary dyslipidaemia caused by?
Caused by underlying medical conditions or drug therapy (up to 40% of cases).
Can be reversed !!
What is Familial Hypercholesterolaemia (FH)?
Common primary dyslipidaemia
Genetic condition that leads to very high cholesterol levels, increasing the risk of cardiovascular disease at an early age.
The heterozygous form affects 0.2% of the population, while the homozygous form is rare and can lead to cardiovascular disease in childhood.
Drugs that affect lipid profiles
alcohol, sex hormones, corticosteroids, thiazide diuretics, beta-blockers, some of corticosteroids, antipsychotics, antiretroviral drugs etc.
Medical conditions known to cause/contribute to dyslipidaemia
Diabetes mellitus, hypothyroidism, chronic kidney disease, chronic liver disease, etc.
What is the recommended lipid screening?
NHS Cardiovascular Risk Assessment
NHS CV Risk Asssessment
- Available to individuals aged 40-74 years in England. (free)
- identify high-risk individuals, prioritizing those with a 10-year CVD risk of 10% or more.
- Includes blood lipid level assessment as part of evaluation.
What is measured
o Total cholesterol
o LDL (Low-Density Lipoprotein) cholesterol ( causes plaque build up)
o HDL (High-Density Lipoprotein) cholesterol (good, removes LDL from blood)
o Triglycerides.
Who are risk calculators not recommended for?
not recommended for patients with established CVD, chronic kidney disease (stage 3 or higher), familial hypercholesterolaemia, or type 1 diabetes.
Risk Assessment Tools
QRISK®2 and JBS3
First line treatment
Statins for hypercholesterolaemia and moderate hypertriglyceridaemia.
Second line treatment and when it is used
If dyslipidaemia is not controlled with the maximal dose- Ezetimibe. To be used as an additional lipid-lowering drug.
If a statin is contraindicated/not tolerated, use..
Inclisiran:
o A small interfering RNA that reduces the production of PCSK9.
o This increases the uptake of LDL cholesterol and reduces its blood levels.
It can be used:
▪ In combination with statins and other lipid-lowering drugs.
▪ Alone if statins are contraindicated or poorly tolerated.
When are alirocumab and evolocumab considered as treatment?
o Used for patients with primary heterozygous familial hypercholesterolaemia (a genetic condition).
o Considered for patients whose LDL-cholesterol has not been adequately controlled despite maximum tolerated lipid-lowering therapy.
Statins MOA
They help lower cholesterol levels by inhibiting HMG-CoA reductase, an enzyme involved in cholesterol synthesis.
What counselling should be given to a patient starting statins?
Counsel the patient on potential side effects (e.g., muscle pain, liver function changes), the importance of adherence, regular follow-up, avoiding grapefruit, and maintaining a healthy lifestyle alongside medication.
When should drug therapy be considered for dyslipidaemia?
Drug therapy, particularly statins, should be considered for individuals with a 10% or greater 10-year cardiovascular disease risk, calculated using the QRISK®3 tool, especially when lifestyle changes are insufficient.
Primary prevention for pt with no CVD
Antiplatelet Therapy: Aspirin isn’t = limited benefits and increased bleeding risk.
* Antihypertensive Therapy: Offered to high-risk patients with sustained hypertension.
o Lipid-lowering Therapy:
o Statins: Target >40% reduction in non-HDL cholesterol; review annually.
o Alternatives: Ezetimibe or bile acid sequestrants for statin intolerance or as add-ons if cholesterol remains uncontrolled. Fibrates may be used for high-risk patients with hypertriglyceridemia and low HDL.
Secondary prevention for pt with CVD
- Antiplatelet Therapy: Low-dose daily aspirin is recommended; use clopidogrel if aspirin is intolerable or contraindicated.
- Antihypertensive Therapy: Recommended for patients with CVD and sustained high blood pressure.
- Lipid-lowering Therapy: Statins. Low-dose atorvastatin is used for CKD. Avoid high-dose simvastatin unless necessary. Annual reviews essential, aiming for >40% non-HDL-cholesterol reduction.
- Additional Options: Add ezetimibe if statins fail; bile acid sequestrants (e.g., colestyramine) are rarely recommended. Icosapent ethyl is suitable for
elevated triglycerides and LDL-cholesterol in specific ranges. - Psychological Risk Factors: Treat mood or anxiety disorders; SSRIs are preferred for depression in coronary heart disease. Refer complex cases to mental health specialists.
- Before Drug Treatment: Address secondary causes of dyslipidaemia (e.g., thyroid disorders, diabetes). Provide dietary and lifestyle advice alongside medications.
Lifestyle advice for prevention of CVD
- Eat at least 5 portions of fruit & veg per day
- Smoking cessation (if a smoker)
- Reduce salt intake to less than 6g per day to manage blood pressure
- Encourage at least 150 minutes of moderate-intensity activity or 75 minutes of
vigorous-intensity activity per week. - Increase omega-3 fatty acids from oily fish and fiber from whole grain,
legumes and veg - Promote weight management to achieve and maintain a healthy weight (BMI 18.5 to
24.9)
