dyslipidemia
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Dyslipidemia Dyslipidemia
Prof Talaat Abdel AttiInternal Medicine Department
Unit of Diabetes and MetabolismUnit of Diabetes and Metabolism
Alexandria Faculty of Medicine
2009 - 2010
AgendaAgenda Lipids (types and function). Digestion and absorption of lipids. Lipoproteins. Dyslipidemia.
Definition. Classification. Diagnosis. Management.
Lipids (types and function). Digestion and absorption of lipids. Lipoproteins. Dyslipidemia.
Definition. Classification. Diagnosis. Management.
LipidsLipids• Lipids are a family of non-polarnon-polar organic
compounds that are characterized by their insolubility in water insolubility in water but dissolve in organic solvents.
• Lipids includes triglyceridestriglycerides, phospholipidsphospholipids, sterolssterols and fat soluble vitamins.
TriglyceridesTriglycerides
• What we refer to as fats and oils.• T.G make up 95% 95% of lipids found in foods.• T.G make up 99% 99% of lipids stored in the body.• Triglyceride = glycerol + 3 fatty acids3 fatty acids
Types of Fatty Acids
I- Saturated fatty acids:• No double bonds between carbon atoms.• Includes
Animal fatPalm oil ( النخيل (زيتCoconut oil ( الهند جوز (زيت
II- Mono-unsaturated F.A
H O
H C C C C OH
H H H
• Only oneone double bond between carbon atoms.
• Includes olive oil and canola oil ( زيت ال. (الحار
III- Poly-unsaturated FA
H H H H O
H C C C C C C OH
H• More than ONE double bond
between carbon atoms.• E.g: Corn oil and sunflower oil.
Essential fatty acids Omega 3 & 6
• The body can make all but two of the fatty acids it needs (Omega-3 and Omega-6)(Omega-3 and Omega-6).
• Because they must be supplied by the diet they are called essential fatty acidsessential fatty acids.
• Foods that help supply these two essential fatty acids are vegetable oils, seeds, nuts, fish, and other meats.
Fats versus oilsFats versus oils• Fats are lipids that are solid at room
temperature.• Oils are lipids that are liquid at room
temperature.
Hydrogenation and Trans-fatHydrogenation and Trans-fat
• Chemical process of adding hydrogen atoms to mono- and polyunsaturated fatty acids creates trans fatstrans fats.
• Adding Hydrogen alters the oils & changes them to more solid /plastic fats.
• Adding H = more saturated = more solid fat.• Why Hydrogenate:
– to prevent RANCIDITY and increases shelf life.
Results of Hydrogenation:Results of Hydrogenation:
• Hydrogenated fats react the same way saturated fats do.
• Trans fats formed during hydrogenation process have been linked to adverse effects on Blood Cholesterol and higher risk of coronary heart disease.
• Food examples of trans-fat includes cakes , biscuits, potato crisps and fast food
PhospholipidsPhospholipids• Compound similar to triglyceride but having a
phosphate group in place of one of fatty acids.• Not an essential nutrient as liver produces lecithin.• Importance of phospholipids:o Constituent of cell membranes.o Facilitate movement of lipids across membranes.o Enable fat soluble vitamins and hormones to pass in
and out of cells.
SterolsSterols• Present in animal foods (cholesterol) and
plant foods (phytosterols).
• Most common sterol is cholesterol.
• Only animal products contain cholesterol.
• Our livers make about 800-1500 mg of cholesterol per day from fragments of carbohydrates, proteins and fat
Two Sources of Cholesterol: Hepatic Synthesis and Absorption from deit
Two Sources of Cholesterol: Hepatic Synthesis and Absorption from deit
Fecal bile acids and neutral sterols (~700 mg/day)
Extrahepatictissues
BiliaryBiliarycholesterolcholesterol
(~1000 mg/day(~1000 mg/day))
Absorption(~700 mg/day)
LiverLiverSynthesis*Synthesis*
Intestine
DietaryDietarycholesterolcholesterol
(~300–700 mg/day)(~300–700 mg/day)
SterolsSterols• Roles of sterols:
– Bile acids (which help to digest fats)– Sex hormones– Adrenal hormones– Vitamin D
• Cholesterol is a major component of nerve & brain tissue.
Functions of Lipids Functions of Lipids • Most concentrated source of energy 1g 9 Kcals.• Fuel reserve.• Carries fat-soluble vitamins in the body. (D,E,K, A) • InsulatesInsulates the body against cold and injury.• Provides longer satietysatiety (satisfaction of hunger).• Carries fat-soluble flavorsflavors.• Nerve transmission Nerve transmission speeds up due to lipids around
nerves (mylin)
Fat Content of Some Dietary FatsFat Content of Some Dietary Fats
Ghee………………………….….100%
Margarines (Synthetic butter)…81%
Butter………………………………81%
Oils…………….………………....100%
Cream……………..…………...20-30%
Lipid DigestionLipid Digestionand Absorptionand Absorption
Lipids Digestion• Stomach:Stomach:
– Little digestion takes place in stomach• Small intestineSmall intestine
– Primary site of fat digestion
– Bile and emulsification.
– Pancreatic and intestinal lipases break T.G → glycerol + fatty acids.
– 95% of fat consumed is absorbed.
I- I- EmulsificationEmulsification:1.Breaking down Large fats to smaller fats.2.Coating small fat globules with bile salts. 3.After emulsification fats are smaller and more exposed to the action of lipases.
II- II- Fat hydrolysisFat hydrolysis:1.Emulsification droplets are acted upon by lipases.2.Lipases break T.G → glycerol + fatty acids.
