1. Department of Family & Community Medicine
DYSLIPIDEMIA
Ruth P. Anglo, MD
Department of Family & Community Medicine
May 5,2012

2. Step 1: Determine and classify lipoprotein levels
ATP Classification of LDL, Total, and HDL Cholesterol
LDL Cholesterol
< 100 mg/dL
Optimal
Near Optimal
Borderline High
High
>/= 190
Very High

3. Total Cholesterol
<200 mg/dL
Desirable
Borderline high
>/= 240
High
HDL Cholesterol
< 40 mg/dL
Low
>/= 60
High

4. Step 2: Identify presence of clinical atherosclerotic disease
Clinical CHD
Symptomatic coronary artery disease
Peripheral artery disease
Abdominal aortic aneurysm

5. Step 3: Major Risk Factors
Cigarette smoking
Hypertension
Low HDL cholesterol (<40 mg/dL)
Family history of premature CHD male: <55 years; female: <65 years
Age: men >/=45 years;
women >/= 55 years

6. CHD or CHDRisk Equivalents
Step 4: Determine risk category
Risk Category
LDL Goal
Initiate TLC
Consider Drug Therapy
CHD or CHDRisk Equivalents
<100 mg/dL
>/= 100 mg/dL
>/= 130 mg/dL
mg/dL (optional)
2+ Risk Factors
<130 mg/dL
>/= 160 mg/dL
0-1 Risk Factors
<160 mg/dL
>/=190 mg/dL

7. Therapeutic Lifestyle Changes Weight management
Increase physical activity
TLC diet
- Saturated fat < 7% of calories
Cholesterol < 200 mg/dL
Fiber g/day

8. Model of Steps in Therapeutic Lifestyle Changes
Visit 1: Begin lifestyle therapies
6 weeks
Visit 2: Evaluate LDL response
If goal not reached,intensify LDL-lowering therapy
6 weeks

9. Visit 3: Evaluate LDL response If LDL goal not reached, consider
adding drug therapy
Q 4-6 weeks
Visit N: Monitor adherence to TLC

10. Progression of Drug Therapy in Primary Prevention
Initiate LDL-lowering therapy
6 weeks
If LDL goal not achieved,intensify LDL-lowering therapy
6 weeks

11. If LDL goal not reached, intensify drug therapy
Q 4-6 mos
Monitor response and adherence to therapy

12. Drugs Affecting Drug Metabolism Statins LDL 18-55% decrease
HDL 5-15% increase
TG % decrease
S/E: Increased liver enzymes, myopathy
CI: Active or chronic liver disease

13. Gemfibrozil, Clofibrate, Fenofibrate
Fibric Acids
Gemfibrozil, Clofibrate, Fenofibrate
LDL % decrease
HDL % increase
TG % decrease
SE: Dyspepsia, gallstones, myopathy
CI: severe renal disease, severe hepatic dse

14. Bile Acid Sequestrants Cholestyramine, Colestipol
LDL % decrrease
HDL % increase
TG no change or increase
SE: GI distress, constipation
CI: Dysbetalipoprotenemia,
TG >200/>400 mg/dL

15. Nicotinic Acid LDL 5-25% decrease HDL 15-35% increase
TG % decrease
SE: Flushing, hyperglycemia, hyperuricemia
upper GI distress, hepatotoxicity
CI: Chronic liver dse, severe gout
DM, hyperuricemia, PUD

16. Identify metabolic syndrome and treat, if present after 3 months of TLC:
Risk Factor
Defining Level
Abdominal Obesity
Men
Women
Waist circumference
>102 cm (>40 in)
>88 cm (>35 in)
Triglyceride
>/= 150mg/dL
HDL cholesterol
<40 mg/dL
< 50 mg/dL
Blood pressure
>/=130/>/=85mmHg
Fasting Glucose
>/= 110 mg/dL

17. Treatment of Metabolic Syndrome Treat underlying causes
-Intensify weight management
-Increase physical activity
Treat lipid & non-lipid risk factors
-Treat hypertension
-Use ASA for CHD patients
-Treat elevated TG and/or low HDL

18. Treat elevated triglycerides:
ATP III Classification of Serum TG (mg/dL)
<150
Normal
Borderline high
High
>/= 500
Very high

19. Treatment of elevated triglycerides (>/= 150mg/dL)
Primary aim of therapy is to reach LDL goal
Intensify weight management
Increase physical activity
If TG is >/=200mg/dL after LDL goal is reached,set secondary goal for non-HDL cholesterol 30mg/dL higher than LDL cholesterol

20. Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals
Risk Category
LDL Goal(mg/dL)
Non-HDL Goal
CHD and CHD Risk Equivalent
<100
<130
Multiple Risk Factors and 10-year Risk <20%
<160
0-1 Risk Factor
<190

21. Treatment of Low HDL Cholesterol (40 mg/dL)
Reach LDL goal
Intensify weight management and increase physical activity
If TG mg/dL,achieve non-HDL goal
If TG < 200 mg/dL in CHD or CHD equivalent consider nicotinic acid or fibrate

22. Thank you!