hyperlipidemia
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Introduction
Hyperlipidemia: Excessive quantity of fat (cholesterol &/or triglycerides) in the blood.
Etiology
- primary hyperlipidemia
- secondary hyperlipidemia
- excess dietary intact of fat, calories, alcohol
- concurrent illnesses
- pharmacologic agents
- smoking[1]
- combinations of 1,2,3, & 4
* increased serum triglycerides & decreased HDL cholesterol
Epidemiology
- 7% of adults have LDL cholesterol level > 190 mg/dL[11]
Clinical manifestations
- generally asymptomatic until symptoms secondary to atherosclerosis occur
- angina pectoris
- claudication
- symptoms of TIA or stroke
- elevation of triglyceride > 1000 mg/dL may cause symptoms of pancreatitis
- xanthomas may occur on extensor tendons
- periorbital xanthelasmas may occur in familial cases
Laboratory
- fasting lipid panel
- non HDL cholesterol = total cholesterol - HDL cholesterol
- useful for serum triglycerides > 200 mg/dL
- target = target LDL cholesterol + 30[1]
- see management for goals of therapy
- non HDL cholesterol = total cholesterol - HDL cholesterol
- laboratory tests that have no impact on mortality[1]
- gene testing* for familial hypercholesterolemia
- gene mutations for familial hypercholesterolemia in < 2% of patients with LDL cholesterol level > 190 mg/dL[13]
* genetic testing for familial hypercholesterolemia
Complications
Management
goals of therapy
- target LDL cholesterol depends upon
- presence of CAD: < 100 mg/dL
- 2 or more cardiovascular risk factors: < 130 mg/dL
- < 2 cardiovascular risk factors: < 160 mg/dL[1]
- no target for treating low HDL cholesterol[1]
diet is primary therapy
- total fat < 30% of calories, < 10% saturated fat
- limit carbohydrates[1]
- cholesterol < 300 mg/day
- lower LDL & HDL cholesterol
- may not affect HDL cholesterol / total cholesterol[2]
- plant-based diet may have additional benefit[2]
- Mediterranean-style diet, fish-oil (2.2 g/day of w-3 polyunsaturated fat) & red yeast rice-extract (2.4-3.6 g/day) as effective as 40 mg simvastatin/day in lowering LDL cholesterol[4]
- viscous fibers (oats, barley, beans)*
- limit alcohol consumption
aerobic exercise
- 20 to 30 minutes 3 times/week
- fitness lowers mortality in hyperlipidemic patients, regardless of statin use
- moderate fitness (5.1-7.0 METS) lowers mortality as much as statin use[6]
pharmacologic agents
- hypercholesterolemia
- HMG CoA reductase inhibitors (statins) 1st line[1]
- beneficial effects on LDL cholesterol, HDL cholesterol, serum triglycerides (see LDL cholesterol for intensity of therapy)
- ezetimibe 10 mg 1st add to statin therapy[10]
- PCSK9 inhibitor evolocumab or alirocumab
- bile acid sequestrant
- affect (lowers) mainly LDL cholesterol
- cholestyramine (Questran) 4 g QD - TID
- no evidence of cardiovascular benefit when added to statin[1]
- nicotinic acid 1-3 g TID
- beneficial effects on LDL cholesterol, HDL cholesterol, serum triglycerides
- better for hypertriglyceridemia than statins[1]
- no benefit as adjunct to statin therapy for patients with low HDL cholesterol & high serum triglycerides[5]
- Probucol (Lorelco) 500 mg PO BID
- estrogen replacement therapy
- red yeast rice (Monascus purpureus, Xue Zhi Kang)*
- can lower LDL cholesterol 35-43 gm/dL
- marked variation among different commercial products
- psyllium* (5% reduction in LDL cholesterol)[8]
- HMG CoA reductase inhibitors (statins) 1st line[1]
- hypertriglyceridemia
- fibrates are 1st line
- gemfibrozil (Lopid) 600 mg PO BID
- nicotinic acid (second choice)
- statins
- fibrates are 1st line
- caution in treating hyperlipidemia in patients with schizophrenia
- increased serum cholesterol & serum triglycerides are associated with better cognitive function in patients with schizophrenia[9]
* GRS8 states evidence stronger to support effectiveness of viscous fibers (oats, barley, beans, psyllium) than for red yeast rice[8] despite lesser effect on LDL cholesterol (apparently because of variation among different commercial products of red yeast rice)
More general terms
More specific terms
- hypercholesterolemia
- hypertriglyceridemia
- lecithin-cholesterol acyltransferase [LCAT] deficiency (Norum disease)
Additional terms
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2018, 2021.