III- III- Lipid uptake by micellesLipid uptake by micelles:1.Micelles in bile pick up products of fat digestion.2.Micelles are a phospholipid bi-layer which can be taken by the intestinal brush border.
Fat Digestion: Formation of MicellesFat Digestion: Formation of Micelles
TriglyceridesTriglyceridesTriglyceridesTriglyceridesDietaryDietaryCholesterolCholesterol
DietaryDietaryCholesterolCholesterol
Fatty Acids +Fatty Acids +Mono-glyceridesMono-glycerides
Fatty Acids +Fatty Acids +Mono-glyceridesMono-glycerides
1. Intestinal cells absorb lipids from micelles.2. Intestinal cells re-synthesize triglycerides.3. Intestinal cells package T.G, cholesterol and
phospholipids into protein coated chylomicron.4. Chylomicron are secreted into lacteals and then
carried via lymph to the veins
Fat Absorption
Cholesterol Absorption Cholesterol Absorption
IntestinalIntestinalcellcell
FFAFFA
MicellesMicelles
Bile acidsBile acids
LiverLiver
CholesterolCholesterol
FFAFFA
ChylomicronsChylomicrons
Digest foodDigest food Cholesteryl esterCholesteryl ester CholesterolCholesterol
FFAFFA
Free Free cholesterolcholesterol
BloodBlood
LymphaticLymphaticchannelschannels
Lipoproteins: Introduction
Triglycerides, long chain FA, phospholipids, cholesterol are insoluble in water.
Their transport in blood from the site of absorption or synthesis to sites of utilization or elimination requires a special mechanism.
This is accomplished when the lipids combine with water soluble proteins.
VLDLVLDL
sd-HDLsd-HDL
FFAFFA
abdominal obesityabdominal obesity+ insulin resistance+ insulin resistance
dysfunctionaldysfunctionaladipose tissueadipose tissue CETPCETP CECE
TG
TGTG
CETPCETP
sd-LDLsd-LDL
TG
lipaseslipases
ApoA-1ApoA-1
TGTGCECE
renalrenalclearanceclearance
TG
lipaseslipaseslipaseslipases
fatty liverfatty liver
TGTG
TG rich, CE poorTG rich, CE poor
TG rich, CE poorTG rich, CE poor
adapted from:adapted from:Bays H. Combination Lipid-Altering Drug Therapy with Statins: An Update, 1999, lipidsonline.orgBays H. Combination Lipid-Altering Drug Therapy with Statins: An Update, 1999, lipidsonline.orgGinsberg H. Diabetic Dyslipidemia and Atherosclerosis, 1999, lipidsonline.org CETP cholesteryl ester transfer proteinGinsberg H. Diabetic Dyslipidemia and Atherosclerosis, 1999, lipidsonline.org CETP cholesteryl ester transfer proteinCE Cholesteral EsterCE Cholesteral Ester
Abnormal Lipid Metabolism
HDL HDL
Clusters of lipids associated with proteins that serve as transporttransport vehicles for lipids in lymph and blood.
Lipoproteins: Definition
ECTG
Apoprotein boat
Structure of Lipoproteins
Rye KA, et al. Atherosclerosis. 1999;145:227-238.
Hydrophobic Core Hydrophobic Core TriglycerideTriglycerideCholesterylCholesteryl
EstersEsters
Surface CoatSurface CoatMonolayer of Monolayer of Phospholipids Phospholipids
and Free and Free CholesterolCholesterol
Apo lipoproteins Apo lipoproteins
Anatomy of a Lipoprotein
Lipoproteins Metabolism
Lipoproteins: Classification
Transport Endogenous
lipids
Transport Exogenous
lipids
Chylomicrons
Intestine to the liver through
lymph
Liver tissuesVLDL-CLDL-C
Tissues LiverHDL-C
Classification ofLipoproteins
Triglyceride rich Cholesterol rich
HDLLDL
Chylomicrons
VLDL
Classes of lipoprotein
Class Source Function
Chylomicrons Intestine Transport dietary TG
VLDLLiver Transport
endogenous TG
LDL circulation by partial
breakdown of IDL.
Delivers cholesterol to
peripheral tissues
HDL Liver. Removes cholesterol from tissues and takes
it to liver.
Chylomicrons
LargestLargest lipoprotein.
LowestLowest density.
Made up primarily of triglycerides triglycerides (85%)
Transporting dietarydietary triglycerides
NotNot found in 12 – 14 hr fasting blood samples.
VLDL Structure
Rich in triglycerides (65%).
More dense than chylomicrons
Contains ApoB-100.
Major carrier of endogenous (liver synthesized) triglyceride.
Delivers triglyceride to the periphery.
The precursor for IDL and LDL.
It is formed after triglyceride in VLDL is hydrolyzed by lipoprotein lipase.
The core is 50% triglyceride and 50% cholesteryl ester.
IDL contains Apo-B-100.
IDL: Structure
LDL-Cholesterol
Core is rich in cholesteryl ester.
Most cholesterol rich lipoprotein.
LDL contains apo B-100.
LDL-Cholesterol
Synthesized from IDL.
Accounts for majority of cholesterol circulating in blood.
LDL plays a major role in development of atherosclerosis.atherosclerosis.
The cholesterol in LDL is often called “bad cholesterol”“bad cholesterol”.
LDL size seems to be an important predictor of cardiovascular events and progression of coronary artery disease.
Predominance of small, dense LDL has been accepted as an emerging cardiovascular risk factor by the National Cholesterol Education Program Adult Treatment Panel III.
LDL – Does Size Matter?
HDL Cholesterol
Smallest lipoproteins.
