Hyperlipidaemia

Question 1

What is Hyperlipidaemia?

Answer 1

Lipids travel around the body in the form of Lipoproteins
• VLDL – Triglyceride from liver to tissue
• Chylomicrons - Triglyceride from gut to liver
• LDL - Cholesterol from liver to body
• HDL - Phospholipid from body to liver

Hyperlipidaemia is a term used to describe when there is too much total cholesterol, LDL, Triglyceride or a mix of the above. This leads to increased cardiovascular risk due to increased atheroma formation. As such we screen people with signs of Hyperlipidaemia or those with a family/medical history of cardiovascular disease. HDL is not a risk factor and is cardio protective.

Question 2

What are the causes of Hyperlipidaemia?

Answer 2

Common – Primary Idiopathic Hyperlipidaemia

Others – Diabetes, Pregnancy, Obesity, Alcohol, Cushing’s, Hypothyroidism, CKD (Nephrotic Syndrome), Obstructive Jaundice

Question 3

What will you ask about/ find on history of a patient with suspected Hyperlipidaemia

Answer 3

Symptoms:
Asymptomatic – However there may be physical signs in familial hyperlipidaemia

Risk Factors:
If in teens/20's consider familial Hyperlipidaemia
Cardiovascular risk factors 
Diabetes 
Obesity 

Specific questions to ask in a history taking:
Ask about diet and exercise - get an idea of how they live (specifically looking for high saturated fats and sedentary lifestyle)
Ask about causes of secondary Hyperlipidaemia
Other associated conditions - High Blood Pressure, Diabetes
If treatment resistant, consider referral for familial hypercholesterolaemia

Question 4

What will you look for/ find on examination of a patient with suspected Hyperlipidaemia

Answer 4

End of the bed:
Obesity (Risk Factor)
Hands:
Elbow-  tendon xanthomata (Familial)
Face:
Corneal Arcus (Familial)
Xanthalasma 
Legs:
Achilles -  tendon xanthomata (Familial)

Question 5

What investigations will you order in suspected hyperlipidaemia?

Answer 5

Bedside:
Glucose -To assess other cardiovascular risk factors and to rule out secondary hyperlipidaemia due to diabetes

Bloods:
Lipid Profile - Consists of Total Cholesterol, triglycerides, LDL, HDL, and non-HDL-cholesterol. These can also be altered in acute illness so consider patient status
TFT - Hypothyroidism can be a cause of secondary hyperlipidaemia
U&E - Assess renal function as CKD/Nephrotic Syndrome can be a cause of secondary hyperlipidaemia
LFT - Will likely be giving a statin so need to know baseline liver function and also looking for fatty liver which is associated with hyperlipidaemia

Question 6

What is the treatment of hyperlipidaemia?

Answer 6

Lifestyle:
Education about the progressive nature of the disease and cardiovascular risk factors that comes with
Optimise BMI 20-25
Mediterranean diet
Increase exercise
Low Sat fat diet, High HDL diet 
Reduce cardiac risk factors 

Medical:
Treat if QRisk2 > 10%, CVS Risk Factors, CVS disease or after lifestyle changes have made no effect
1st Line - Atorvastatin, Higher dose in secondary prevention or kidney disease
Target reduction is 40% of lipid levels
2nd Line – Add Ezetimibe
3rd Line -Add Fibrate/Anionic Exchange Resin/Nicotinic Acid/Bile acid sequestrant
In Familial - Refer to specialist e.g. Biochemists
In Secondary – Manage underlying cause as well as giving lipid lowering therapy
Hypertriglyceridemia – Fibrates and Nicotinic Acid First Line, High fish oil diet