Lipids

Hypertension among middle age adults

5% to 10% for patients with hypertension have a secondary cause •In middle-age adults, the most common secondary cause (non-idiopathic) of hypertension is hyperaldosteronism.

Hypertension among older age adults

5% to 10% for patients with hypertension have a secondary cause •In older adults, atherosclerotic renal artery stenosis, renal failure, and hypothyroidism predominate as secondary causes. There are many drugs causative for an elevation in blood pressure in some

Hypertension among young adults

5% to 10% for patients with hypertension have a secondary cause •Young adults with secondary hyper- tension are often explained by abnormalities in thyroid function and fibromuscular dysplasia.

Factors Affecting Cholesterol: Age and gender

As you get older, cholesterol levels rise. Before menopause, women tend to have lower total cholesterol levels than men. After menopause, though, women's LDL levels tend to rise

The Framingham score

Assessment of Cardiovascular Risk total cholesterol, HDL cholesterol, age, gender, smoking status, and blood pressure.

The PROCAM score

Assessment of Cardiovascular Risk •LDL cholesterol, HDL cholesterol, triglycerides, family history of coronary artery disease, smoking status, age, and presence of diabetes. This score is validated only in men.

The Reynolds score

Assessment of Cardiovascular Risk •high-sensitivity C-reactive protein (hs-CRP), total cholesterol, HDL cholesterol, age, gender, parental history, smoking status, and blood pressure. In women with diabetes, the hemoglobin A1C result is also included.

Systematic coronary risk evaluation (SCORE)

Assessment of Cardiovascular Risk •total cholesterol, HDL cholesterol, age, gender, smoking status, and blood pressure.

Factors Affecting Cholesterol

Diet Weight Exercise Age and gender Diabetes Heredity Medications and other medical conditions

Abnormal Lipid profile: Genetics

Genetic causes for an abnormal lipid profile are rare!

The lipoprotein profile evaluates the following:

HDL LDL Total cholesterol level Triglycerides

Vasculitis

Inflammation in the blood vessel wall. The large number of different vasculitides, which are sometimes overlapping in their clinical or anatomic characteristics, ofter make the diagnosis of a specific form of vasculitis challenging.

Friedewald calculation

LDL = Total - HDL - Triglycerides/5 •Friedewald calculation fails if the triglyceride concentration in the fasting sample is higher than 400 mg/dL, and tends to underestimate LDL even at triglyceride concentrations of 150 mg/dL (not an accurate calculations to use) Friedewald is why they want you to fast

LDL testing

LDL is normally calculated, not measured •LDL = Total - HDL - Triglycerides/5 •If patient doesn't fast, elevated triglycerides will result in low LDL calculation Direct measurement is available

Triglyceride Values

Less than 150 = Normal 150 - 199 = Mildly High 200 - 499 = High 500 or higher = Very high

Health Effects of Hypercholesterolemia

Major risk factor for heart disease and stroke •High cholesterol is associated with an elevated risk of cardiovascular disease. •That can include coronary heart disease, stroke, and peripheral vascular disease. •High cholesterol has also been linked to diabetes and high blood pressure. •The main risk from high cholesterol is coronary heart disease if the cholesterol level is too high, cholesterol can build up in the walls of your arteries (atherosclerosis)

Adrenal causes of hypertension

Primary aldosteronism Cushing syndrome Thyroid disorders

Renal and vascular causes of hypertension

Renal artery stenosis Chronic renal disease of multiple etiologies Polycystic kidney disease Renin-secreting tumor Coarctation of the aorta (decreased blood flow to kidney resulting from a defect in the aorta)

Factors Affecting Cholesterol: Diet

Saturated fat and cholesterol in the food you eat increase cholesterol levels. To lower your cholesterol level, try to reduce the saturated fat and cholesterol in your diet