The major structural protein is apo A-I.
Core is predominantly cholesteryl ester.
Carries 20-35% of plasma cholesterol.
HDL: Reverse Cholesterol Transport
BloodBloodBloodBloodPeripheralPeripheralTissuesTissues
PeripheralPeripheralTissuesTissues
LiverLiverLiverLiver
BileBile
ExcessExcessCholesterolCholesterol
HDL- Cholesterol
Removes excess cholesterol from body cells and transports it to the liver for elimination.
known as "good "good cholesterol" cholesterol" as it prevents accumulation of cholesterol in blood vessels and is associated with a reduced risk of coronary artery disease.
Anti-Atherogenic Properties of HDLAnti-Atherogenic Properties of HDL::
Reverse Cholesterol TransportReverse Cholesterol Transport..
Anti-Oxidant PropertiesAnti-Oxidant Properties..
Anti-Inflammatory PropertiesAnti-Inflammatory Properties::
Vasodilator.Vasodilator.
Anti-Thrombotic.Anti-Thrombotic.
Endothelial ProtectionEndothelial Protection..
Causes of Low HDL-CCauses of Low HDL-C Smoking Obesity (visceral fat) Very-low-fat diet Hypertriglyceridemia Drugs
– Beta-blockers – Androgenic steroids– Androgenic progestins
Smoking Obesity (visceral fat) Very-low-fat diet Hypertriglyceridemia Drugs
– Beta-blockers – Androgenic steroids– Androgenic progestins
Tangier DiseaseTangier Disease
Autosomal codominant disorder due to mutations in both alleles of ABC1 gene
Extremely marked reduction in HDL-C and apoA-I
Markedly accelerated catabolism of apoA-I and apoA-II
Cholesterol accumulation:– Enlarged orange tonsils– Hepatosplenomegaly– Peripheral neuropathy
Autosomal codominant disorder due to mutations in both alleles of ABC1 gene
Extremely marked reduction in HDL-C and apoA-I
Markedly accelerated catabolism of apoA-I and apoA-II
Cholesterol accumulation:– Enlarged orange tonsils– Hepatosplenomegaly– Peripheral neuropathy
To increase the level of HDL life style modification Exesise Stop smoking Drugs Fibrate And Nicin
To increase the level of HDL life style modification Exesise Stop smoking Drugs Fibrate And Nicin
Dyslipidemia Dyslipidemia
DyslipidemiaDyslipidemia is a range of disorders is a range of disorders that include both abnormally high that include both abnormally high and low lipoprotein levels, as well as and low lipoprotein levels, as well as disorders in the composition of these disorders in the composition of these particlesparticles..
Dyslipidemia: Classification During the 1960's; based on
the composition of serum lipoproteins, Fredrickson suggested 5 different phenotypes of hyper-lipoproteinemia.
This classification became commonly used for distinguishing hyper-lipidemic conditions. Donald S.
Fredrickson
Fredrickson Classification Fredrickson Classification of the Hyperlipidemiasof the Hyperlipidemias
PhenotypePhenotypeLipoprotein(s) Lipoprotein(s)
elevatedelevated
Plasma Plasma cholesterol cholesterol
levellevel
Plasma Plasma triglyceride triglyceride
levellevelAthero-Athero-genicitygenicity
Relative Relative frequency frequency
in USin US
II ChylomicronChylomicronss
Normal to Normal to
–– <<1%1%
IIaIIa LDLLDL NormalNormal ++++++ 10%10%
IIbIIb LDL and LDL and VLDLVLDL
++++++ 40%40%
IIIIII IDLIDL ++++++ <<1%1%
IVIV VLDLVLDL Normal to Normal to
++ 45%45%
VV VLDL and VLDL and chylomicronchylomicron
ss
to to ++ 5%5%
Classification of DyslipidemiaClassification of Dyslipidemia
• Etiologic classification: Etiologic classification:
I.I. Primary dyslipidemia:Primary dyslipidemia:o Polygenic hypercholestermia.Polygenic hypercholestermia.o Familial hypercholestermia.Familial hypercholestermia.o Familial hyper-triglycerdemia.Familial hyper-triglycerdemia.o Chylomicronemia.Chylomicronemia.o Familial combined dyslipidemia.Familial combined dyslipidemia.
Classification of DyslipidemiaClassification of Dyslipidemia
• Polygenic hypercholestermia:Polygenic hypercholestermia:o ↑↑ ↑↑ LDL.LDL.o Multiple gene defects.Multiple gene defects.o Increased cardiovascular risk.Increased cardiovascular risk.
Classification of DyslipidemiaClassification of Dyslipidemia
• Familial hypercholestermia:Familial hypercholestermia:o ↑↑↑ ↑↑↑ LDL.LDL.o ↓ ↓ LDL receptor activity.LDL receptor activity.o Markedly ncreased cardiovascular risk.Markedly ncreased cardiovascular risk.
Classification of DyslipidemiaClassification of Dyslipidemia
• Familial hypertriglycerdemia:Familial hypertriglycerdemia:o ↑↑↑ ↑↑↑ TG.TG.o ↓ ↓ Lipoprotein lipase activity.Lipoprotein lipase activity.o No increase in cardiovascular risk.No increase in cardiovascular risk.
Classification of DyslipidemiaClassification of Dyslipidemia
• Chylomicronemia:Chylomicronemia:o ↑↑↑ ↑↑↑ TG.TG.o ↓ ↓ Lipoprotein lipase activity or apo C-II Lipoprotein lipase activity or apo C-II
deficiency.deficiency.o No increase in cardiovascular risk.No increase in cardiovascular risk.o Pancreatitis.Pancreatitis.
