Management of Management of Dyslipidemia Dyslipidemia ( ( lecture given to General Practioners in lecture given to General Practioners in Narshingdhi organized by local BMA and Beximco ) Narshingdhi organized by local BMA and Beximco ) Dr. Md.Toufiqur Rahman Dr. Md.Toufiqur Rahman MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI, MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI, FAPSC, FAPSIC, FAHA FAPSC, FAPSIC, FAHA Associate Professor of Cardiology Associate Professor of Cardiology National Institute of Cardiovascular Diseases National Institute of Cardiovascular Diseases Sher-e-Bangla Nagar, Dhaka-1207 Sher-e-Bangla Nagar, Dhaka-1207 Consultant, Medinova, Malbagh branch. Consultant, Medinova, Malbagh branch. Honorary Consultant, Apollo Hospitals, Dhaka and Honorary Consultant, Apollo Hospitals, Dhaka and Life Care Centre, Dhanmondi Life Care Centre, Dhanmondi
Dyslipidemia, Metabolic Syndrome, Risk factors, Classification, Therapeutic life style changes, Drug treatment, Hypertriglyceridemia,
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Management of DyslipidemiaManagement of Dyslipidemia((lecture given to General Practioners in Narshingdhi organized by lecture given to General Practioners in Narshingdhi organized by
Major Risk Factors (Exclusive of LDL Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL GoalsCholesterol) That Modify LDL Goals Cigarette smokingCigarette smoking Hypertension (BP Hypertension (BP 140/90 mmHg or on 140/90 mmHg or on
antihypertensive medication)antihypertensive medication) Low HDL cholesterol (<40 mg/dL)Low HDL cholesterol (<40 mg/dL)†† Family history of premature CHDFamily history of premature CHD
– CHD in male first degree relative <55 yearsCHD in male first degree relative <55 years– CHD in female first degree relative <65 CHD in female first degree relative <65
yearsyears Age (men Age (men 45 years; women 45 years; women 55 years)55 years)
† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.
In ATP III, diabetes is regarded In ATP III, diabetes is regarded as a CHD risk equivalent. as a CHD risk equivalent.
Diabetes as a CHD Risk Diabetes as a CHD Risk EquivalentEquivalent
10-year risk for CHD 10-year risk for CHD 20% 20% High mortality with established CHDHigh mortality with established CHD
– High mortality with acute MIHigh mortality with acute MI– High mortality post acute MIHigh mortality post acute MI
CHD Risk EquivalentsCHD Risk Equivalents
Other clinical forms of atherosclerotic Other clinical forms of atherosclerotic disease (peripheral arterial disease, disease (peripheral arterial disease, abdominal aortic aneurysm, and abdominal aortic aneurysm, and symptomatic carotid artery disease)symptomatic carotid artery disease)
DiabetesDiabetes Multiple risk factors that confer a 10-Multiple risk factors that confer a 10-
year risk for CHD >20%year risk for CHD >20%
Risk CategoryRisk Category
CHD and CHD riskCHD and CHD riskequivalentsequivalents
100–129100–129 Near optimal/above Near optimal/above optimaloptimal
130–159130–159 Borderline highBorderline high
160–189160–189 HighHigh
190190 Very highVery high
ATP III Lipid and ATP III Lipid and Lipoprotein Classification Lipoprotein Classification (continued)(continued)
HDL Cholesterol HDL Cholesterol (mg/dL)(mg/dL)
<40<40 Low Low
6060 High High
ATP III Lipid and ATP III Lipid and Lipoprotein Classification Lipoprotein Classification (continued)(continued)
Total Cholesterol (mg/dL)Total Cholesterol (mg/dL)
<200<200 DesirableDesirable
200–239200–239 Borderline highBorderline high
240240 HighHigh
Primary Prevention With Primary Prevention With LDL-Lowering TherapyLDL-Lowering Therapy
Public Health ApproachPublic Health Approach
Reduced intakes of saturated fat and Reduced intakes of saturated fat and cholesterolcholesterol
Increased physical activityIncreased physical activity Weight controlWeight control
Causes of Secondary Causes of Secondary DyslipidemiaDyslipidemia
DiabetesDiabetes HypothyroidismHypothyroidism Obstructive liver diseaseObstructive liver disease Chronic renal failureChronic renal failure Drugs that raise LDL cholesterol and Drugs that raise LDL cholesterol and
lower HDL cholesterol (progestins, lower HDL cholesterol (progestins, anabolic steroids, and corticosteroids)anabolic steroids, and corticosteroids)
Secondary Prevention With Secondary Prevention With LDL-Lowering TherapyLDL-Lowering Therapy
Benefits: reduction in total mortality, Benefits: reduction in total mortality, coronary mortality, major coronary events, coronary mortality, major coronary events, coronary procedures, and strokecoronary procedures, and stroke
LDL cholesterol goal: <100 mg/dLLDL cholesterol goal: <100 mg/dL Includes CHD risk equivalentsIncludes CHD risk equivalents Consider initiation of therapy during Consider initiation of therapy during
190 190 (160–189: LDL-(160–189: LDL-lowering drug lowering drug
optional)optional)
Benefit Beyond LDL Lowering: The Metabolic Benefit Beyond LDL Lowering: The Metabolic Syndrome as a Secondary Target of TherapySyndrome as a Secondary Target of Therapy
General Features of the Metabolic SyndromeGeneral Features of the Metabolic Syndrome
Raised blood pressureRaised blood pressure Insulin resistance (Insulin resistance ( glucose intolerance) glucose intolerance) Prothrombotic stateProthrombotic state Proinflammatory stateProinflammatory state
