questions 2

Hypercholersterolemia / Hyperlipidemia

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Topic updated on 06/06/17 11:42am

Snapshot
  •  A 44-year-old obese Caucasian gentleman presents to his primary care physician for a routine check-up after having some blood work done. He is found to have a total cholesterol level of 430 mg/dL. He complains of calf pain while walking to the grocery store, which only seem to resolve with rest. He states that he has a follow up appointment with his cardiologist because of some "plugged up vessels". Additionally, you notice that he has well demarcated yellow deposits around his eyes. 
Introduction
  • Excess cholesterol/lipids in the blood
    • cholesterol is transported in the blood by lipoproteins
      • VLDL - very low density lipoprotein
      • IDL - intermediate density lipoprotein
      • LDL - low density lipoprotein
      • HDL - high density lipoprotein
  • Causes
    • environmental
      • obesity and dietary choices
      • diabetes mellitus type 2
      • nephrotic syndrome
      • hypothyroid
      • medications
        • thiazides, beta-blockers, glucocorticoids
      • alcohol
      • exogenous testosterone
    • genetics
      • commonly multigenic in nature
      • can have single gene defect - familial hypercholesterolemia
        • autosomal dominant
        • characterized by very high LDL and early cardiovascular disease
        • heterozygotes 1:500
          • cholesterol approximately 300 mg/dL
        • homozygotes (very rare)
          • cholesterol approximately 700+ mg/dL
        • mutations
          • LDLR gene
          • protein encoded for LDL receptor protein
  • Associated conditions
    • atherosclerosis
    • coronary artery disease
Presentation
  • Signs and symptoms
    • atheromas 
      • plaques in blood vessel walls
    • xanthomas
      • accumulation of lipid-laden histiocytes in the skin
      • xanthelasma - on the eyelids
      • tendinous xanthoma - on tendons, especially Achilles
    • corneal arcus 
      • lipid deposit in cornea
    • tissue ischemia (secondary to arterial occlusion)
      • TIA 
      • MI
      • claudication
      • mesenteric ischemia
Evaluation
  • Labs
    • NIH classifies total cholesterol of
      • < 200 mg/dL as desirable
      • 200-239 mg/dL as borderline high
      • > 240 as high 
    • HDL level results of
      • > 60 mg/dL as desirable
      • 40-59 mg/dL as acceptable
      • < 40 mg/dL as low and increasing risk of heart disease
    • LDL level results of 
      • < 100 mg/dL as optimal
      • 100-129 as near optimal
      • 130-159 as borderline high
      • > 160 as high
  • Secondary imaging may be necessary for work up of disease sequelae 
Treatment
  • Conservative
    • lifestyle modifications
      • indications
        • mildly elevated cholesterol
      • modalities
        • smoking cessation
        • decrease EtOH intake
        • increase physical activity
        • maintain healthy weight
      • outcomes
        • dietary modifications can alter cholesterol levels by 15%
  • Pharmacologic
    • statins (HMG-CoA reductase inhibitors)
      • indications
        • moderately elevated cholesterol
        • when lifestyle modifications have failed
      • first-line treatment
        • choose high intensity statin if the patient has the following risk factors
          • clinical atherosclerotic cardiovascular disease (ASCDV)
          • LDL-C > 190
          • diabetes between 45-70 years old
          • > 7.5% risk of ASCVD in next 10 years
        • otherwise choose medium intensity statin
      • outcomes
        • can reduce total cholesterol by ~50% in most people
      • side effects
        • elevated liver enzymes
        • myopathy/myositis/myalgia/rhabdomyolysis
        • diabetes
        • drug-drug interactions
    • fibrates
      • indications
        • accessory to statins in hypercholesterolemia
        • not used in monotherapy
      • side effects
        • mild stomach pain
        • myopathy
        • gallstones 
          • increase cholesterol content of bile
        • AKI
    • nicotinic acid (niacin; vitamin B3)
      • indications
        • helps to increase HDL
        • can also decrease LDL, VLDL, TGs
      • side effects
        • skin flushing
          • treat with aspirin
        • GI symptoms such as dyspepsia
        • hepatic toxicity
        • hyperglycemia
        • hyperuricemia
    • cholestyramine
      • indications
        • hypercholesterolemia
        • it is a bile acid sequestrant 
      • side effects
        • constipation - most frequent
        • gallstones
        • increased plasma TGs
        • drug-drug interactions
Prognosis and Prevention
  • Prognosis varies depending on severity 
  • Screening
    • 2 rounds of universal screening for children
      • 9 - 11 years old - before puberty
      • 17 - 21 years old - after puberty
  • Prevention
    • USPSTF recommends routine screening
      • men > 35 years old
      • women > 45 years old
    • USPSTF recommends screening if there are other risk factors (coronary heart disease)
      • men 20-35
      • women 20-45


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Qbank (1 Questions)

TAG
(M2.CV.13) A 27-year-old woman presents to your medical clinic with a chief complaint of bilateral lesions along the medial canthus of her eyes as shown in Figure A. She is quite concerned about the cosmetic appearance of these lesions and would like them removed. She has no other complaints nor any significant past medical history. In addressing this patient's chief complaint, what would be the next appropriate step in management? Topic Review Topic
FIGURES: A          

1. Refer to a dermatologist for Mohs surgery
2. Obtain a lipid panel
3. Obtain anti-topoisomerase antibodies
4. Obtain anti-transglutaminase antibodies
5. Provide reassurance and refer to an oculoplastic surgeon for removal of the lesions

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