Classification of DyslipidemiaClassification of Dyslipidemia
• Chylomicronemia:Chylomicronemia:o Retinal lipemia.Retinal lipemia.o Milky serum.Milky serum.
Classification of DyslipidemiaClassification of Dyslipidemia
• Chylomicronemia:Chylomicronemia:o Eruptive xanthoma.Eruptive xanthoma.
Classification of DyslipidemiaClassification of Dyslipidemia
• Chylomicronemia:Chylomicronemia:o Eruptive xanthoma.Eruptive xanthoma.
Classification of DyslipidemiaClassification of Dyslipidemia
• Familial combined dyslipidemia:Familial combined dyslipidemia:
o ↑↑↑ ↑↑↑ TG.TG.
o ↑↑↑ ↑↑↑ LDL.LDL.
o Apo B overproductionApo B overproduction
o Increased cardiovascular risk.Increased cardiovascular risk.
Classification of DyslipidemiaClassification of Dyslipidemia
• Etiologic classification: Etiologic classification:
II. Secondary dyslipidemia:II. Secondary dyslipidemia:o Diabetic dyslipidemia.Diabetic dyslipidemia.o Obesity, insulin resistance or metabolic Obesity, insulin resistance or metabolic
syndrome.syndrome.o Hypothyroidism.Hypothyroidism.o Nephrotic syndrome.Nephrotic syndrome.
Classification of DyslipidemiaClassification of Dyslipidemia
• Etiologic classification: Etiologic classification:
II. Secondary dyslipidemia:II. Secondary dyslipidemia:o Cholestatic liver disease.Cholestatic liver disease.o Steroids, non selective beta blockers, Steroids, non selective beta blockers,
diuretics, esterogen and ciclosporin.diuretics, esterogen and ciclosporin.
Classification of DyslipidemiaClassification of Dyslipidemia
• Diabetic dyslipidemia:Diabetic dyslipidemia:
o ↑ ↑ TG.TG.
o ↓ ↓ HDL.HDL.
o ↑↑Small dense LDL.Small dense LDL.
o Due to VLDL overproduction.Due to VLDL overproduction.
o Increased cardiovascular risk.Increased cardiovascular risk.
Causes of secondary dyslipidemiaDiabetes mellitus
Alcohol abuse
Therapeutic i.e. iatrogenic (Diuretics, oral contraceptives, retinoids, corticosteroids, anabolic steroids, etc…)
Hypothyroidism
Chronic Renal failure
Nephrotic syndrome
Cholestasis
Bulimia and Anorexia nervosa
Pregnancy
Classification of Classification of HypertriglyceridemiaHypertriglyceridemia
TG (mg/dL)TG (mg/dL) Primary concernPrimary concern
<<150150 NormalNormal
150150––199199 Borderline Borderline highhigh
Metabolic Metabolic syndromesyndrome
200200––499499 HighHigh CHD riskCHD risk
500500 Very highVery high PancreatitisPancreatitis
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-
2497.
Agenda
Introduction. Definition of dyslipidemia. Classification of dyslipidemia. Diagnostic steps:i. History.ii. Examination.iii.Investigations.iv.NCEP-ATP III Guidelines.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Diagnostic goals:Diagnostic goals:
o Detect / classify lipoprotein abnormalities.Detect / classify lipoprotein abnormalities.
o Assess cardiovascular risk:Assess cardiovascular risk:
Screen for other cardiovascular risk factors.Screen for other cardiovascular risk factors.
Detect already existing atherosclerotic disease.Detect already existing atherosclerotic disease.
Traditional Risk FactorsTraditional Risk Factors
Non modifiable
Age – middle to late.
Sex – Males.
Family history.
Potentially Modifiable
Dyslipidemia.
Hypertension.
Smoking.
Diabetes
Life style.
Emerging Risk FactorsEmerging Risk Factors
Lipid risk factors:
Lipoprotein (a) .
Lipoprotein remnants .
Small dense LDL particles .
↑ Apolipoprotein B.
↓Apolipoprotein A-I.
Non-lipid risk factors:
Homocysteine .
Inflammatory markers CRP .
Fibrinogen & PAI-1.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• History taking:History taking:o Signs & symptoms of coronary heart disease, Signs & symptoms of coronary heart disease,
cerebrovascular disease and peripheral cerebrovascular disease and peripheral arterial disease.arterial disease.
o History of other cardiovascular risk factors.History of other cardiovascular risk factors.o History of disease causing secondary History of disease causing secondary
dyslipidemia.dyslipidemia.o Dietary habits.Dietary habits.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• History taking:History taking:o Medications.Medications.o Family history of:Family history of:Cardio-vascular disease.Cardio-vascular disease.Diabetes.Diabetes.Hypertension.Hypertension.Dyslipidemia.Dyslipidemia.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas.Xanthomatas.o Arcus lipoides.Arcus lipoides.o Blood pressure.Blood pressure.o Ankle brachial index (A.B.I).Ankle brachial index (A.B.I).o Waist circumference.Waist circumference.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Xanthelasma:Xanthelasma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Xanthelasma:Xanthelasma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Xanthelasma:Xanthelasma: Cholesterol depostion in the epidermal layer Cholesterol depostion in the epidermal layer
of the orbita.of the orbita. LDL-hypercholestermia.LDL-hypercholestermia.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Planer xanthomata:Planer xanthomata:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Planer xanthomata:Planer xanthomata: Yellow orange deposit in the skin of inter-Yellow orange deposit in the skin of inter-
digital area or buttocks.digital area or buttocks. Familial hypercholestermia. Familial hypercholestermia.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tendon xanthoma:Tendon xanthoma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tendon xanthoma:Tendon xanthoma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tendon xanthoma:Tendon xanthoma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tendon xanthoma:Tendon xanthoma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tendon xanthoma:Tendon xanthoma: Cholesterol deposits in tendons of extensor Cholesterol deposits in tendons of extensor
muscles (hand, achilles tendon or elbow).muscles (hand, achilles tendon or elbow). Severe LDL-hypercholestermia.Severe LDL-hypercholestermia.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tuberous xanthoma:Tuberous xanthoma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tuberous xanthoma:Tuberous xanthoma:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Xanthomatas:Xanthomatas:Tuberous xanthoma:Tuberous xanthoma: Elevated xanthomata at pressure areas.Elevated xanthomata at pressure areas. Dys-lipoproteinemia.Dys-lipoproteinemia.