Therapeutic Lifestyle ChangesTherapeutic Lifestyle ChangesNutrient Composition of TLC DietNutrient Composition of TLC Diet
NutrientNutrient Recommended IntakeRecommended Intake Saturated fatSaturated fat Less than 7% of total caloriesLess than 7% of total calories Polyunsaturated fatPolyunsaturated fat Up to 10% of total caloriesUp to 10% of total calories Monounsaturated fat Monounsaturated fat Up to 20% of total caloriesUp to 20% of total calories Total fatTotal fat 25–35% of total calories25–35% of total calories CarbohydrateCarbohydrate 50–60% of total calories50–60% of total calories FiberFiber 20–30 grams per day20–30 grams per day ProteinProtein Approximately 15% of total caloriesApproximately 15% of total calories CholesterolCholesterol Less than 200 mg/dayLess than 200 mg/day Total calories (energy)Total calories (energy) Balance energy intake and expenditure Balance energy intake and expenditure
to maintain desirable body weight/to maintain desirable body weight/prevent weight gainprevent weight gain
Reduce major coronary eventsReduce major coronary events Reduce CHD mortalityReduce CHD mortality
Drug TherapyDrug TherapyNicotinic AcidNicotinic Acid
Major actionsMajor actions– Lowers LDL-C 5Lowers LDL-C 5––25%25%
– Lowers TG 20Lowers TG 20––50%50%
– Raises HDL-C 15Raises HDL-C 15––35%35%
Side effects: flushing, hyperglycemia, Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hyperuricemia, upper GI distress, hepatotoxicityhepatotoxicity
Contraindications: liver disease, severe gout, Contraindications: liver disease, severe gout, peptic ulcerpeptic ulcer
Reduce progression of coronary Reduce progression of coronary lesionslesions
Reduce major coronary eventsReduce major coronary events
LDL-cholesterol goal: <100 mg/dLLDL-cholesterol goal: <100 mg/dL Most patients require drug therapyMost patients require drug therapy First, achieve LDL-cholesterol goalFirst, achieve LDL-cholesterol goal Second, modify other lipid and non-Second, modify other lipid and non-
lipid risk factorslipid risk factors
Secondary Prevention: Drug TherapySecondary Prevention: Drug Therapyfor CHD and CHD Risk Equivalentsfor CHD and CHD Risk Equivalents
Progression of Drug Therapy in Primary Prevention
If LDL goal not achieved, intensifyLDL-lowering therapy
If LDL goal not achieved, intensify drug therapy or refer to a lipid specialist
Monitor response and adherence to therapy
• Start statin or bile acid sequestrant or nicotinic acid
• Consider higher dose of statin or add a bile acid sequestrant or nicotinic acid
6 wks 6 wks Q 4-6 mo
• If LDL goal achieved, treat other lipid risk factors
Acquired causesAcquired causes– Overweight and obesityOverweight and obesity– Physical inactivityPhysical inactivity– High carbohydrate diets (>60% of energy High carbohydrate diets (>60% of energy
Management of Overweight and ObesityManagement of Overweight and Obesity
Overweight and obesity: lifestyle risk factorsOverweight and obesity: lifestyle risk factors Direct targets of interventionDirect targets of intervention Weight reductionWeight reduction
Causes of Elevated TriglyceridesCauses of Elevated Triglycerides
Obesity and overweightObesity and overweight Physical inactivityPhysical inactivity Cigarette smokingCigarette smoking Excess alcohol intakeExcess alcohol intake
Specific Dyslipidemias: Specific Dyslipidemias: Elevated TriglyceridesElevated Triglycerides
Causes of Elevated TriglyceridesCauses of Elevated Triglycerides (continued)(continued)
High carbohydrate diets (>60% of energy intake)High carbohydrate diets (>60% of energy intake) Several diseases (type 2 diabetes, chronic renal Several diseases (type 2 diabetes, chronic renal
failure, nephrotic syndrome)failure, nephrotic syndrome) Certain drugs (corticosteroids, estrogens, Certain drugs (corticosteroids, estrogens,
retinoids, higher doses of beta-blockers)retinoids, higher doses of beta-blockers) Various genetic dyslipidemiasVarious genetic dyslipidemias
Specific Dyslipidemias: Specific Dyslipidemias: Elevated Triglycerides Elevated Triglycerides (continued)(continued)
Specific Dyslipidemias: Specific Dyslipidemias: Elevated TriglyceridesElevated Triglycerides
Management of Very High TriglyceridesManagement of Very High Triglycerides ((500 mg/dL)500 mg/dL)
Goal of therapy: prevent acute pancreatitisGoal of therapy: prevent acute pancreatitis Very low fat diets (Very low fat diets (15% of caloric intake)15% of caloric intake) Triglyceride-lowering drug usually required Triglyceride-lowering drug usually required
(fibrate or nicotinic acid)(fibrate or nicotinic acid) Reduce triglycerides Reduce triglycerides before before LDL lowering LDL lowering
Specific Dyslipidemias: Specific Dyslipidemias: Low HDL CholesterolLow HDL Cholesterol
Causes of Low HDL Cholesterol (<40 mg/dL)Causes of Low HDL Cholesterol (<40 mg/dL)
Elevated triglyceridesElevated triglycerides Overweight and obesityOverweight and obesity Physical inactivityPhysical inactivity Type 2 diabetesType 2 diabetes Cigarette smokingCigarette smoking Very high carbohydrate intakes (>60% energy)Very high carbohydrate intakes (>60% energy) Certain drugs (beta-blockers, anabolic steroids, progestational Certain drugs (beta-blockers, anabolic steroids, progestational