Presented by: Tareq Abualnadi
Supervised by: Dr. Abdullah Jad
Definition
• Disorders of lipoprotein metabolism manifested as:
• Elevated: Total cholesterol, LDL, TAGs
• Reduced: HDL
Prevalence (%) in Jordan
1994 2017
Hypercholesterolemia 23 44.3
Hypertriglyceridemia 23.8 41.9
High LDL - 75.9
Low HDL - 59.5
The elevated LDL and reduced HDL promote atherosclerosis, hence
dyslipidemia is a major risk factor for atherosclerotic cardiovascular
disease (ASCVD)
Etiology
A. Acquired – more common
• Obesity
• Physical inactivity
• DM / Insulin resistance
• Hypothyroidism
• Cushing disease
• Nephrotic Syndrome
• Cholestatic liver disease
• Heavy alcohol consumption
• Drugs – Thiazides, B-blockers, antipsychotics, HIV protease inhibitors, OCPs
B. Inherited
Frederickson classification of inherited hyperlipoproteinemia
Clinical manifestations
1. Skin
Xanthomas Xanthelasmas
2. Eye
Arcus lipoides corneae Lipemia retinalis
3. Gastrointestinal 4. Premature Atherosclerosis
• Hepatic Steatosis – associated with: • Associated with: Syndromes 2,3,4
abetalipoproteinemia
metabolic • Manifests with ACVD
syndrome
alcohol
consumption
• Pancreatitis – TAGs>>1000mg/dL
Approach
1. Screen for lipid disorders
*Consider earlier screening in family Hx of : - familial hypercholesterolemia (2a)
- premature ASCVD
2. Tests (Lipid profile)
• Non-fasting – adequate in most cases
• Fasting – when:a) evaluating familial lipid disorders
b) non-fasting triglyceride > 400mg/dL
Lipid panel
Total Cholesterol = LDL + HDL + (TAG/5)
3. Assess for secondary causes of hyperlipidemia
• Indications: 20-39 years old with hyperlipidemia
• Tests: - Fasting blood glucose / HbA1c
- TSH/T4
- LFT
- Urinalysis/Serum creatinine
4. Assess ASCVD risk to guide treatment
Statins Intensity
Intensity Expected reduction in Agents
LDL level
High >50% Atorvastatin (40-80mg)
Rosuvastatin (20-40mg)
Moderate 30-49% Atorvastatin(10-20mg)
Rosuvastatin (5-10mg)
Simvastatin (20-40mg)
Lovastatin (40mg)
Low <30% Simvastatin (10mg)
Lovastatin (20mg)
Pitavstatin (1mg)
Non-statin Lipid lowering agents
• Ezetimibe – Lowers LDL by 13-20%
• Bile acid sequestrants (cholestyramine) – Lowers LDL by 15-30%
• PCKS9 inhibitors (evolcumab, alirocumab) – Lowers LDL by 43-64%
Primary Prevention of ASCVD
Treatment of hypercholesterolemia in adults
• Patients ≥ 20 years of age with clinical ASCVD Consider high-intensity statin therapy
• Patients 20–75 years of age and LDL ≥ 190 mg/dL: high-intensity statin therapy
• Patients 40–75 years of age and LDL 70–189 mg/dL: Treatment is based on the 10-year ASCVD
risk.
High (≥ 20%): high-intensity statin therapy
Borderline to intermediate (5–20%): moderate-intensity statin therapy
• Patients 40–75 years of age with diabetes mellitus
• Initiate moderate-intensity statin therapy
• Consider high-intensity statin therapy in patients with several ASCVD risk factors
• Patients 20–39 years of age if LDL ≥ 160 mg/dL and family history positive for premature ASCVD
- Consider statin therapy.
Treatment of hypertriglyceridemia in
adults
Triglyceridemia Definition Treatment
Moderate Fasting/Non-fasting 175- In all patients > 20yo:
499mg/dL a) Recommended lifestyle modifications
b) Manage associated conditions
Severe Fasting >=500mg/dL a) intermediate/high risk ASCVD – statin
b) Lifestyle modifications
c) If persistent:
• Omega-3
• Fibrates