Eruptive XanthomaEruptive XanthomaEruptive XanthomaEruptive Xanthoma
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Arcus lipoides:Arcus lipoides:
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Blood pressure:Blood pressure: Patient seated.Patient seated. Adequate size of blood pressure cuff.Adequate size of blood pressure cuff.
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Clinical examination:Clinical examination:o Waist cirumfernce:Waist cirumfernce: Correlates with cardio-vascular risk.Correlates with cardio-vascular risk. > 94 cm in men.> 94 cm in men. > 80 cm in women.> 80 cm in women.
Measurement of WaistMeasurement of Waist
Normal Visceral Adiposity
Visceral Fat DistributionVisceral Fat Distribution
Diagnosis of DyslipidemiaDiagnosis of Dyslipidemia
• Investigations:Investigations:o Fasting lipid profile.Fasting lipid profile.o Lipoprotein electrophoresis.Lipoprotein electrophoresis.o Lipoprotein ultracentrifugation.Lipoprotein ultracentrifugation.o Lipoprotein (a).Lipoprotein (a).o Apo-lipoproteins measurement.Apo-lipoproteins measurement.o Determination of enzymatic activity.Determination of enzymatic activity.o Small dense LDL.Small dense LDL.
Tendinous XanthomaTendinous XanthomaTendinous XanthomaTendinous Xanthoma
Management ofManagement of
DyslipidemiaDyslipidemia
Diagnostic approach for dyslipidemia (A case of
Xanthoma)
Diagnostic approach for dyslipidemia (A case of
Xanthoma)1. To prove dyslipidemia.
– Fasting lipid profile (TC, T.G, HDL.C, LDL.C).2. To prove the cause of
dyslipidemia. - Complete history taking (especially drug
history) and physical examination– Thyroid function.– Glycemic profile.– Kidney functions.– Assessment for obstructive jaundice.
3. To determine the target.
1. To prove dyslipidemia.– Fasting lipid profile (TC, T.G, HDL.C, LDL.C).
2. To prove the cause of dyslipidemia.
- Complete history taking (especially drug history) and physical examination
– Thyroid function.– Glycemic profile.– Kidney functions.– Assessment for obstructive jaundice.
3. To determine the target.
Step 2: Identify presence of clinical Step 2: Identify presence of clinical CHDCHD or or CHD Risk EquivalentsCHD Risk Equivalents..
Step 3: Determine the presence of major Step 3: Determine the presence of major Risk FactorsRisk Factors..
Step 4: If 2 + risk factors (other than CHD) are present without Step 4: If 2 + risk factors (other than CHD) are present without CHD or CHD risk equivalent, assess 10-y CHD risk.CHD or CHD risk equivalent, assess 10-y CHD risk.
Step 5: Determine risk category to establish Step 5: Determine risk category to establish LDL-C GoalLDL-C Goal, need for , need for TLC & drug therapy. TLC & drug therapy.
Step 8: Treat decreased Step 8: Treat decreased HDL-CHDL-C..
Step 7: Treat elevated Step 7: Treat elevated TrigyceridesTrigycerides..
Step 6: Identify Metabolic Syndrome and treat.Step 6: Identify Metabolic Syndrome and treat.
Step 9: How to estimate (Framingham Risk-Scores) 10-y riskStep 9: How to estimate (Framingham Risk-Scores) 10-y risk
Step 1: Determine Lipoprotein Step 1: Determine Lipoprotein LevelsLevels. .
Management of DyslipidemiaManagement of DyslipidemiaAccording to NCEP-ATP III Guidelines According to NCEP-ATP III Guidelines
What is Framingham Risk Score?What is Framingham Risk Score?
The new Canadian Cardiovascular Society position statement – Recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease
– Recommended for the initial assessment of the majority of patients in the primary prevention category
– The Framingham risk estimate tables adjust for certain risk factors such as TC and smoking status for age, and correct for the effects of treatment on blood pressure measurement
– Provides an estimate of the 10-year risk estimate of hard cardiac end points
The new Canadian Cardiovascular Society position statement – Recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease
– Recommended for the initial assessment of the majority of patients in the primary prevention category
– The Framingham risk estimate tables adjust for certain risk factors such as TC and smoking status for age, and correct for the effects of treatment on blood pressure measurement
– Provides an estimate of the 10-year risk estimate of hard cardiac end points
Can J Cardiol 2006;22(11):913-27.
