Dyslipidemia

Source: Talbert RL. Dyslipidemia. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7974214. Accessed July 6, 2012.

• Hyperlipidemia
• Hypercholesterolemia
• Hyperlipoproteinemia
• Lipid disorders

• 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.

• Genetic abnormalities
• Hypothyroidism
• Liver disease
• Nephrotic syndrome
• Cushing’s disease
• Drugs
  • Progestins
  • Thiazide diuretics
  • Glucocorticoids
  • β-blockers
  • Isotretinoin
  • Protease inhibitors
  • Cyclosporine
  • Sirolimus
  • Mirtazapine

• 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)
  • IV (VLDL)
  • V (VLDL + chylomicrons)
• Clinical outcomes may include:
  • Angina
  • Myocardial infarction (MI)
  • Arrhythmias
  • Stroke
  • Peripheral arterial disease
  • Abdominal aortic aneurysm
  • Sudden death

• 46.8% or 10.2 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.

• 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.

• Obesity
• Sedentary lifestyle
• Diabetes mellitus
• Alcohol use
• Hypothyroidism
• Nephrotic syndrome
• Chronic kidney disease
• Liver disease
• Cushing’s disease
• Certain medications (see Etiology)

Signs and Symptoms

• 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)

Means of Confirmation and Diagnosis

• After confirming a lipid abnormality, perform medical history, physical examination, and laboratory tests.

Laboratory Tests

• Fasting lipid profile elevations in total cholesterol, LDL-C, triglycerides, apolipoprotein B, and C-reactive protein (CRP); low HDL-C.
• Lipoprotein (a) and small, dense LDL (pattern B), HDL-C subclassification, apolipoprotein E isoforms, apolipoprotein A-1, fibrinogen, folate, lipoprotein-associated phospholipase A2.
• Screening tests for diabetes: Fasting glucose, oral glucose tolerance test, A1C.
• Serum thyroid-stimulating hormone (TSH) to screen for hypothyroidism.

Diagnostic Procedures

• Screening tests for vascular disease: Ankle-brachial index, exercise testing, magnetic resonance imaging.

Differential Diagnosis

• Hypothyroidism
• Nephrotic syndrome
• Chronic kidney disease
• Liver disease
• Cushing’s disease

• Lower total and LDL cholesterol to reduce risk of first or recurrent cardiovascular events.

• Major Risk Factors for CHD (excluding LDL-C)
  • Age: Men 45 years and older; women 55 years and ...