Hyperlipidemia

Evaluation
- General—a significant contributor to atherosclerosis and consequently coronary heart disease (CHD)
  - Low-density lipoprotein (LDL) is a primary mediator of atherosclerosis.
- Epidemiology—CHD accounts for 500,000 deaths per year in the United States (no.1 cause of morbidity and mortality)
- Screening—fasting lipid profile (total cholesterol, LDL, high-density lipoprotein [HDL], and triglycerides [TG]) q5yr for patients of age 20 years or older.
- Risk factors impacting LDL goals
  - Age (men of age 45 years or older, women of age 55 years or older)
  - HDL <A onclick="get_content(event,'AB1-M12'); return false;" onmouseover="window.status=this.title; return true;" onmouseout="window.status=''; return true;" title="<40 mg per dL
  - Smoking
  - Hypertension (blood pressure [BP] ” class=LK href=”javascript:void(0)” target=right xpath=”/CT{06b9ee1beed59419a81e5e1e1a4f60b0cc8cd1057525de73425b2b43f4df7f1b75d2129a25d01f3042ff2fa0b188b440}/ID(AB1-M10)”>>140/90 or patient is taking antihypertensives)
  - Family history of premature CHD (first degree male younger than 55 years, first degree female younger than 65 years)
- CHD risk equivalents
  - Diabetes
  - Framingham risk score (age, cholesterol, HDL, BP, smoking status) of 20% or higher
- Risk stratification and assessment (see Table 2.35.1)
Treatment—may try therapeutic lifestyle changes (TLC) for 12 weeks before considering medications.
- TLC
  - Diet—low in saturated fat and trans fatty acids; cholesterol <A onclick="get_content(event,'AB1-M12'); return false;" onmouseover="window.status=this.title; return true;" onmouseout="window.status=''; return true;" title="<200 mg per day
  - Physical activity—aerobic exercise increases HDL and decreases TG
  - Weight loss—decreases LDL and improves insulin sensitivity
  - No smoking—increases HDL
- Medications (initially check lipid profile and liver function tests (LFTs) every 6 weeks, then q6mo to every 12 months when LDL is normal)
  - Statins (↓ LDL significantly, ↑ HDL somewhat, ↓ TG somewhat)
    - Rosuvastatin (Crestor) 5 to 40 mg PO daily
    - Atorvastatin (Lipitor) 10 to 80 mg PO daily
    - Simvastatin (Zocor) 10 to 80 mg PO every evening
    - Lovastatin (Mevacor) 10 to 80 mg PO every evening
    - Pravastatin (Pravachol) 10 to 80 mg PO daily
    - Fluvastatin (Lescol) 20 to 80 mg PO every evening
      
      Note: Watch for myalgias and rhabdomyolysis with statins.
  - Fibric acids (↓ LDL slightly, ↑ HDL, ↓ TG significantly)
    
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