Framingham Score Card – Framingham Score Card – Female 10-year risk of CVDFemale 10-year risk of CVD
Age
Age Risk Points
20-34 -7
35-39 -3
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 12
70-74 14
75-79 16
Risk Factor Risk Points
Smoker
Age Group, Yr
20-39 40-49 50-59 60-69 70-79
No 0 0 0 0 0
Yes 9 7 4 2 1
Total Risk Points
10-Year Risk (%)
<9 1
9-12 1
13-14 2
15 3
16 4
17 5
18 6
19 8
20 11
21 14
22 17
23 22
24 27
<25 <30
HDL-C Level (mmol/L)
Systolic Blood Pressure (mm Hg)
Untreated Treated
<1.55 -1 <120 0 0
1.30-1.54 0 120-129 1 3
1.04-1.29 1 130-139 2 4
<1.04 2140-159 3 5
<160 4 6
Total Cholesterol Level (mmol/L)
Age
20-39 40-49 50-59 60-69 70-79
4.14 0 0 0 0 0
4.15-5.19 4 3 2 1 1
5.20-6.19 8 6 4 2 1
6.20-7.20 11 8 5 3 2
<7.21 13 11 7 4 2
CHD Risk EquivalentsCHD Risk Equivalents
Diabetes.
Peripheral Arterial Disease (PAD).
Abdominal Aortic Aneurysm.
Carotid Artery Disease
Diabetes.
Peripheral Arterial Disease (PAD).
Abdominal Aortic Aneurysm.
Carotid Artery Disease
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Assessing CHD Risk in MenAssessing CHD Risk in MenStep 1: Age
YearsPoints
20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13
Step 2: Total Cholesterol
TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69
Age 70-79 <160 0 0 0 0
0160-199 4 3 2 1
0200-239 7 5 3 1
0240-279 9 6 4 2
1280 11 8 5 3
1
HDL-C(mg/dL) Points
60 -1
50-59 0
40-49 1
<40 2
Step 3: HDL-Cholesterol
Systolic BP PointsPoints
(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2
160 2 3
Step 4: Systolic Blood Pressure
Step 5: Smoking Status
Points at Points at Points at Points atPoints at
Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79
Nonsmoker 0 0 0 00
Smoker 8 5 3 11
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Point Total 10-Year Risk Point Total 10-Year Risk
<0 <1% 118%
0 1% 1210%
1 1% 1312%
2 1% 1416%
3 1% 1520%
4 1% 1625%
5 2% 1730%
6 2%7 3%8 4%9 5%10 6%
Step 7: CHD Risk
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Men
YearsPoints20-34 -935-39 -440-44045-49350-54655-59860-641065-691170-741275-7913
Step 1: AgeStep 1: Age
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Women
YearsPoints20-34 -735-39 -340-44045-49350-54655-59860-641065-691270-741475-7916
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 2: Total CholesterolStep 2: Total Cholesterol
Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
MenTC Points at Points at Points at Points at
Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age
70-79 <160 0 0 0 0
0160-199 4 3 2 1
0200-239 7 5 3 1
0240-279 9 6 4 2
1280 11 8 5 3
1
WomenTC Points at Points at Points at Points at
Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age
70-79 <160 0 0 0 0
0160-199 4 3 2 1
1200-239 8 6 4 2
1240-279 11 8 5 3
2280 13 10 7 4
2
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 3: HDL-CholesterolStep 3: HDL-Cholesterol
Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Men
HDL-C(mg/dL)
Points60 -1
50-59 0
40-49 1
<40 2
Women
HDL-C(mg/dL)
Points60 -1
50-59 0
40-49 1
<40 2
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 4: Systolic Blood PressureStep 4: Systolic Blood PressureMen
Systolic BP Points Points(mm Hg) if Untreated if Treated
<120 0 0120-129 0 1130-139 1 2140-159 1 2
160 2 3
Note: The average of several BP measurements is needed for an accuratemeasurement of baseline BP. If an individual is on antihypertensive treatment,extra points are added.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
WomenSystolic BP PointsPoints
(mm Hg) if Untreated if Treated
<120 0 0120-129 1 3130-139 2 4140-159 3 5
160 4 6
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 5: Smoking StatusStep 5: Smoking Status
Note: Any cigarette smoking in the past month.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Men Points at Points at Points at Points at
Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age
70-79 Nonsmoker 0 0 0 00Smoker 8 5 3 11
Women Points at Points at Points at Points at
Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69
Age 70-79 Nonsmoker 0 0 0 00Smoker 9 7 4 21
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 6: Adding Up the Points(Sum From Steps 1–5)
Step 6: Adding Up the Points(Sum From Steps 1–5)
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
AgeTotal cholesterolHDL-cholesterolSystolic blood pressureSmoking statusPoint total
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Step 7: CHD Risk for MenStep 7: CHD Risk for Men
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Point Total10-Year Risk Point Total 10-Year Risk
<0 <1% 118%
0 1% 1210%
1 1% 1312%
2 1% 1416%
3 1% 1520%
4 1% 1625%
5 2% 1730%
6 2%7 3%8 4%9 5%
10 6%
ATP III Framingham Risk Scoring
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
Major CHD Risk Factorsthat Modify LDL Goals
Major CHD Risk Factorsthat Modify LDL Goals
† HDL cholesterol ³60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the
(1)(1) AgeAge (>45 years in Men & >55years in Women).(>45 years in Men & >55years in Women).
(2) (2) Family HistoryFamily History of Premature CHD of Premature CHD (<55 years in Male & <65 years in Female).(<55 years in Male & <65 years in Female).
(3) (3) HypertensionHypertension(BP>140/90 mmHg or Antihypertensive medication).(BP>140/90 mmHg or Antihypertensive medication).
(4) Cigarette (4) Cigarette SmokinSmokingg..
(5) Low (5) Low HDL-CHDL-C (<40 mg/dl). (<40 mg/dl).
(1)(1) AgeAge (>45 years in Men & >55years in Women).(>45 years in Men & >55years in Women).
