Dyslipidemia and it's management is such a topic that one single PPT is not enough to express all sorts of problems or scopes. This PPT will give you an overview on "Dyslipidemia and it's management"

2. A soft waxy substance found among lipids
(fats) in the bloodstream and all cells
Needed for digesting fats, making
hormones, building cell walls
Carried in particles called lipoproteins that
act as transport vehicles delivering
cholesterol to various body tissues to be
used, stored or excreted
Excess circulating cholesterol can lead to
plaque formation- Atherosclerosis

5. HMG Co-A reductase is the rate limiting
enzyme in the cholesterol synthesis.
Rate Limiting Enzyme

6.  Elevated Total Cholesterol (TC)
 Elevated Low-density lipoproteins (LDL)
 Elevated triglycerides (TG)
 Decreased High-density lipoproteins (HDL)

8.  SINGLE OR MULTIPLE GENE MUTATION –
RESULTING IN DISTURBANCE OF LDL, HDL AND
TRIGYLCERIDE, PRODUCTION OR CLEARANCE.
Should be suspected in patients with
 premature heart disease
 family hx of atherosclerotic dx.
 Or serum cholesterol level >240mg/dl.
 Physical signs of hyperlipidemia.

9. Sedentary lifestyle
Excessive consumption of cholesterol –
saturated fats and trans-fatty acids.

10. Moderately common
Hypothyroidism
Pregnancy
Cholestatic liver disease
Drugs (diuretics, ciclosporin, corticosteroids, androgens)
Less common
 Nephrotic syndrome
Anorexia nervosa
Porphyria
Hyperparathyroidism
Secondary Dyslipidemia

11. Diabetes mellitus (type 2)
Chronic renal disease
Abdominal obesity
Excess alcohol
Hepatocellular disease
Drugs (β-blockers, retinoids, corticosteroids)

17. During routine health checkup
Clinical manifestation e.g. Xanthelesma
Associated diseases e.g. CHD,DM,HTN

18. At least 12 hrs fasting
Friedwald formula:
LDL-C= TC — HDL-C — ( TG/2.2) mmol/L
Applicable up to TG: 4mmol/L

19. TC= HDL + VLDL + LDL
TC = HDL + TG/5 + LDL
LDL= TC — ( HDL + TG/5)
Applicable up to TG: 350 mg/dl

21. LDL- (“bad” cholesterol) The major
cholesterol carrier in the blood. Excess
most likely to lead to plaque formation.
Goal: LOW
HDL- (“good” cholesterol) Transports
cholesterol away from arteries and back to
the liver to be eliminated. Removes excess
cholesterol from plaques, slowing growth.
Goal: HIGH

23. LDL Cholesterol (mg/dl) HDL Cholesterol (mg/dl)
<100 Optimal < 40 Low
100-129 Near/Above Optimal > 60 High (Desirable)
130-159 Borderline High
160-189 High
>190 Very High
Categories of Risk that Modify LDL Goals
CHD and CHD risk equivalents <100
Multiple (2+) risk factors <130
Zero to one risk factor <160

24. Cigarette smoking
Hypertension (BP >140/90 or on BP med)
Low HDL cholesterol (<40mg/dl)
Family Hx premature CHD
- CHD in male 1st degree relative <55 years old
- CHD in female 1st degree relative <65 years old
Age (men >45 yrs. women >55 yrs)
 HDL >60 counts as a “negative” risk factor. It’s presence removes one risk
factor from the total count

25. DM regarded as a CHD equivalent
For patients with multiple (2+) risk factors
-Perform 10 year risk assessment
For patients with 0-1 risk factor
-Most have 10 year risk assessment <10%;
risk assessment scoring unnecessary

26. Risk
Category
LDL Goal
(mg/dl)
LDL level to
initiate TLC
LDL level to
consider Rx
therapy
CHD or
Equivalents
<100
<70 Ideal
> 100 > 130
(100-129 Rx
optional)
2+ Risk
Factors
<130 > 130 > 130 (10 Year
risk 10-20%)
> 160 (Risk <10%)
0-1 Risk
Factor
<160 > 160 > 190
(160-189 Rx
optional)

27. Visit 1
Begin TLC
•Emphasize
reduction in
saturated fat
& chol.
•Encourage
moderate
Physical
activity
•Consider
referral to
dietician
Visit 2 (6 wks)
Eval. LDL response
Intensify Tx if not to
goal
•Reinforce dietary
recommendations
•Consider adding
plant stanols/sterols
•Increase fiber
intake
•Consider dietician
Visit 3 (6 wks)
Eval LDL response
Consider adding Rx
if not to goal
•Evaluate for
Metabolic syndrome
•Intensify wt mgmt &
physical activity
•Consider dietician
Visit N
Monitor
adherence to
TLC Q4-6
mos

28. Classification of Serum Triglycerides
Normal <150 mg/dl
Borderline High 150-199 mg/dl
High 200-499mg/dl
Very High >500 mg/dl

