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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
Q

What other medications do statins have an important interaction with?

A

Erythromycin/clarithromycin (macrolides) - can cause myopathy and increase likelihood of rhabdomyolysis

26
Q

What time of day should statins be taken in hyperlipidaemia?

A

Last thing at night to improve efficacy

27
Q

When should statin treatment be discontinued?

A

If serum transaminase concentrations rise to and persist at 3x the upper limit of reference range

28
Q

What is the second-line treatment for hyperlipidaemia if intolerance to statins?

A

Ezetimibe - cholesterol absorption inhibitor

29
Q

How can we treat xanthelasma if it is affecting patient’s activities of daily living?

A

Laser therapy or surgical excision

30
Q

How do we manage hyperlipidaemia with triglycerides>5.7?

A

Fibric acid derivatives or fish oil

31
Q

How do we manage hyperlipidaemia with LDL>4.92?

A

High intensity statin (40-80mg atorvastatin)

32
Q

How do we manage hyperlipidaemia with CVD/diabetes?

A

High intensity statin (20mg atorvastatin)

33
Q

How do we manage hyperlipidaemia if >75y or other presentation?

A

Moderate intensity statin

34
Q

What medications are used in hyperlipidaemia?

A
  • 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
Q

What are the treatment priorities regarding statins for hyperlipidaemia?

A
  • 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 </=4mmol/L
36
Q

What are some complications of hyperlipidaemia? (5)

A
  • CAD
  • stroke
  • PVD
  • high triglycerides –> pancreatitis
  • statin toxicity

Year 3 (212 decks)

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