(2) (2) Family HistoryFamily History of Premature CHD of Premature CHD (<55 years in Male & <65 years in Female).(<55 years in Male & <65 years in Female).
(3) (3) HypertensionHypertension(BP>140/90 mmHg or Antihypertensive medication).(BP>140/90 mmHg or Antihypertensive medication).
(4) Cigarette (4) Cigarette SmokinSmokingg..
(5) Low (5) Low HDL-CHDL-C (<40 mg/dl). (<40 mg/dl).
NCEP ATP III LDL-C GoalsNCEP ATP III LDL-C Goals
Risk CategoryRisk Category LDL-C GoalLDL-C Goal(mg/dl)(mg/dl)
CHD or CHD Risk Equivalents <100
2+ Risk Factors <130
0–1 Risk Factor <160
NCEP ATP= National Cholesterol Education Program Adult Treatment Panel.
LDL-C = low-density lipoprotein cholesterol.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
Non-HDL CholesterolNon-HDL Cholesterol
Non-HDL Cholesterol = TC – HDL Cholesterol1
Secondary target of therapy when serum TG
200 mg/dL1
New non-HDL-C goal for patients with elevated
TG is LDL-C goal + 30 mg/dL1
Non-HDL-C includes all atherogenic lipoprotein particles including LDL-C, Lp(a), IDL-C, and
VLDL-C2
Non-HDL Cholesterol = TC – HDL Cholesterol1
Secondary target of therapy when serum TG
200 mg/dL1
New non-HDL-C goal for patients with elevated
TG is LDL-C goal + 30 mg/dL1
Non-HDL-C includes all atherogenic lipoprotein particles including LDL-C, Lp(a), IDL-C, and
VLDL-C21. NCEP, Adult Treatment Panel III. JAMA. 2001;285:2486-2497. 2. Cui Y, et al. Arch Intern Med. 2001;161:1413-1419.
Therapeutic Lifestyle ChangeTherapeutic Lifestyle ChangeTherapeutic Lifestyle ChangeTherapeutic Lifestyle Change
Dietary Management of Dyslipidemia
(ATP III Recommendations)
Dietary Management of Dyslipidemia
(ATP III Recommendations)NutrientNutrient Recommended IntakeRecommended Intake
CarbohydratesCarbohydrates 50-60%50-60% of total caloriesof total calories
Fiber Fiber 20-30 g/day20-30 g/day
Protein Protein 15% of total calories15% of total calories
Total fat Total fat 25-35% of total calories25-35% of total calories
Polyunsaturated Fat Polyunsaturated 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
Saturated FatSaturated Fat < 7% of total calories< 7% of total calories
Total calories Total calories (energy)(energy)
Balance energy intake and Balance energy intake and expenditure to maintain desirable expenditure to maintain desirable body weight .body weight .
† Carbohydrate should be derived predominantly from foods rich in complex carbohydrates including grains, especially whole grains, fruits, and vegetables.
Drugs Used in the Treatment Drugs Used in the Treatment of Dyslipidemiaof Dyslipidemia
Drugs Used in the Treatment Drugs Used in the Treatment of Dyslipidemiaof Dyslipidemia
Primary treatment goal Primary treatment goal
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
High LDL-CHigh LDL-CHigh LDL-CHigh LDL-C
Therapeutic Lifestyle ChangeTherapeutic Lifestyle ChangeTherapeutic Lifestyle ChangeTherapeutic Lifestyle Change
Drug TherapyDrug TherapyDrug TherapyDrug Therapy
Therapy of Choice: Therapy of Choice: StatinStatinTherapy of Choice: Therapy of Choice: StatinStatin
Alternative:Ezetimibe ,Alternative:Ezetimibe ,Resin or niacinResin or niacin
Treatment of Mixed HyperlipidemiaTreatment of Mixed Hyperlipidemia
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
High LDL-C and TGsHigh LDL-C and TGsHigh LDL-C and TGsHigh LDL-C and TGs
Therapeutic Lifestyle ChangeTherapeutic Lifestyle ChangeTherapeutic Lifestyle ChangeTherapeutic Lifestyle Change
Drug TherapyDrug TherapyDrug TherapyDrug Therapy
Achieve the LDL-C goalAchieve the LDL-C goal11STEPSTEP
Achieve the non-HDL-C goalAchieve the non-HDL-C goalIncrease LDL-C lowering orIncrease LDL-C lowering orAdd a fibrate, niacin or fish oilsAdd a fibrate, niacin or fish oils22STEPSTEP
StatinsStatins
Inhibit synthesis of cholesterol by cells
Inhibition HMG-CoA reductase enzyme which is the key enzyme of Cholesterol synthesis.
Lower LDL cholesterol
Statins are considered the primary pharmacological modality for LDL-C lowering.
Inhibit synthesis of cholesterol by cells
Inhibition HMG-CoA reductase enzyme which is the key enzyme of Cholesterol synthesis.
Lower LDL cholesterol
Statins are considered the primary pharmacological modality for LDL-C lowering.