Cholesterol Associated Morbidities

Stroke Peripheral vascular disease Diabetes Hypertension

Assessment of Cardiovascular Risk

The Framingham score The Reynolds score The PROCAM score Systematic coronary risk evaluation (SCORE)

Initial approach to the patient for routine evaluation or for monitoring the status of atherosclerotic vascular disease

The initial approach is to determine if the patient has an elevation in serum or plasma total cholesterol and LDL cholesterol concentrations, and a low HDL cholesterol concentration, and if so, to first determine if the likely cause is excess intake of dietary fat

Thrombus

When an atherosclerotic plaque (a collection of mainly cholesterol and macrophages covered by a fibrous cap) ruptures, a thrombus can form over the ruptured plaque and totally occlude blood flow. These thrombi can also break free and migrate

Commonly accepted definition of hypertension

a systolic reading of >140mmHg or a diastolic reading of >90mmHg on at least 3 occasions with a minimum of 2 weeks between each of the 3 readings

High-sensitivity C-reactive Protein levels

•< 1.0 mg/L low CV risk •1.0 - 3.0 mg/L borderline CV risk •> 3.0 mg/L high cardiovascular risk

DVT positioning

•A DVT in the leg that is above the knee presents a significantly greater risk for pulmonary embolism

Hypertension among children

•Among children, up to 85% with hypertension have a secondary cause •In children up to the age of 18 years, coarctation of the aorta and renal parenchymal disease are common etiologies for hypertension.

Stroke

•Atherosclerosis causes arteries that lead to the brain to become narrowed and even blocked. If a vessel carrying blood to the brain is blocked completely, you could have a stroke.

Atherosclerosis

•Atherosclerosis is the underlying cause of heart attack and stroke. Early observations that cholesterol is a key component of arterial plaques gave rise to the cholesterol hypothesis for the pathogenesis of atherosclerosis. •As the underlying cause of heart attack, stroke, and peripheral vascular disease, atherosclerosis is the major cause of death and morbidity in the United States and the industrial world. •Over time, increased cholesterol buildup (called plaque) causes hardening of the arteries (atherosclerosis). This causes arteries to become narrowed, which slows the blood flow to the heart muscle. Reduced blood flow can result in angina (chest pain) or in a heart attack if a blood vessel gets blocked completely

Congenital or acquired risk factors for thrombosis

•Both DVT and PE are commonly associated with one or more congenital or acquired risk factors for thrombosis

Non-high-density Lipoprotein Cholesterol

•Can be a better indicator of cardiac risk •Directly measured •LDL, VLDL, IDL, and LP(a)—are all atherogenic •Fasting not needed

Vasculitis characterization

•Characterized by size of affected vessel •Thickening, weakening, narrowing and scarring... mostly in legs •Some affect the kidney

Lipoprotein

•Cholesterol travels through the blood attached to a protein. The combination protein and cholesterol is called a lipoprotein. There are three types of lipoproteins in your blood: high density, low density, and very low density. The specific type depends on how much protein there is in relation to fat.

Screening tests

•Complete blood count to determine if the patient is anemic or polycythemic (increased fluid) •Electrolyte measurements to measure the potassium and bicarbonate levels •Creatinine concentration in plasma or serum and creatinine clearance to assess renal function •Glucose (usually a fasting level) to diagnose diabetes, because diabetic patients have an approximately 2-fold higher incidence of hypertension than nondiabetic patients •Urinalysis to detect the presence of diabetes by glucose in the urine; urinalysis also may indicate the presence of significant parenchymal disease in the kidney if proteinuria, hematuria, or pyuria is present

Testing for DVT and PE

•D-dimer test can rule out both DVT and PE Imaging (probably better with contrast, and will be hard to separate form healthy tissue without)

Daily variability in Total cholesterol

•Daily variability in Total cholesterol is 10-30% •If elevated repeat test 1-8 weeks later

