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Chapter 5: Dyslipidemia

Rebecca F. Edwards

FOUNDATION OVERVIEW

General Overview

Dyslipidemia is defined as elevated total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), or high density lipoprotein cholesterol (HDL-C). LDL-C incites the atherosclerotic inflammatory response promoting unstable lesions concentrated with lipid-laden macrophages. The degree of LDL-elevation is proportionally linked with risk of developing atherosclerotic cardiovascular disease (ASCVD) (1 mg/dL: 1% change). Elevated TG have indirect atherosclerotic effects from procoagulant properties and an adverse impact on endothelial function. In contrast, HDL-C is an inverse predictor for ASCVD risk (1 mg/dL: 2% change) due to reverse cholesterol transport (delivering cholesterol from the cell wall to the liver for disposal). Additionally, HDL-C inhibits LDL-C oxidation and platelet aggregation and activation.

Dyslipidemia is a risk factor for clinical ASCVD, defined as coronary heart disease (CHD), cerebrovascular disease, or peripheral artery disease. Dyslipidemia is asymptomatic until vascular disease develops. Patients may present with pain or cramping with walking, cold extremities, shortness of breath, chest pain, sweating, difficulty with speech or movement, and sudden death. Severe hypertriglyceridemia (TG >1000 mg/dL) can lead to abdominal pain, nausea, vomiting, and other symptoms of pancreatitis.

Diagnosis

For adults 20 years of age or older, a lipid profile is recommended once every 5 years after a 12-hour overnight fast. The National Cholesterol Education Program (NCEP) ATP III classifies optimal and abnormal findings (Table 5-1). If testing is nonfasting, only HDL-C and TC will be accurate, and follow-up fasting lipid panel (FLP) is required for TC more than or equal to 200 or HDL-C less than 40 mg/dL. The LDL-C can be measured directly or calculated using the Friedewald equation (LDL-C = TC − HDL-C − TG/5). The calculation is less accurate when TG are more than 200 and inaccurate when more than 400 mg/dL.

TABLE 5-1Classification of Total-, LDL-, HDL-C, and TG
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TABLE 5-1Classification of Total-, LDL-, HDL-C, and TG
Total cholesterol  
<200 mg/dL (<5.17 mmol/L) Desirable
200-239 mg/dL (5.17-6.20 mmol/L) Borderline high
≥240 mg/dL (≥6.21 mmol/L) High
LDL cholesterol  
<100 mg/dL (<2.59 mmol/L) Optimal
100-129 mg/dL (2.59-3.35 mmol/L) Near or above optimal
130-159 mg/dL (3.36-4.13 mmol/L) Borderline high
160-189 mg/dL (4.14-4.90 mmol/L) High
≥190 mg/dL (≥4.91 mmol/L) Very high
HDL cholesterol  
<40 mg/dL (<1.03 mmol/L) Low
≥60 mg/dL (≥1.55 mmol/L) High
Triglycerides  
<150 mg/dL (<1.70 mmol/L) Normal
150-199 mg/dL (1.70-2.25 mmol/L) Borderline high
200-499 mg/dL (2.26-5.64 mmol/L) High
≥500 mg/dL (≥5.65 mmol/L) Very high

Reproduced with permission from DiPiro JT, Talbert RL, Yee GC, et al: Pharmacotherapy: A Pathophysiologic Approach, 10th ed. New York, NY: McGraw-Hill; 2017

Secondary causes of dyslipidemia such as obesity, obstructive liver disease, Cushing syndrome, tobacco use, alcohol overuse, hypothyroidism, anorexia nervosa, nephrotic syndrome, and undiagnosed or uncontrolled diabetes should be considered. TG level can be lowered by improving glucose control. ...

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