Lipid Disorders

Measurements

• Lipoproteins lipids (cholesteryl esters & triglycerides) • phospholipids - proteins include: chylomicrons. VLDLIDL LDL HDL lp(a)

• Measure after 12-h fast; LDL is calculated = TC - HDL - (TG 5) (if TG -400. order direct LDL measurement as calc. LDL inaccurate). Lipid levels stable up to 24 h after ACS and other acute illnesses, then A and may take 6 wks to return to nl.

• Metabolic syndrome (¿3 of following): waist -40" in man or t35" in woman;TG ¿150; HDL

<40 mg dl in man or <50 mg dl in woman; BP -130 85 mmHg; fasting glc ^130 mg dl

Secondary Dyslipidemias

Category

Disorders

Endocrinopathies

Hypothyroidism (T LDL TTG): hyperthyroidism (i LDL)

Cushing's syndrome & exogenous steroids (t TG)

Renal diseases Hepatic diseases

Renal failure (T TG); nephrotic syndrome (T LDL)

Cholestasis. PBC (! LDL); liver failure (1 LDL); acute hepatitis (TTG)

Lifestyle

Obesity (T TG. 1 HDL); sedentary lifestyle (1 HDL); alcohol (TTG. T HDL); tobacco (I HDL)

Medications

Thiazides f LDL): P-blockers (" TG. 1 HDL) Estrogens (' TG. T HDL); protease inhibitors (" TG)

Primary dyslipidemias

• Familial hypercholesterolemia (FH. 1:500): defective LDL receptor; Ti chol, nl TG; T CAD

• Familial defective apoB100 (FDB. 1:1000): similar to FH

• Familial combined hyperlipemia (FCH. 1:200): polygenic; T chol. T TG. A HDL: T CAD

• Familial dysbetalipoproteinemia (FDBL 1:10.000): apoE f2 c2 - DM. obesity, renal disease.

etc.; T chol andTG; tube roe rupove and palmar striated xanthomas; T CAD

• Familial hypertriglyceridemia (FHTG. 1:500): TTG. t T chol. A HDL. pancreatitis Physical examination findings

• Tendon xanthomas: seen on Achilles, elbows, and hands; imply LDL -300 mg dl

• Eruptive xanthomas: pimplelike lesions on extensor surfaces; imply TG >1000 mg dl

• Xanthelasma: yellowish streaks on eyelids seen in various dyslipidemias

• Corneal arcus: common in older adults, imply hyperlipidemia in young Pts Treatment

• Every 1 mmol (39 mg dl) A LDL —♦ 21% i major vascular events (CV death. Ml. stroke.

revaSC) in individuals w & w O CAD (Lone« 2005:366:1267)

• Fewer clinical data. butTG <400 and HDL >40 are additional reasonable targets

NCEP Guidelines

Clinical risk

LDL Goal

High: CHD. CVD. PAD. AAA. DM. or 22 RFs a 10-y risk >20%

< 100 mg dl or <70 if very high risk (ACS. CAD ■ multiple RFs or - met syndrome)

Mod high: -2 RFs & 10-y risk 10-20%

<130 mg dL (optional < 100 mg dl)

Mod -2 RFs & 10-y risk <10%

<130 mg dl

Lower: 0-1 RFs

<160 mg dl

Rh: mile --45 or female .-55. smoking.HTN. • FHx. HDL - 40 H HCL -60 subtract 1 RF. Frammgham 10-y CHD risk score at www.nhlbi-nih.gov guidelines cholesterol. {jama 2001:285 2486: Gnutann 2004:110227)

Drug Treatment

Drug

iLDL

T HDL

J TG

Side effects comments

Statins

20-60%

5-10%

10-25%

T aminotransferases in 0.5-3%; j LFTs before, at 8-12 wks, and then q6mos; risk dose-depend. Myalgias <10% (not always T CK), myositis 0.5%, rhabdo < 0.1%, risk dose-depend. Doubling of dose - 6% further 1 LDL

Ezetimibe

15-20%

-

-

Well tolerated; typically w statin

Fibrates

5-15%

5-15%

35-50%

Myopathy risk T with statin Dyspepsia, gallstones

Niacin

10-25%

-30%

40%

Flushing (Rx w ASA), pruritis, T glc, gout, nausea, severe hepatitis (rare)

Resins

20%

3-5%

it

Bloating, binds other meds

Was this article helpful?

0 0

Post a comment