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Hyperlipidaemia (E&M) Flashcards

1
Q

Define hyperlipidaemia.

A

Elevated blood lipid levels (total cholesterol, LDL, triglycerides)

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2
Q

What are the different classes of lipids? (4)

A
  • chylomicrons
  • VLDL (triglyceride)
  • LDL (cholesterol)
  • HDL (phospholipid)
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3
Q

What are some causes of hyperlipidaemia? (7)

A
  • obesity
  • DM
  • physical inactivity
  • hypothyroidism
  • nephrotic syndrome
  • alcohol
  • cholestatic liver disease
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4
Q

How can hypertriglyceridaemia be classified?

A
  • primary or secondary
  • increased VLDL, reduced VLDL clearance or both
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5
Q

What is primary hypertriglyceridaemia?

A
  • familial hypertriglyceridaemia (types IV and V)
  • familial combined dyslipidaemia (types IIb and IV)
  • polygenic hypocholesterolaemia (type IIb) and broad beta disease (type III)
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6
Q

What medications can cause hypertriglyceridaemia?

A
  • glucocorticoids
  • oestrogens
  • 13-cis-retinoic acid (Accutane)
  • some antihypertensives (hydrochlorthiazide and non-selective beta-blockers), antiretroviral therapy, interferons
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7
Q

What is hypercholesterolaemia?

A
  • as a result of abnormal lipoprotein metabolism
  • reduction of LDL receptor expression or activity
  • diminishes hepatic LDL clearance from plasma
  • common primary hyperlipidaemia (only LDL high) - accounts for 70%
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8
Q

What is familial hypercholesterolaemia (FH)?

A
  • autosomal dominant inherited disorder
  • caused by a mutation in the gene coding the LDL receptor
  • causes early-onset hypercholesterolaemia and hyperlipidaemia –> CVD in young patients
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9
Q

What does hyperlipidaemia increase risk of?

A

Elevated LDL and reduced HDL –> promote atherosclerosis –> increased risk of cardiovascular events

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10
Q

What is mixed hyperlipidaemia?

A

Both LDL and triglycerides high - due to T1DM, metabolic syndrome, alcohol abuse, chronic renal failure

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11
Q

What are the clinical features of hyperlipidaemia? (5)

A
  • xanthomata - nodular lipid deposits in the skin and tendons
  • xanthoma - tendinous especially Achilles tendon, elbow and knee tendons, and over MCPJs
  • xanthelasma - yellow, flat plaques on upper eyelids (xanthoma of eyelid)
  • corneal arcus - grey/white crescentic-shaped opacity at the periphery of the cornea (xanthoma of the cornea)
  • lipaemia retinalis - retina is pale and retinal vessels are white
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12
Q

What specific clinical features may be found in familial hypercholesterolaemia?

A

May also have planar xanthomas (orange streaks in palmar creases) and tuberous xanthomas (plaques on elbows and knees), alongside other features of hyperlipidaemia e.g. xanthelasma, corneal arcus

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13
Q

What are some risk factors for hyperlipidaemia? (9)

A
  • excess body weight (BMI>25)
  • insulin resistance and T2DM
  • physical inactivity
  • hypothyroidism
  • nephrotic syndrome
  • smoking and alcohol
  • cholestatic liver disease
  • use of certain medications
  • family Hx of hyperlipidaemia
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14
Q

What is the first-line main investigation that is done for hyperlipidaemia?

A

Serum lipid profile - total cholesterol, LDL, HDL, triglycerides

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15
Q

What does a serum lipid profile look like in hyperlipidaemia?

A
  • total cholesterol >5mmol/L (>200mg/dL)
  • LDL >2.6mmol/L (>100mg/dL)
  • HDL <1mmol/L (<50mg/dL)
  • triglycerides >1.7mmol/L (>150mg/dL)
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16
Q

What other investigations can we do for hyperlipidaemia? (5)

A
  • lipoproteins - values >50mg/dL or >125nmol/L are high
  • TSH - may be high in primary hypothyroidism
  • HbA1c/fasting glucose
  • LFTs
  • urinalysis
17
Q

What score do we calculate in hyperlipidaemia and why?

A

QRISK2 - screens for risk of CVD (>10% is important)

18
Q

What are some differential diagnoses for hyperlipidaemia? (7)

A
  • diabetes
  • hypothyroidism
  • nephrotic syndrome
  • obstructive liver disease
  • chronic renal insufficiency
  • medications
  • HIV
19
Q

What diagnostic criteria is used for clinical diagnosis of familial hypercholesterolaemia?

A

Simon Broome criteria:

  • in adults TC>7.5mmol/L and LDL-C>4.9mmol/L OR children TC>6.7mmol/L and LDL-C>4.0mmol/L PLUS
  • for definite FH: tendon xanthoma in patients 1st/2nd-degree relatives or DNA-based evidence of hyperlipidaemia
  • for possible FH: Fx of MI <50y in 2nd-degree relative, <60y in 1st-degree relative, or Fx raised cholesterol levels
20
Q

What lifestyle modifications can we prescribe for hyperlipidaemia? (5)

A
  • diet - <7% calories from saturated fat, high fibre, fresh fruit and veg, Omega-3 FA
  • physical activity
  • weight management (aim for BMI 20-25)
  • alcohol intake reduction
  • stop smoking
21
Q

What is the management for hyperlipidaemia if QRISK<10%?

A

Lifestyle modifications (as above)

22
Q

What is the first-line management for hyperlipidaemia if QRISK>10% (primary prevention)?

A

Atorvastatin 20mg (alternative: Simvastatin) - decreases cholesterol synthesis by inhibiting HMG-CoA reductase

23
Q

What secondary prevention is there for hyperlipidaemia with known IHD/cerebrovascular disease/PAD?

A

Atorvastatin 80mg

24
Q

Who are statins contraindicated in?

A

Pregnant women

25
What other medications do statins have an important interaction with?
Erythromycin/clarithromycin (macrolides) - can cause myopathy and increase likelihood of rhabdomyolysis
26
What time of day should statins be taken in hyperlipidaemia?
Last thing at night to improve efficacy
27
When should statin treatment be discontinued?
If serum transaminase concentrations rise to and persist at 3x the upper limit of reference range
28
What is the second-line treatment for hyperlipidaemia if intolerance to statins?
Ezetimibe - cholesterol absorption inhibitor
29
How can we treat xanthelasma if it is affecting patient's activities of daily living?
Laser therapy or surgical excision
30
How do we manage hyperlipidaemia with triglycerides>5.7?
Fibric acid derivatives or fish oil
31
How do we manage hyperlipidaemia with LDL>4.92?
High intensity statin (40-80mg atorvastatin)
32
How do we manage hyperlipidaemia with CVD/diabetes?
High intensity statin (20mg atorvastatin)
33
How do we manage hyperlipidaemia if >75y or other presentation?
Moderate intensity statin
34
What medications are used in hyperlipidaemia?
- statins - high intensity: primary prevention (atorvastatin 20mg), secondary prevention (atorvastatin 80mg) - low intensity (simvastatin 10mg and 20mg) - fibrates - bezafibrate, cholesterol absorption inhibitors (ezetimibe, PCSK9 inhibitors)
35
What are the treatment priorities regarding statins for hyperlipidaemia?
- using statins in primary prevention may cause side effects and be expensive - 1st priority: all those with known CVD - 2nd: all those with DM - 3rd: those with 10y risk of CVD>20% - aim for target plasma cholesterol
36
What are some complications of hyperlipidaemia? (5)
- CAD - stroke - PVD - high triglycerides --> pancreatitis - statin toxicity

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