Cholesterol
TSH
hypothyroidism may cause increased triglyceride level (used as screening in newly diagnosed patient's with hyperlipidemia)
BMP
metabolic panel to look for renal function and glucose (r/t risk factors of DM, obesity)
When should the ARNP measure triglycerides at the same time as cholesterol?
All adults greater than 20 years old should have a fasting or nonfasting lipoprotein profile obtained at least every 5 years or if risk factors change such as Metabolic syndrome, high BMI, hyperlipidemia, family history of high cholesterol, family history of early MI, low HDL levels. Lifestyle habits (diet, cigarette smoking, and alcohol abuse)
Chylomicrons
Largest and least dense lipoprotein, function is to transport dietary triglycerides and cholesterol absorbed by the intestinal epithelial cells
High intensity statins
daily dose lowers LDL-C by approximately > 50% Atorvastatin 40-80mg Rosuvastatin 20mg
What is a xanthoma?
an irregular yellow patch or nodule on the skin, caused by deposition of lipids.
Moderate intensity statins
daily dose lowers LDL-C by approximately 30% - < 50 % Atorvastatin 10-20mg Rosuvastatin 5-10mg Simvastatin 20-40mg Pravastatin 40-80mg Lovastatin 40mg
AST/ALT
r/t gathering baseline due to risk factors of ETOH intake
Discuss controversy and concerns surrounding lipid screening guidelines in children and adolescents.
universal screening should not be performed, as it would identify a large number of patients who may be harmed by screening (ie, further testing and initiation of drug therapy of questionable benefit and known adverse effects). Children may benefit from statin treatment for high LDL, and may also be exposed to a small but important risk of rhabdomyolysis and new-onset diabetes mellitus type 2 (known statin side effects in adults
Hs-CRP
used to assess risk for cardiovascular disease r/t hyperlipidemia and family hx of cardiac events
What are secondary causes of hyperlipidemia ?
• Diets (trans fat, weight gain, anorexia) • drugs (diuretics, cyclosporine, glucocorticoids) • disease/disorders (hypothyroid, DM, liver, chronic renal failure) • and altered states of metabolism
According to the 2013 ACC/AHA guidelines which groups need to have a statin initiated?
1. Clinical ASCVD 2. Primary prevention - Primary LDL-C ‡190 mg/dL 3. Primary prevention - Diabetes 40-75 years of age and LDL-C 70-189 mg/dL 4. Primary prevention - No diabetes 40-75 years of age and LDL-C 70-189 mg/dL 5. Primary prevention when LDL-C <190 mg/dL and age <40 or >75 y, or <5% 10-y ASCVD risk
What _______ percentage of patients report symptoms of muscle complaints on high-dose statin therapy?
10-15% percent of patients report symptoms of muscle complaints on high dose statin therapy
What is the difference between the ATEP III and 2013 ACC/AHA guidelines on the treatment of blood cholesterol?
ATEP III uses cholesterol levels as goals. 2013 guidleines use categories (1) clinical ASCVD, (2) LDL ≥190 mg/dl, (3) diabetes 40-75 years and LDL 70-189 mg/dl, or (4) without clinical ASCVD or diabetes, LDL 70-189 mg/dl, and estimated ASCVD risk ≥7.5%.
Major Coronary Artery Disease Risk Factors according to AACE guidelines 2012.
Advancing age High total serum cholesterol High non-HDL C High LDL-C Low HDL-C Diabetes Mellitus Hypertension Cigarette smoking Family history of CAD
How often should cholesterol or lipids be tested once a patient has reached target or optimal cholesterol?
After target cholesterol is reached, a fasting lipid panel should be performed every 3-12 months as clinically indicated
Project Heart Beat was a longitudinal study looking at lipid screening in children. What screening criteria was used?
Family history and/or BMI of children/adolescents was used for the screening criteria
Identify moderate level risk factors in children and adolescents.
