Hypercholesterolaemia

Question 1

A 35 year old asymptomatic man presents for a check-up. His total serum cholesterol is 6.6 mmol/L (<4.0 mmol/L). How would you assess and manage him?

Answer 1

Impression
This patient has dyslipidaemia with an elevated cholesterol. Hypercholesterolaemia carries increased risks for cardiovascular disease, so my main goals of this consult would be to further characterise these risks, screen for any other evidence of CVD/complications of high cholesterol, and institute appropriate short- and long-term management options.

Ddx:
- would want to rule out familial hypercholesterolaemia
- other causes include; obesity, physical inactivity,
alcoholism, cushings, hypothyroid, etc
- Metabolic: cushings, steroid use, hypothyroid

Question 2

Hypercholesterolaemia - History

Answer 2

History

• sx: screen for CVD; chest pain, SOB, exercise intolerance, claudication, orthopnoea
• screen for other causes: thyroid sx, Cushing sx,
• Risk factors: diabetes, HTN, obesity, fam hx, male gender, smoking and alcohol
• PMHx, FamHx, Medications
• SNAP

Question 3

Hypercholesterolaemia - Examination

Answer 3

Examination

• General appearance: obesity, SOB, exercise intolerance
• Vitals
• anthropometric measurements: BMI
• absolute cardiovascular disease risk calculation
• Cardiovascular examination: xanthelasmata, corneal arcus,

Question 4

Hypercholesterolaemia - Investigations

Answer 4

Investigations
- diagnostics already performed, Ix would mainly be around further baselines measure and characterising CVD risk

• Bedside: ECG, vitals, BSL (random)
• Bloods: FBC, HbA1C, fasting BSL, lipid panel, UEC, LFT, TSH
• Imaging: nil indicated at present

Question 5

Hypercholesterolaemia - Management

Answer 5

Management
Pharmacological
Manage according to absolute cardiovascular disease risk.
Likely not start meds straight away, would have a trial of non-pharmacological life-style interventions for 3-6 months and if no improvement in cholesterol then start medication.
- 1st line: Statin (atorvastatin, rosuvastatin)
- 2nd: ezetemibe
- 3rd: PCSK9 inhibitors (only subsidised if familial hypercholesterolaemia)
Different pathway of treatment if hypertriglyceridaemia is the predominant
- ?metformin if pre-diabetic

Non-pharmacological

• lifestyle modifications
• dietician input