29. Management of Very High Triglycerides (>500 mg/dl)
 Goal of therapy: Prevent acute pancreatitis
 Very low fat diets (< 15% of caloric intake)
 Triglyceride-lowering drug usually required (fibrate or
nicotinic acid)
 Reduce triglycerides before lowering LDL

30. Atherosclerosis
 The main Consequence
Acute pancreatitis ( in High TG)

38. Risk assessment
Treat modifiable risk factors
Optimization of lifestyle factors

39. Reduce intake of saturated and trans-
unsaturated fat to less than 7-10% of total
energy
Reduce intake of cholesterol to < 250
mg/day
Replace sources of saturated fat and
cholesterol with alternative foods such as
lean meat, low-fat dairy products,
polyunsaturated spreads and low
glycaemic index carbohydrates

40. Reduce energy-dense foods such as fats
and soft drinks
Increase consumption of cardioprotective
and nutrient-dense foods such as
vegetables, unrefined carbohydrates, fish,
pulses, nuts, legumes, fruit etc.
Adjust alcohol consumption, reducing
intake if excessive or if associated with
hypertension, hypertriglyceridaemia or
central obesity

41. Achieve additional benefits with
supplementary intake of foods containing
lipid-lowering nutrients such as n-3 fatty
acids, dietary fibre and plant sterols.

44. Nutrient Recommended Intake
 Saturated fat < 7% of total calories
 Polyunsaturated fat Up to 10% of total calories
 Monounsaturated fat Up to 20% of total calories
 Total fat 25-30% of total calories
 Carbohydrates 50-60% of total calories
 Fiber 20-30 grams/day
 Protein Approx. 15% of total calories
 Cholesterol <200 mg/day
 Total calories Balance energy intake and
expenditure to maintain
desirable body weight/prevent
weight gain

45. HMG-CoA Reductase Inhibitors (Statins)
 Partially block an enzyme necessary for formation of
cholesterol
 Speed removal of LDL from blood
 18%-60% reduction in LDL
 Most effective at lowering LDL; esp. HS dosing
 Liver enzymes MUST be monitored. Check baseline,
3mos., then semi-annually (D/C if > 3x normal limits)
 Side effects: Myalgias (D/C if total CK >10x normal),
rhabdomyolysis
 Metabolized by CP450 (watch for drug interactions)
 Contraindicated in pregnancy.

46. Atorvastatin
Simvastatin
Rosuvastatin
Pitavastatin
Fluvastatin
Pravastatin

47. Bile Acid Sequestrants:
Cholestyramin , Cholestipol
Convert cholesterol to bile acids
Bind bile acids and prevent reabsorption in
the gut
May increase triglyceride levels
Most common side effects: GI-constipation
Alternative for statins

48. Cholesterol Absorption Inhibitor(Ezetimibea):
 Monotherapy or in combination with statin
 Not recommended with fibrates
 Reduces LDL number : esp. Lp(a)
hepatic LDL receptor,Inhibit intestinal mucosa
transporter NPCILT.
Lipid-Regulating Agent: Omega 3 acid ethyl esters
 Omega 3 Fish oil (salmon, herring, mackerel, swordfish,
albacore tuna, sardines, lake trout)
 Only FDA approved supplement for tx of dyslipidemias
 Decreases hepatic production of TG and VLDL
 Increases LDL size to large buoyant particles

49. Nicotinic Acid/Niacin (B3)
Inhibition of lipolysis
 Reduces production and release of LDL
 Effective in reduction of triglycerides (<400mg/dl)
 Increases HDL
 Very effective in increasing LDL particle size
 Monitor liver enzymes and glucose
 Most common side effect: FLUSHING (take
ASA/ibuprofen 30 min. prior and take with light
snack). Decreased with time released formulas
 Liver function disterbance
 Exacerbation of gout and hyperglycemia.

50. Fibric Acid Derivatives/Fibrates
M/A: PPAR∞- stimulation metabolism of TG & LDL
 Very effective in reducing triglycerides (>400)
 Increase HDL
SIE: Myolgia,Myopathy,Abnormal LFT,Choleclithiasis
 Containdications: Gallbladder disease, hepatic
disease, renal dysfunction
 Increase LDL particle size but not quantity
 Caution with statins
 Gemfibrozil, Benza fibrates, feno fibrates.

52. After 6 weeks ( 12 weeks for fibrates)
Parameter:
1. Lipid response
2. Side effects- CK, LFT
3. Others-a) Dietary compliance
b) Exercise
c) Cardiovascular signs and symptoms
d) Wt.
e) BP

53. Dyslipidemia(Silent killer)
Artherosclerosis MI,Stroke
At least 12 hrs fasting for the
measurement of lipid profile.
TLC-very important But usually ignored
Statin-(Commission is better than
omission)widely well tolerated
Other risk factors should be addressed
appropriately.

54. Act Commission is
Better than
Omission

55. THANK YOU