BMI in the 95th to 96th percentile • High blood pressure without treatment • HDL- C level < 40 mg/dL • Kawasaki disease with regressed coronary aneurysms • Systemic lupus • Juvenile rheumatoid arthritis • Human immunodeficiency virus infection • Nephrotic syndrome
How often should lever enzymes be routinely measured in patients taking statins?
Baseline measurement of hepatic transaminase levels (ALT) should be done at initiation of statin therapy. It is reasonable to measure hepatic function if symptoms suggesting hepatotoxicity arise. Do not routinely monitor ALT or CK unless symptomatic
How often should creatinine kinase be measures in patients taking statins?
CK should not be routinely monitored in individuals receiving statin therapy.
Intermediate Density Lipoproteins (IDL)
Carries cholesterol esters and triglycerides
High Density Lipoproteins (HDL)
Carries cholesterol esters from organs back to the liver for degradation into bile acids. Often referred to as the "Good" cholesterol.
Low Density Lipoproteins (LDL)
Carries cholesterol esters from the liver to rest of the body and is associated with apolipoprotein B100. Often referred to as the "Bad" cholesterol
What guides the lipoprotein for interaction with blood and tissue?
Chylomicrons, Very Low Density Lipo-proteins, Intermediate Density Lipo-proteins, and Low Density Lipo-proteins are all responsible for transporting fats and cholesterol from liver to the tissues. Low density lipo-proteins (LDL) comprise 75% of the circulating cholesterol carried by lipo-protein particles other than HDL. High density lipo-proteins (HDL) are associated with reduced atherosclerotic cardiovascular disease (ASCVD) due to the fact that HDL assists in removing cholesterol from blood vessel walls and transporting it to the liver for disposal.
What are the major lipoprotein classes?
Chylomicrons, Very Low Density Lipoproteins (VLDL), Intermediate Density Lipoproteins (IDL), Low Density Lipoproteins (LDL), High Density Lipoproteins (HDL)
What if creatinine kinase becomes raised <5x upper limit of normal in a person taking a statin?
Consider secondary causes of myopathy if CK remains elevated if less than or equal to 5 times the upper limit of normal If no muscle symptoms, continue statin. (patients should be alerted to report symptoms, consider further checks of CK). If muscle symptoms, monitor symptoms and CK regularly if CK continues to rise
Other tests for patient with hyperlipidemia
Dependent on pharmacological intervention: -ALT : r/t to hepatic baseline gathered before start of statin therapy , or for non-statin therapy ALT, hgb A1c, and uric acid (to gain baseline before initiation of therapy)
Non-traditional risk factors Coronary Artery Disease according to AACE guidelines 2012
Elevated lipoprotein (A) Elevated clotting factors Inflammation markers (hsCRP; Lp-PLA2) Hyperhomocysteinemia Apo E4 isoform Elevated uric acid
Project Heart Beat was a longitudinal study looking at lipid screening in children. What were the findings?
Family history screening had a low yield for identifying children with abnormal lipids and lipoproteins. Combining family history and/or BMI as a criterion for blood lipid and lipoprotein screening significantly increased the sensitivity and a significant decrease in the specificity. Using the criterion of family history and/or BMI ≥ 85th percentile improved the sensitivity of dyslipidemia screening and decreased specificity. Despite the increase in the screening sensitivity, a clinically significant number of children may still be misclassified
Epidemiologic studies have found that higher than normal triglycerides level increase the risk of coronary artery disease and triglycerides levels > ____ mg/dL are associated with __________.
Greater than 500 are associated with pancreatitis
Identify high level risk factors risk factors in children and adolescents.
History of current cigarette smoking • BMI ≥ 97 percentile • High blood pressure without treatment • Diabetes mellitus (type 1 or 2) • Kawasaki disease with recurrent aneurysms • Postorthotopic heart transplant • Chronic renal disease
What if liver enzymes become raised (>3x upper limit of normal) in a person taking a statin?
If on high intensity statin therapy, lower to moderate intensity or the highest intensity therapy the patient can tolerate.
