Hyperlipidaemia

Question 1

Aetiology of hyperlipidaemia

Answer 1

Primary:
- Familial hypercholesterolaemia
- Polygenic hypercholesterolaemia
- Familial hyper𝛼lipoproteinaemia
- Phytosterolaemia

Secondary:
Hormonal: Hypothyroidism, pregnancy, exogenous sex-hormones
Metabolic: Diabetes, liver disease, gout, obesity, partial lipodystorphy
Renal: nephrotic syndrome, renal failure
Alcohol
iatrogenic: anti-HTN, immunosuppressants

Question 2

Signs of hyperlipidaemia on examination

Answer 2

Tendon xanthomata
Corneal arcus
Xanthelasma
Eruptive xanthoma
Ankle xanthomata

Question 3

Investigations for hyperlipidaemia

Answer 3

Full lipid profile
- Total cholesterol >7.5
- non-HDL-C
- HDL-C
- Triglyceride levels >2.3
± fasting lipid profile
LFTs: for statins
CK: for statin SE

Broome criteria for genetic testing (takes months)

U&Es/renal function
HbA1c
TFTs
Lipoprotein A

Question 4

Management for established hyperlipidaemia

Answer 4

Lifestyle
- Diet: avoid Red meat, dairy (cheese, butter, yoghurt, milk), fried foods, low carb diets
- Exercise: At least 150 minutes aerobic exercise a week
- Stop smoking

Statins (HMG-coA) - lowers LDL by 40%
Other
- Omacor (?)
- Ezetimibe - lowers by 20%, can ADD to statin
- Bempedoic acid - acts on the lipid pathway and does not have the SE of aches and pains BUT risk of gout

Question 5

Primary prevention regimen for hyperlipidaemia

Answer 5

Done if QRISK >10% + 25-84 OR T1DM, CKD, familial

1. Lifestyle
2. Medication
   First line: low-dose statin e.g. atorvastatin 20mg OD
   Second: ezetimibe ± bempedoic acid
   Third: evolocumab/alirocumab

Review annually
LFTs before statin, within 3 months of starting and at 12 months

Question 6

Secondary prevention regimen for hyperlipidaemia

Answer 6

For those who have CVD/CV event
First line: high intensity statin e.g. atorvastatin 80mg once a day
Check LFTs within 3 months of starting treatment and again at 12 months

Question 7

Complications of statins

Answer 7

Myopathy (incidence 5 cases per 100,000 person years)
Rhabdomyolysis (incidence 1.6 cases per 100,000 person years)

Question 8

Complications and prognosis of hyperlipidaemia

Answer 8

Cardiovascular disease
Stroke and TIA
Peripheral arterial disease

Vast majority of patients do well with statin therapy without adverse events
Cases of myopathy and any muscle-related symptoms associated with statin therapy generally resolve after discontinuation of treatment.