Hyperlipidaemia Flashcards
What are the risk factors of hyperlipidaemia?
Non-modifiable:
- Increasing age (most important risk factor for CHD)
- Male gender (3-4x higher in men compared to pre-menopausal women; post-menopausal women have increased CHD risks)
- Family history of premature CHD
- Indian ethnicity
Modifiable:
- Dyslipidaemia
- Hypertension
- Diabetes mellitus (as high risk of developing AMI compared to non-diabetic with previous MI)
- Cigarette smoking (~2x risk of CHD)
- Obesity
- Sedentary lifestyle
- Stress
Others:
- Elevated C-reactive protein levels
- Elevated homocysteine levels
- Elevated lipoprotein (a) levels
- Elevated fibrinogen levels
What are the physical examination findings in someone with hyperlipidaemia?
- Tendon xanthomas: seen on Achilles, elbows and hands; imply LDL>7.76mmol/L (>300mg/dL)
- Eruptive xanthomas: pimple-like lesions on extensor surfaces; imply TG>11.29mmol/L (>1000mg/dL)
- Xanthelasma: yellowish streaks on eyelids seen in various dyslipidaemias
- Corneal arcus: common in older adults, imply hyperlipidaemia in young patients
Who/ when/ what to screen for hyperlipidaemia?
All patients > 40YO
All patients >18YO w/ RF including: Smoking, Obesity
Patients with vascular diseases including: PVD, CVA, CAD, HTN, DM / IFG / IGT
- FHx of CV Dz before 50YO in make relatives OR before 60YO in female relatives
- What this means = screen anyone w/ Metabolic Syndrome or Complications
All patients with family hx of familial hypercholesterolemia 🡪 screening can start as early as 2YO
A lipid profile should include TC, TG, LDL cholesterol and HDL cholesterol. These should be obtained after 10 to 12 hours of fasting, which is required for the
measurement of TG.
What is the recommended LDL cholesterol target level?
The recommended LDL cholesterol target level for the very high risk group is <2.1mmol/L (80mg/dL)
- Established CAD (eg: post AMI, severe IHD), CVA, AAA, PVD
- DM with CKD (stage 3, eGFR < 60)
- Familial hypercholesterolemia
The recommended LDL cholesterol target level for the high risk group is <2.6mmol/L (100mg/dL)
- Moderate-severe CKD (eGFR <60) w/o DM
- DM without established CAD or CKD (stage 3)
- Not falling into the categories above but having a 10-year CAD risk of >20%
The recommended LDL cholesterol target level for the intermediate risk group is <3.4mmol/L (130mg/dL)
- 10-20% 10-year CAD risk
The recommended LDL cholesterol target level for
the low risk group is <4.1mmol/L (160mg/dL)
- <10% 10-year CAD risk
What is the management for HL?
Lifestyle changes
- Patients who smoke should be advised to stop smoking immediately.
- If body mass index is above 23 kg/m2, weight reduction through diet modification and exercise is recommended
- 150 to 300 minutes per week (~30-60 minutes per day) of moderate intensity aerobic activity spread out over 5 to 7 days per week
- A diet rich in wholegrain foods, vegetables, fruit, legumes, nuts, fish and unsaturated oils and low in
saturated and trans fat, refined grains and cholesterol should be encouraged.
Drug therapy
- Statins are the first line drug for both hypercholesterolemia (elevated LDL cholesterol) and mixed hyperlipidemia when pharmacotherapy is indicated, except when TG > 4.5mmol/L (400mg/dL).
What are the C/Is for statins?
Active liver dz, Decompensated Liver Cirrhosis
Pregnancy, breastfeedin
What are the S/Es for statins?
SE dose dependent: muscle symptoms (myalgia, myositis, rhabdo, pain, tenderness, cramping, weakness), hepatotoxicity (e.g. elevated LFTs, fatigue, weakness, loss of appetite, jaundice)
- Do LFT for baseline PRIOR to starting statins
What are the C/Is for fibrates?
Severe hepatic Dz
Severe Renal dz CrCl<30
PBC, Pre-existing gallbladder dz
What are the S/Es for fibrates?
No mortality benefit in primary prevention
SE:
- common: GI upset, rash, abdo pain
- Rare: decreased renal function, myopathy
What are the C/Is for niacins?
Severe PUD
Chronic liver dz
Severe gout
What are the s/es niacins?
No mortality benefit in primary prevention
SE: flushing, may increase uric acid and glucose
What are the C/Is for bile acid binding resins?
Complete biliary or bile obstruction
What are the S/Es of bile acid binding resins?
No mortality benefit in primary prevention
SE: GI (constipation, nausea, bloating)🡪 poor adherence
DI: separate from warfarin, digoxin and amiodarone >2h
Before meals
What are the S/Es of omega3 FA
Reasonable alternative in pts with CHD and cannot tolerate statins.
SE: dyspepsia, diarrhoea, fishy taste
What are the investigations needed to initiate statin therapy?
Order baseline LFTs + Creatinine Kinase
Pt w/ transaminitis <3x upper limit of normal can still be considered for statin therapy.
Pt w/ transaminitis >3x upper limit of normal statin use is C/I –> refer too gastro
Pt with CK > 5x upper limit of normal –> Refer to gen med for further evaluation
Pt with CK >10x upper limite of normal –> refer to emed TRO rhabdomyolysis
