Hyperlipidaemia Flashcards
What are the 4 classes of lipids?
Chylomicrons (mainly triglyceride)
VLDL (mainly triglyceride)
LDL (mainly cholesterol)
HDL (mainly phospholipid)
Evidence that cholesterol is a major risk factor for?
Cardiovascular disease (CVD)
may even be the green light that allows other risk factors to act
proportion of the UK population with a high serum cholesterol
half the uk population
putting them at a significant risk of CVD. HDL appears to correlate inversely with CVD.
Who to screen for hyperlipidaemia?
Those at risk of hyperlipidaemia: family history of hyperlipidaemia, corneal arcus <50 years old, xanthomata or xanthelasmata
Those at risk of CVD: known CVD, family history <60 years old, DM or impaired glucose tolerance, hypertension, smoker, high BMI, low socioeconomic or Indian asian background
Types of hyperlipidaemia
Common primary hyperlipidaemia: 70% of hyperlipidaeima, high LDL only
Familial primary hyperlipidaemias: multiple phenotypes exist, risk of CVD high!!
Secondary hyperlipidaemias: Causes include: Cushing’s syndrone, hypothyroidism, nephrotic syndrome, or cholestasis, high LDL, treat the cause first
Mixed hyperlipidaemia: Results in high LDL and triglycerides. Caused by type 2 diabetes mellitus, metabolic syndrome, alcohol abuse, and chronic renal failure
Lifestyle management of hyperlipidaemia?
Aim for BMI 20-25
Encourage mediterranean-style diet
Fruit, veg, fish, unsaturated fats, less red meat, EXERCISE
Top RISK priority are those with known CVD, second priority is primary prevention in patients with CKD or type 1 diabetes.
Medical management of hyperlipidaemia?
1st line: Atorvastatin 20mg PO at night, for primary prevention, and 80mg for secondary prevention and primary prevention in those with kidney disease
2nd-line: Ezetimibe - a cholesterol absorption inhibitor, may be used in statin intolerance or combination with statins to achieve target reduction
3rd-line: Alirocumab
Atorvastatin is CI in?
Porphyria, cholestasis, pregnancy
SE of Atorvastatin?
Myalgia with or without myositis
abdominal pain and increased LFTs
(stop if AST more than >100u/L)
Cytochrome P450 inhibitors increase serum concentrations (eg grapefruit juice)
What is Alirocumab?
(3rd line therapy for hyperlipidaemia)
monoclonal antibody against PCSK9 (acts to reduce hepatocyte LDL receptor expression)
Very effective in reducing LDL, but expensive and needs to be given by injection every 2 weeks
Hypertriglyceridaemia responds best to?
fibrates, nicotinic acid, or fish oil
What are xanthomata?
Yellow lipid deposits which may be - eruptive (itchy nodules in crops in hypertriglyceridaemia)
- Tuberous (plaques on elbows and knees)
- planar (also called palmar, orange streaks in palmar creases)
diagnostic of remnant hyperlipidaemia or in tendons, eyelids (xanthelasma), or cornea
Primary prevention
10 year CVD risk >10% OR most type 1 diabetics OR CKD if eGFR < 60ml/min/m2
= Atorvastatin 20mg od
(if non-HDL has not fallen by >-40% then consider titrating up to 80mg)
Secondary prevention
Known ischaemic heart disease OR cerebrovascular disease OR peripheral arterial disease
= Atorvastatin 80mh od
In the vast majority of patients the cholesterol measurements will be fed into the QRISK2 tool. If however, the patient’s cholesterol is very high we should consider familial hyperlipidaemia. NICE recommend the following that we should consider the possibility of familial hypercholesterolaemia and investigate further if:
the total cholesterol level greater than 7.5 mmol/L and/or
there is a personal or family history of premature coronary heart disease (an event before 60 years in an index person or first-degree relative [parents, siblings, children])