What underlying diseases could influence these lab findings? normal patient Total Cholesterol 100-199 mg/dL 316 T. Chol/HDL Ratio 0-3.99 ratio 5.9 Triglycerides 0-149 mg/dL 248 Estimated CHD Risk 0-1 times average 1.6 LDL Cholesterol Calc 0-99 mg/dL 212 Very LDL 0-40 mg/dL 50 HDL Cholesterol 40-500 mg/dL 34
Leading Hypothesis: Dyslipidemia Active Alternative: Hemochromatosis Nonalcoholic Fatty Liver Disease Alcoholic Liver Disease (ALD) Pancreatitis Must Not Miss: Pancreatic Cancer
How often should patient's lipids be tested after starting lipid lowering agents?
Lipid profile should be repeated after 6-12 weeks after starting lipid lowering agents It is recommended to recheck lipid profile after 8(±4) weeks after adjusting lipid lowering therapy to check if the target level has been reached After reaching target lipid levels, it is recommended to do annual follow up of lipid levels to assess adherence
How often should cholesterol or lipids be tested when assessing a patient's coronary risk?
Lipids and Total cholesterol- all adults >20years of age should have fasting lipid at minimum of every five years Clinical Judgement may determine more frequent monitoring in different patient populations -obesity -patient history of cardiovascular event -cardiovascular event in first degree relative (male<55years female<65years) -smoker -diabetic -hypothyroidism
Define the structure of a lipoprotein.
Lipoproteins are macromolecular structures formed by the association of proteins and lipids, bound to proteins, which allow fat to move through water in and outside the cell, whose main function is to facilitate the transport of lipids in the blood. Structure consists of a phospholipid shell, cholesterol ester, triglycerides & apolipoproteins Insoluble lipid core with water soluble outer surface
Very Low Density Lipoproteins (VLDL)
Low density particles that carry endogenous triglycerides and to a less extent cholesterol from the liver to other parts of the body
Additional Coronary Artery Disease Risk Factors according to AACE guidelines 2012.
Obesity, abdominal obesity Family history of hyperlipidemia Small, dense LDL-C Elevated Apo B Elevated LDL particle number Fasting/postprandial hypertriglyceridemia Polycystic ovarian syndrome Dyslipidemic triad
Identify screening guidelines for children and adults according to AACE guidelines 2012.
Screening based on age and risk, not gender • Adults with diabetes: annually • Young adults (men aged 20-45; women aged 20-55): every 5 years • Middle-aged adults (men aged 45-65; women aged 55-65): every 1-2 years without risk factors, more frequent when multiple risk factors are present • Older adults (over 65): annually • Children (older than 2): every 3-5 years if risk factors present • Adolescents (older than 16): every 5 years or more frequently if risk factors present (ie. obesity, insulin resistance, or have no available family history)
What ferries (carries) cholesterol through the blood stream?
Small packages called lipoproteins carries cholesterol through the blood stream. The packages are made up of fat (lipids) on the inside and proteins on the outside. Two types of lipoproteins are LDL and HDL
What if liver enzymes become raised (< 3x upper limit of normal) in a person taking a statin?
Statin therapy should not be excluded in these patients. Monitor liver enzymes (recommendations vary, repeat monitoring suggested at 6 weeks)
What if creatinine kinase becomes raised >5x upper limit of normal in a person taking a statin?
Stop treatment, check renal function and monitor CK every 2 weeks.
What are therapeutic lifestyle interventions?
TLC Diet: — Saturated fat <7% of calories, cholesterol <200 mg/day — Consider increased viscous (soluble) fiber (10-25 g/day) and plant stanols/sterols (2g/day) as therapeutic options to enhance LDL lowering Weight management Increased physical activity.
Describe the current lipid screening guidelines for children and adolescents.