Statin Adverse EventsStatin Adverse Events Common side effects
– Headache – Myalgia – Fatigue– GI intolerance – Flu-like symptoms
Increase in liver enzymes
– Occurs in 0.5 to 2.5% of cases in dose-dependent manner
– Serious liver problems are exceedingly rare Myopathy
– Occurs in 0.2 to 0.4% of patients– Rare cases of rhabdomyolysis– Presence of muscle toxicity requires the
discontinuation of the statin
Common side effects
– Headache – Myalgia – Fatigue– GI intolerance – Flu-like symptoms
Increase in liver enzymes
– Occurs in 0.5 to 2.5% of cases in dose-dependent manner
– Serious liver problems are exceedingly rare Myopathy
– Occurs in 0.2 to 0.4% of patients– Rare cases of rhabdomyolysis– Presence of muscle toxicity requires the
discontinuation of the statin
FibratesFibrates
Indications:Indications: HypertriglyceridemiaHypertriglyceridemia
Combined DyslipidemiaCombined Dyslipidemia
Mechanism of Mechanism of Action:Action:
Decrease Decrease hepatichepatic TG productionTG production
Efficacy:Efficacy: Decrease Decrease TGTG 20–50% 20–50%LDL-CLDL-C decreases slightly 5-20% decreases slightly 5-20%Increase Increase HDL-C HDL-C 10–20%10–20%
Side Effects:Side Effects: GI upsetGI upset (8%), (8%), cholelithiasischolelithiasis, , myositismyositis, , abn abn LFTsLFTs
Contraindications:Contraindications: HepaticHepatic or or renalrenal dysfunction dysfunctionPre-existing Pre-existing GB diseaseGB disease
Net Effect: Net Effect: LDL-C LDL-CNet Effect: Net Effect: LDL-C LDL-C
Gall Gall BladderBladder
LDL ReceptorsLDL Receptors
VLDL and LDL VLDL and LDL removalremoval
Cholesterol 7-Cholesterol 7- hydroxylasehydroxylase Conversion of cholesterol Conversion of cholesterol to BAto BA BA SecretionBA Secretion
LiverLiver
BA ExcretionBA Excretion
Terminal Terminal IleumIleum
Bile AcidBile Acid
Enterohepatic Enterohepatic
RecirculationRecirculation
Reabsorption Reabsorption of of
bile acidsbile acids
Cholesterol Absorption Inhibitors Bile Acid Resins:
Cholesterol Absorption Inhibitors Bile Acid Resins:
Adverse effectsAdverse effects
– GI intolerance: constipation, bloating, abdominal pain, GI intolerance: constipation, bloating, abdominal pain, flatulenceflatulence
– Lack systemic toxicityLack systemic toxicity
Drug interactionsDrug interactions (colestipol and cholestyramine) (colestipol and cholestyramine)
– Bind other negatively charged drugsBind other negatively charged drugs
– Impede the absorption of drugs and/or fat-soluble Impede the absorption of drugs and/or fat-soluble vitaminsvitamins
– Must give other drugs 1 hour before or 4–6 hours after Must give other drugs 1 hour before or 4–6 hours after BARsBARs
Mechanism of Action of Niacin Mechanism of Action of Niacin
LiverLiver CirculationCirculationHDLHDL
Serum VLDL Serum VLDL results in results in reduced reduced lipolysis to lipolysis to LDL LDL Serum Serum LDLLDL
VLDL
Decreases hepatic production of VLDLDecreases hepatic production of VLDL
VLDL VLDL
secretiosecretio
nn
Apo BApo B
HepatocyeHepatocye Systemic CirculationSystemic Circulation
Mobilization of Mobilization of FFAFFA
TG TG
synthesissynthesis
VLDL
LDL
Nicotinic AcidNicotinic Acid Products available (daily dose)Products available (daily dose)
– Immediate-releaseImmediate-release, 2–4 g/d, 2–4 g/d– Extended-releaseExtended-release (Niaspan (Niaspan®®), 1–2 g/d), 1–2 g/d
Best agent to raise Best agent to raise HDL-CHDL-C Adverse effectsAdverse effects
– FlushingFlushing, itching, , itching, headacheheadache, , hepatotoxicityhepatotoxicity. . – Activation of Activation of peptic ulcerpeptic ulcer– HyperglycemiaHyperglycemia..
ContraindicationsContraindications– Active Active liver liver disease or unexplained LFT disease or unexplained LFT
elevationselevations– Peptic ulcer diseasePeptic ulcer disease
DuodenumDuodenumDuodenumDuodenum
JejunumJejunumJejunumJejunum
IleumIleumIleumIleum
CMapoB48
Liver
CM RemnantapoB48
VLDLapoB100
EzetimibeXX
LDLapoB100
ColonColonColonColon
Indications: Adjunctive therapy to dietHypertriglyceridemia With statins or other LDL-C–lowering drugs in mixed hyperlipidemia
Efficacy: Decrease TG 30–40%LDL-C remains the same or increasesNo change in HDL-C
Side Effects:
GI upset and a “fish burp”
LDL - HYPERCHOLEST
TARGETACHIEVED AND
TOLERATED
STATIN
NOT TOLERATED
EZETEMIBE
BILE ACIDBINDING RESIN
FIBRATE/NIACIN
TARGET VALUES NOTACHIEVED
COMBINATION WITHEZETIMIBE
ADDITITIONALBILE ACID BINDING
LDL-APHERESISCAD
HYPERTRIGLICEREDEMIA
LIFE STYLE MODIFICATION SECONDARY CAUSES; ALCOHOL,DIABETES,OBESITY
TARGET VALUES
ACHIEVEDAND WELL TOLERATED
FIBRATE
NOT TOLERATED
STATIN
NIACIN
TARGET VALUES NOT ACHIEVED
CONSIDER COMBINATIONWITH NIACIN
COMBINED HYPERLIPOPROT
LIFE STYLE MODIFICATION
STATIN
TARGET NOT ACHIEVED
FIBRATE
POSIBLE COMBINATION
STATIN WITH NICOTINIC
FIBRATE WITHG NICOTINIC
FIBRATE WITH EZETIMIBEAND
STATIN WITH FIBRATE
Thank YouThank You
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