2. Hyperlipidaemia is an
umbrella term that refers to any of
several acquired or genetic disorders
that result in a high level of lipids (fats,
cholesterol and triglycerides) circulating
in the blood. These lipids can enter the
walls of arteries and increase your risk of
developing atherosclerosis (hardening of
the arteries), which can lead to stroke,
heart attack ,etc.
A 4-ml sample of hyperlipidemic blood in
a vacutainer with EDTA. Left to settle for
four hours without centrifugation, the
lipids separated into the top fraction.
3. KEY CONCEPTS
Hypercholesterolemia, elevated low-density lipoprotein (LDL) levels,
and low high-density lipoprotein (HDL) levels are unequivocally linked
to increased risk for coronary heart disease and cerebrovascular
morbidity and mortality.
Multiple genetic abnormalities and environmental factors are
involved in clinical lipid abnormalities, and routinely used clinical
laboratory measurements do not define the underlying
abnormalities.
Initial therapy for any lipoprotein disorder is therapeutic lifestyle
changes with restricted intake of total and saturated fat and
cholesterol and a modest increase in polyunsaturated fat intake along
with a program of regular exercise and weight reduction if needed.
If pharmacologic therapy is insufficient after therapeutic lifestyle
changes, lipid-lowering agents should be chosen based on the
specific lipoprotein disorder presentation and the severity of the lipid
abnormality.
4. Patients who do not respond to statin monotherapy can be treated
with combination therapy for hypercholesterolemia but should be
monitored closely because of an increased risk for adverse effects
and drug interactions.
Low high-density lipoprotein-cholesterol (HDL-C) levels are
addressed with lifestyle modifications, such as smoking cessation
and increased exercise. Niacin, gemfibrozil, and fenofibrate can
significantly increase HDL-C.
Decreasing elevated total cholesterol and low-density lipoprotein
cholesterol (LDL-C) levels reduce coronary heart disease mortality
and total mortality; increasing HDL reduces coronary heart disease
events as well.
Considering compliance, adverse effects, and effectiveness, for
patients with hypercholesterolemia statins are the drugs of choice
because they are the most potent form of monotherapy and are
cost effective in patients with known coronary artery disease or
multiple risk factors and in high-risk primary prevention patients.
5. ANATOMY &PHYSIOLOGY
Hyperlipidaemia simply is a disorder in which there are
abnormally elevated levels of fat particles in the blood known as
lipids. This lipids can adhere to the walls of the arteries and
restrict blood flow which in turn leads to significant risk of heart
attack and stroke.
6. There are 3 major lipids in the body
CHOLESTEROL TRIGLYCERIDES
PHOSPHOLIPIDS
7. These lipids are in soluble in blood plasma, so they have to be
transported through out the body in a protein capsule known
as Lipoprotein.
Depending on the variation
in lipid and Apo lipoprotein
composition as well as
density, lipoproteins can be
divided into 4 major types,
Chylomicrons
VLDL
LDL
HDL
8. Dietary
lipids Deliver energy rich triglycerides to
cells throughout the body
Synthesis of steroid hormones
and cell membrane
50%
9. Now the problem arises
when we have abnormally high
levels of LDL cholesterol which can
accumulate on the innermost layer
of the artery wall and lead to
formation of atherosclerotic
lesions. This is why LDL is often
referred to as bad cholesterol.
HDL on the other
hand prevents formation of
atherosclerotic lesions by
removing cholesterol as well as
suppressing LDL oxidation and
vascular inflammation. This is why
HDL cholesterol is often referred to
as good cholesterol. So abnormally
low level of HDL can also leads to
atherosclerosis. Cross section of Normal &
Clogged artery
10.
11. Classification of Total, LDL, and HDL Cholesterol,
and Triglycerides
Total cholesterol
<200 Desirable
200–239 Borderline high
≥240 High
LDL cholesterol
<100 Optimal
100–129 Near or above optimal
130–159 Borderline high
160–189 High
≥190 Very high
HDL cholesterol
<40 Low
≥60 mg/dL High
Triglycerides
<150 Normal
150–199 Borderline high
200–499 High
≥500 Very high
All values are given in milligrams per deciliters.
12. EPIDEMIOLOGY
Cardiovascular disease (CVD) is the leading cause of death
among adults in the United States, and people with
hyperlipidaemia are at roughly twice the risk of developing CVD
as compared to those with normal total cholesterol
levels.1Patients with familial hypercholesterolemia (FH) have an
even greater risk of developing CVD at an earlier age.
More than 3 million people have this genetic disorder in the
United States and Europe. It is extremely common for those
who live in developed countries and follow a Western high-fat
diet.
13. ETIOLOGY
Hyperlipidemia can be caused by primary causes (genetic
predisposition) or secondary causes (diet, underlying disease,
or medications). Primary hyperlipidemia is associated with
high morbidity and mortality. A defect often occurs in lipid
metabolism or transport in primary hyperlipidemia, resulting in
reduced LDL receptor activity and accumulation of LDL
cholesterol in the plasma, leading to atherogenesis.