Targeted screening is recommended for any child ≥ two years of age with any of the following: • One or both parents known to have hypercholesterolemia or are receiving lipid-lowering medications. • Family history of premature Atherosclerotic cardiovascular disease (ASCVD) (men, 55 years of age; women ,65 years of age). • Family history is unknown (eg, children who were adopted). • Moderate to high risk for premature ASCVD. Universal screening is recommended beginning at 9 to11 years of age. If normal, screening should be repeated every 5 years throughout life
What are the recommendations of the USPSTF for lipid screening in children?
The US preventative task force determines that there is insufficient evidence (grade I) for the routine screening of children for dyslipidemia. While there is sufficient evidence that children with lipid disorders will continue to have lipid disorders as an adult, the USPSTF concluded that the benefits versus harm of screening children up to the age of 20 cannot be determined
Characteristics of xanthoma
Xanthomas vary in size. Some are very small. Others are bigger than 3 inches in diameter. They appear anywhere on the body, but are most often seen on the elbows, joints, tendons, knees, hands, feet, or buttocks. Certain cancers Diabetes Hyperlipidemia Inherited metabolic disorders such as familial hypercholesterolemia Primary biliary cirrhosis Pancreatitis Hypothyroidism
Low intensity statins
daily dose lowers LDL-C by approximately < 30% Simvastatin 10mg Pravastatin 10-20mg Lovastatin 20mg
What questions should the ARNP ensure is asked during the history?
eating habits Are you allergic to any food products? Are there any cultural influences on the diet? Any recent weight gain / weight gain? Any shortness of breath or chest pain? Fatigue on exertion? (more than expected) Previous lipid studies? Were they normal, high, low?
What were key findings implemented in clinical practice from the PRIMO study?
mild to moderate muscular symptoms may be more common and exert a greater influence on the quality of life of patients than previously thought; consideration of the risk of these symptoms is important when prescribing statins and increasing dosages; muscular symptoms with fluvastatin XL appears to be lower than with high dosages of other statins
What are the associated diagnosis with ICD 10 codes that need to be coded for this patient?
• Dyslipidemia E78.6 (low HDL) + E78.1 (increased fasting triglycerides) • Diabetes Mellitus with hyperglycemia E11.65 • Obesity E66.9 • Metabolic Syndrome E88.81
Which screening tests are recommending for the detection of cardiovascular risk?
• Fasting lipid profile • Low-density lipoprotein cholesterol (LDL-C) • High-density lipoprotein cholesterol (HDL-C) • Non-high-density lipoprotein cholesterol • Triglycerides • Apolipoproteins • Secondary causes of dyslipidemia • Additional tests (C-reactive protein [CRP], lipoprotein-associated phospholipase A2 [Lp-PLA2]) • Noninvasive measures of atherosclerosis such as carotid intima media thickness (IMT) and coronary artery calcification (not recommended routinely)
What should the ARNP assess for in the physical examination?
• Mostly asymptomatic • Vital signs • Height, weight, and waist circumference • Carotid bruits • Presence of abnormal heart sounds • Claudication • Presence of xanthomas under the eyelids or skin • Jaundice
Differentiate between low, moderate, high intensity statin therapy
• Patients with clinical ASCVD o < 75 years old: high intensity statin o >75 years old: moderate intensity statin • Patients without clinical ASCVD o LDL > 190mg/dl (20-75 years old): high intensity statin o LDL 70-89 mg/dl (40-79 years old): • With diabetes & 10-year ASCVD risk: • <7.5% risk: moderate intensity statin • >7.5% risk: high intensity statin • Without diabetes & 10-year ASCVD risk >7.5% moderate to high intensity statin
Identify non pharmaceutical therapy for lowering cholesterol
• Physical activity • weight loss • diet- saturated fat should consist of less than 7% of total daily calorie intake
What are secondary causes of hyperlipidemia and what diagnostic investigations are required?
• fasting lipid panel • TSH • A1C • Fasting glucose • AST/ALT • BUN/Creatinine • Vital signs • 10 year Framingham risk assessment • Meds that affect cholesterol (oral estrogens, glucocorticoids, bile acid sequestrates) • nephrotic syndrome or renal failure
