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Chapter 6. Lipid Disorders

Elizabeth M. Urteaga

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  • Lipoproteins transport hydrophobic lipids (primarily triglycerides & cholesterol) through body fluids
  • 5 classes of lipoproteins based on size & density: chylomicrons, very-low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL), low-density lipoprotein (LDL), high-density lipoprotein (HDL)

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  • Pertinent evaluation: lipid profile (dyslipidemia = elevated TC, LDL, TG, &/or reduced HDL); if TG >400mg/dL, perform direct LDL measurement
  • NCEP ATP III guidelines recommend fasting lipid panel beginning at age 20y; if normal, repeat every 5y, or earlier if coronary heart disease (CHD) risk increases
  • Classify patient by risk (Framingham risk calculator) to guide & determine aggressiveness of treatment
    • Risk factors for CHD: cigarette smoking, HTN (BP ≥140/90mmHg or on antihypertensive), HDL <40mg/dL, CV event in 1st-degree male relative <55 yo, or female <65 yo at time of event, age ≥45 men, ≥55 women; HDL ≥60mg/dL is a negative risk factor (subtract 1 RF)
    • CHD risk equivalents: DM, aortic aneurysm, peripheral vascular disease, carotid artery disease (TIA, stroke), 10-y risk >20% for CHD based on Framingham
  • Rule out secondary causes of dyslipidemia

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Clinical Pearl 6-1

TC & HDL remain the same fasting & non-fasting

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Table 6-1 Evaluation of Lipid Profile
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Table 6-1 Evaluation of Lipid Profile

LDL Cholesterol (LDL = TC-HDL – [TG/5] if TG <400)

Fasting (12h) Lipid Panel

Value (mg/dL)

Optimal

<100

Near or above optimal

100–129

Borderline high

130–159

High

160–189

Very high

≥190

Total Cholesterol

Desirable

<200

Borderline high

200–239

High

≥240

HDL Cholesterol

Low

<40

High

≥60

Triglycerides

Normal

<150

Borderline high

150–199

High

200–499

Very high

≥500

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Table 6-2 LDL Cholesterol Goals & Cutpoints for Therapeutic Lifestyle Changes & Drug Therapy in Different Risk Categories
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Table 6-2 LDL Cholesterol Goals & Cutpoints for Therapeutic Lifestyle Changes & Drug Therapy in Different Risk Categories

Risk Category

LDL Goal (mg/dL)

LDL Level to Initiate TLC (mg/dL)

LDL Level to Consider Drug Therapy (mg/dL)

High risk: CHD or CHD risk equivalents (10-y risk >20%)

<100 (optional goal: <70)

≥100

≥100

(<100mg/dL; consider drug options)

Moderately high risk: 2+ risk factors (10-y risk >10–20%)

<130

≥130

≥130

(100–129: consider drug options)

Moderate risk: 2+ risk factors (10-y risk <10%)

<130

≥130

≥160

Lower risk: 0–1 risk factor

<160

≥160

≥190

(160–189: LDL-lowering drug optional)

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Table 6-3 Secondary Causes of Dyslipidemia
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Table 6-3 Secondary Causes of Dyslipidemia

Secondary Cause

Lipid Changes

End-stage renal disease

↑ triglycerides, ↓ HDL

Nephrotic syndrome

↑ VLDL & triglycerides

Hypothyroidism

↑ LDL & triglycerides

Drugs: glucocorticoids, anabolic steroids, estrogens & progestins, tamoxifen, protease inhibitors, diuretics, β-blockers, bile acid resins, isotretinoin, mirtazapine, sirolimus

Variable effects

Cigarette use

↓ HDL

Diabetes mellitus

↑ triglycerides, ↓ HDL

Excessive alcohol consumption

↑ triglycerides

Obstructive liver disease

↑ LDL

Pregnancy

↑ LDL & triglycerides

Anorexia

↑ LDL

Caloric excess or diet high in saturated fat

↑ LDL

Sedentary lifestyle

↓ HDL

Adapted from Ross LA, Ross BS, East H. Dyslipidemia. In: Linn W, Wofford M, O'Keefe ME, Posey LM (eds). Pharmacotherapy in Primary Care. New York: McGraw-Hill, 2009.

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