All patients should be evaluated for secondary causes of
hyperlipidemia. Diseases such as diabetes mellitus,
hypothyroidism, Cushing's syndrome, obstructive liver
disease, nephrotic syndrome, and alcoholism are all common
causes of high cholesterol.
17. CLINICAL PRESENTATION
General
■ Most patients are asymptomatic for many years before disease is
clinically evident
■ Patients with the metabolic syndrome may have three or more of
the following: abdominal obesity, atherogenic dyslipidemia,
increased blood pressure, insulin resistance with or without glucose
intolerance, prothrombotic state, or proinflammatory state.
Symptoms
■ None to severe chest pain, palpitations, sweating, anxiety,
shortness of breath, loss of consciousness or difficulty with speech or
movement, abdominal pain, sudden death
18. Signs
■ None to severe 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)
Laboratory Tests
■ Elevations in total cholesterol, LDL, triglycerides, apolipoprotein
B, C-reactive protein
■ Low HDL
Other Diagnostic Tests
■ Lipoprotein(a), homocysteine, serum amyloid A, small dense LDL
(pattern B), HDL subclassification, apolipoprotein E isoforms,
apolipoprotein A-1, fibrinogen, folate, Chlamydia pneumoniae titer,
lipoprotein-associated phospholipase A2, omega-3
■ Various screening tests for manifestations of vascular disease
(ankle–brachial index, exercise testing, magnetic resonance imaging)
and diabetes (fasting glucose, oral glucose tolerance test)
24. GENERAL APPROACH TO TREATMENT
Establishing targeted changes and outcomes with consistent
reinforcement of goals and measures at follow-up visits to attain
goals are important to reduce barriers for optimizing Therapeutic
Lifestyle Changes(TLC) and pharmacologic therapy. TLC should be
implemented in all patients prior to considering drug therapy. The
components of TLC include reduced intake of saturated fats and
cholesterol, dietary options to reduce LDL, such as consumption of
plant stanols and sterols and soluble fibre, weight reduction, and
increased physical activity.
In general, physical activity of moderate intensity 30 minutes per
day for most days of the week should be encouraged. Patients with
known CAD or who are at high risk should be evaluated before they
undertake vigorous exercise. Weight and BMI should be determined
at each visit, and lifestyle patterns to induce a weight loss of 10%
should be discussed with persons who are overweight. All patients
should be counselled to stop smoking.
25. NON-PHARMACOLOGIC TREATMENT
Eat a heart-healthy diet
Making changes to your diet can lower your “bad” cholesterol levels and
increase your “good” cholesterol levels. Here are a few changes you can
make:
Choose healthy fats. Avoid saturated fats that are found primarily in red
meat, bacon, sausage, and full-fat dairy products. Choose lean proteins
like chicken, turkey, and fish when possible. Switch to low-fat or fat-free
dairy. And use monounsaturated fats like olive and canola oil for
cooking.
Cut out the trans fats. Trans fats are found in fried food and processed
foods, like cookies, crackers, and other snacks. Check the ingredients on
product labels. Skip any product that lists “partially hydrogenated oil.”
Eat more omega-3s. Omega-3 fatty acids have many heart benefits. You
can find them in some types of fish, including salmon, mackerel, and
herring. They can also be found in some nuts and seeds, like walnuts and
flax seeds.
DIET
26. Weight
Being overweight is a risk factor for hyperlipidemia and heart
disease. Losing weight can help reduce LDL, total cholesterol, and
triglyceride levels. It can also boost HDL, which helps to remove
the bad cholesterol out of the blood.
To lose weight, adopt a low-calorie diet and increase your physical
activity
Increase your fiber intake. All fiber is heart-healthy, but soluble
fiber, which is found in oats, brain, fruits, beans, and vegetables,
can lower your LDL cholesterol levels.
Eat more fruits and veggies. They’re high in fiber and vitamins and
low in saturated fat.
27. Physical activity
A lack of physical activity is a risk factor for heart disease.
Regular exercise and activity helps lower LDL, raise HDL, and
encourage weight loss. At least 30 minutes of physical activity is
recommended, at least 5 days a week. Brisk walking is an excellent
and easy choice.
Quit smoking
Smoking triggers many problems that contribute to heart disease.
It promotes plaque buildup on the walls of the arteries, increases
LDL levels, and it encourages blood clot formation
and inflammation. Quitting smoking will result in higher HDL. This
may be one reason why cardiovascular disease risk falls after
quitting.
28. Macronutrient Recommendations for the Therapeutic
Lifestyle Changes Diet
Component a Recommended Intake
Total fat 25%–35% of total calories
Saturated fat Less than 7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Carbohydrates b 50%–60% of total calories
Cholesterol <200 mg/day
Dietary fibre 20–30 g/day
Plant sterols 2 g /day
Protein Approximately 15% of total calories
Total calories To achieve and maintain desirable body weight
a Calories from alcohol not included.
b Carbohydrates should derive from foods rich in complex carbohydrates, such as whole
grains, fruits, and vegetables.