- ↑ 2.0 2.1 2.2 Journal Watch 25(12):97, 2005 Gardner CD, Coulston A, Chatterjee L, Rigby A, Spiller G, Farquhar JW. The effect of a plant-based diet on plasma lipids in hypercholesterolemic adults: a randomized trial. Ann Intern Med. 2005 May 3;142(9):725-33. Summary for patients in: Ann Intern Med. 2005 May 3;142(9):I35. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15867404
- ↑ Prescriber's Letter 14(1): 2007 Intensive LDL Reduction: What's the Evidence? Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230107&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 4.0 4.1 Becker DJ et al. Simvastatin vs therapeutic lifestyle changes and supplements: Randomized primary prevention trial. Mayo Clin Proc 2008 Jul; 83:758. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18613992
- ↑ 5.0 5.1 NIH News: Thursday, May 26, 2011 NIH stops clinical trial on combination cholesterol treatment Lack of efficacy in reducing cardiovascular events prompts decision http://www.nih.gov/news/health/may2011/nhlbi-26.htm
Prescriber's Letter 18(7): 2011 Niacin Plus Statin to Reduce Cardiovascular Risk: AIM-HIGH Study Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=270701&pb=PRL (subscription needed) http://www.prescribersletter.com
The AIM-HIGH Investigators. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011 Nov 15 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22085343 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1107579 - ↑ 6.0 6.1 Kokkinos PF et al. Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia: A cohort study. Lancet 2012 Nov 28 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23199849
- ↑ Stone NJ et al 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk on Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. Nov 12, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24222016 <Internet> http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a
Stone NJ et al Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults: Synopsis of the 2013 ACC/AHA Cholesterol Guideline. Ann Intern Med. Published online 28 January 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24474185 <Internet> http://annals.org/article.aspx?articleid=1818923 - ↑ 8.0 8.1 8.2 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
- ↑ 9.0 9.1 Brooks M Hyperlipidemia: Bad for the Heart, Good for the Brain? Medscape News from the American Psychiatric Association (APA) 2015 Annual Meeting http://www.medscape.com/viewarticle/844814
- ↑ 10.0 10.1 10.2 Lloyd-Jones DM et al 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk. J Am Coll Cardiol. April 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27046161 Free Article <Internet> http://content.onlinejacc.org/article.aspx?articleID=2510936#tab1
- ↑ 11.0 11.1 Watson KE How Many Patients with Severe Hypercholesterolemia Have FH? NEJM Journal Watch. April 19, 2016 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Khera AV et al. Diagnostic yield of sequencing familial hypercholesterolemia genes in patients with severe hypercholesterolemia. J Am Coll Cardiol 2016 Apr 3 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27050191 - ↑ Roth EM, McKenney JM, Hanotin C, et al. Atorvastatin with or without an antibody to PCSK9 in primary hypercholesterolemia. N Engl J Med. 2012;367(20):1891-1900 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23113833 Free Article
- ↑ 13.0 13.1 Grundy SM, Stone NJ, Bailey AL et al 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Jun 18;139(25):e1082-e1143. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30586774
Grundy SM, Stone NJ, Bailey AL et al 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Jun 18;139(25):e1046-e1081. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30565953
Forman DE, Stone NJ, Grundy SM. Treating Hypercholesterolemia in Older Adults. JAMA. 2019 Aug 20;322(7):695. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31429891