Hyperlipidemias

Defined as elevated lipid (fat) levels in the blood. Hyperlipidemia can be inherited and increases the risk of diseases (accelerated atherosclerosis of the blood vessels leading to stroke and heart disease)

Hyperlipidemia is one most important modifiable risk factors of CAD

Types of Hyperlipidemia
1. Primary Hyperlipidemia
Inherited e.g Familial dyslipidemia (Classes IIA, IIB and IV = >80% of cases)
Congenital defects
2. Secondary causes of Hyperlipidemias
A. Endocrine/Metabolic
- Diseases that causes increased cholesterol e.g DM, hypothyroidism.
B. Renal disorders
- Nephrotic syndrome 
In nephrotic syndrome (Loss of protein in urine), hypoalbuminuria causes Hepatic lipogenesis, leads to hypercholesterolemia.
- Uremia
due to increased liver synthesis of VLDL, Uremia, loss of proteins transporting/binding fats in urine
C. Chronic Liver disease 
- Liver fails to utilize cholesterol to produce bile acids, Vitamin D (1-OH vit D), etc leads to hypercholesterolemia
D. Medications (BETS)
- Beta blockers
- Estrogens
- Thiazides diuretics
- Steroids/Protease Inhibitors
E. Pregnancy
- Increased estrogen

Risk Factors of Hyperlipidemias
Are causes of Primary and Secondary hypercholesterolemia
1. Diet
- Saturated fatty acids and xterols = Inc. LDL and TC
- High calorie diets = Inc TGs
- Alcohol = Inc TGs and HDL, no effect on TC
2. Age
- xterol inc with age until 65 years
- greatest durin g early adulthood
3. Inactive lifestyle
4. Abdominal obesity
5. Fam hx
6. Gender
- Men > women befire menopaue
- women > men after menopause
7. Medications (BETS)
8. Genetic mutations
9. secondary causes

Lipids associated with Cardiovascular risk
1. LDL
- 2/3 of Total Cholesterol
- Most atherogenic of all lipoproteins
- calculation LDL in serum
LDL = TC - HDL - TG/5
2. Total Cholesterol
- CAD increases sharply when TC > 240mg/dL
3. HDL
- Removes excess cholesterol from arterial walls
- opposing atherogenic effect with same intensity
- every increase in 10mg/dL, decreases CAD risk by 50%
- > 60 mg/dL is a good prognostic factor
4. Total Cholesterol to HDL ratio
- < 4.5 is desirable
- 10 = double risk
5. Triglycerides (TGs)
- Elevatd levels are associated with coronary risk
- lowering TGs is Controversial in reducing CAD

Features of Hypertriglycedemia
1. No symptoms
2. Xanthelasma
3. Xanthoma (Finger extensors, Achilles tendon , Plantar tendons)
4. Pancreatitis
- In severe hypertriglyceridemia

Diagnosis of Hyperlipidemia
1. Lipid screening
- If TC and/or HDL
- if any is high, do a fasting lipid profile
2. Exclude 2o causes of Hypertriglycedemia

Treatment for Hyperlipidemias
- Goal is to reduce CAD risk
- Use of Non-statins to lower LDL not recommended
- Risk calculator at http://my.americanheart.org/cvriskcalculator

Therapy for Atherosclerotic Cardiovascular risk reduction
Life style modification is Important regardless of pharmacological treatment
1. Diet
2. Exercise
- Increase HDL
- decreases other CAD risk
3. Weight loss
- reduces total cholesterol
- reduces diabetes and other CAD risk factors
4. stop smoking
5. Drug
- Statin is drug of choice
- Decreases CAD risk by 20-30% independent of LDL levels
- may cause hepatotoxicity (check LFTs before and after Treatment)
- Use other classes if patient can't tolerate Statins

Therapy for high Triglycerides
- Fairly limited Data
- First Line (Life style modifications)
Weight loss
Aerobic exercise
Glycemic control
Low fat diet
- Medications
Fibrates
Niacin
Fish oil
Statins

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