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SOURCE

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Source: Talbert RL. Dyslipidemia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146057587. Accessed May 18, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Hyperlipidemia.

  • Hypercholesterolemia.

  • Hyperlipoproteinemia.

  • Lipid disorders.

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DEFINITION

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  • Elevated total cholesterol, low-density lipoprotein cholesterol (LDL-C), or triglycerides (TG); a low high-density lipoprotein cholesterol (HDL-C); or a combination of these abnormalities.

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ETIOLOGY

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  • Genetic abnormalities.

  • Hypothyroidism.

  • Liver disease.

  • Nephrotic syndrome.

  • Cushing’s disease.

  • Drugs.

    • Progestins.

    • Thiazide diuretics.

    • Glucocorticoids.

    • β-blockers.

    • Isotretinoin.

    • Protease inhibitors.

    • Cyclosporine.

    • Sirolimus.

    • Mirtazapine.

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PATHOPHYSIOLOGY

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  • Oxidized LDL, injury to vascular endothelium, excessive homocysteine, immunologic attack, and infection-induced changes lead to atherosclerosis.

  • Repeated plaque injury and repair lead to fibrous cap protecting underlying core; plaque rupture results in coronary thrombosis.

  • Primary or genetic lipoprotein disorders:

    • I (chylomicrons)

    • IIa (LDL)

    • IIb (LDL + very-low-density lipoprotein [VLDL])

    • III (intermediate-density lipoprotein [IDL])

    • IV (VLDL)

    • V (VLDL + chylomicrons)

  • Clinical outcomes may include:

    • Angina.

    • Myocardial infarction (MI)

    • Arrhythmias.

    • Stroke.

    • Peripheral arterial disease.

    • Abdominal aortic aneurysm.

    • Sudden death.

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EPIDEMIOLOGY

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  • 42.8% or 10.1 million American adults over age 20 years have total cholesterol levels of ≥200 mg/dL.

  • Established coronary heart disease (CHD) or prior MI increases risk of MI 5–7 times that of men or women without CHD.

  • About 50% of all MIs and at least 70% of CHD deaths occur in patients with known CHD.

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PREVENTION AND SCREENING

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  • Measure fasting lipid profile (FLP) including total cholesterol, LDL, HDL, and triglycerides in all adults 20 years of age or older at least once every 5 years.

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RISK FACTORS

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  • Obesity.

  • Sedentary lifestyle.

  • Diabetes mellitus.

  • Alcohol use.

  • Hypothyroidism.

  • Nephrotic syndrome.

  • Chronic kidney disease.

  • Liver disease.

  • Cushing’s disease.

  • Certain medications (see Etiology)

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Symptoms range from none to:

    • Chest pain.

    • Palpitations.

    • Sweating.

    • Anxiety.

    • Shortness of breath.

    • Loss of consciousness or difficulty with speech or movement.

    • Abdominal pain.

    • Sudden death.

  • Signs range from none to:

    • Abdominal pain.

    • Pancreatitis.

    • Eruptive xanthomas.

    • Peripheral polyneuropathy.

    • High blood pressure.

    • Body mass index >30 kg/m2 or waist size >40 inches in men (35 inches in women)

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • After confirming a lipid abnormality, perform medical history, physical examination, and laboratory tests.

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LABORATORY TESTS
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  • Fasting lipid profile elevations in total cholesterol, LDL-C, triglycerides, apolipoprotein B, and C-reactive protein (CRP); low HDL-C.

  • Screening tests for diabetes: Fasting glucose, oral glucose tolerance test, A1C.

  • Serum thyroid-stimulating hormone (TSH) to screen for hypothyroidism.

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DIAGNOSTIC PROCEDURES
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  • Screening tests for vascular disease: Ankle-brachial index, exercise ...

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