Diabetes

•Diabetes can upset the balance between HDL and LDL cholesterol levels. People with diabetes tend to have LDL particles that stick to arteries and damage blood vessel walls more easily. Glucose (a type of sugar) attaches to lipoproteins (a cholesterol- protein package that enables cholesterol to travel through blood). Glycosylated LDL remains in the bloodstream longer and may lead to the formation of plaque. People with diabetes tend to have low HDL and high triglyceride (another kind of blood fat) levels. Both of these boost the risk of heart and artery disease. Glycosylation more plaque formation

Total cholesterol test

•HDL cholesterol •LDL cholesterol •VLDL cholesterol •Intermediate-density lipoprotein cholesterol (IDL cholesterol)* •Cholesterol associated with LP(a)* •Cholesterol in LDL and LP(a) normally very much lower than in other lipoproteins •Fasting not needed

Hypertension

•High blood pressure and high cholesterol also are linked. When the arteries become hardened and narrowed with cholesterol plaque and calcium, the heart has to strain much harder to pump blood through them. As a result, blood pressure becomes abnormally high. High blood pressure is also linked to heart disease. •In the United States, approximately 1 in 3 adults suffers from hypertension, most withno identifiable cause.

Peripheral vascular disease

•High cholesterol also has been linked to peripheral vascular disease. This refers to diseases of blood vessels outside the heart and brain. In this condition, fatty deposits build up along artery walls and affect blood circulation. This occurs mainly in arteries that lead to the legs and feet... mostly in the extremities

LDL of 190 or more treatment

•If your LDL is 190 or more, it is considered very high. Your doctor will most likely recommend a statin in addition to making healthy lifestyle choices. Statins are medicines that can help lower cholesterol levels. You may also need to take a statin even though your LDL level is lower than 190. After figuring your 10-year risk, your doctor will recommend a percentage by which you should try to lower your LDL level through diet, exercise, and medication if necessary.

Factors Affecting Cholesterol: Weight

•In addition to being a risk factor for heart disease, being overweight can also increase cholesterol. Losing weight can help lower your LDL and total cholesterol. And it can also increase the level of HDL.

4 treatment groups for statin therapy have been identified

•Individuals with clinical atherosclerotic vascular disease •Those with LDL cholesterol levels greater than 190 mg/dL •Those with diabetes between 40 and 75 years old with LDL cholesterol levels between 70 and 189 mg/dL without evidence of atherosclerotic vascular disease Individuals without evidence of cardiovascular disease or diabetes who have LDL cholesterol levels between 70 and 180 mg/dL and a 10-year risk of atherosclerotic vascular disease greater than 7.5%

Causes of Atherosclerosis

•Ingestion of excess or atherogenic dietary fat, which is primarily saturated fatty acids and cholesterol. This is the most common cause of atherosclerotic vascular disease. •Primary lipid disorders, also known as primary hyperlipidemias Non-lipid disorders •disorders that are associated with direct damage to the blood vessel wall, independent of lipid levels, such as high circulating concentrations of homocysteine. elevated levels of lipoprotein(a)

HDL Cholesterol testing

•Low levels of HDL cholesterol (<40 mg/dL) represent a cardiac risk factor. •Elevated HDL cholesterol concentration (>=60 mg/dL) reduces cardiovascular risk •Fasting not needed Alcohol consumptions can also lead to an increased HDL , so an increased HDL does not mean you are healthy

Non-infectious causes of vasculitis

•Many associated with the production of ANCA •ANCA are autoantibodies, typically IgG, directed against antigens in neutrophils (most commonly) and monocytes

High-sensitivity C-reactive Protein

•Order only after a full lipid panel, for patients with borderline cardiovascular risk •Transient elevations in CRP associated with benign processes occur frequently •Repeat testing within 2 weeks if elevated

Metabolic Syndrome

•Over time commonly leads to atherosclerotic vascular disease (myocardial infarction and stroke), kidney dysfunction, and type 2 diabetes with its associated risks and complications

Factors Affecting Cholesterol: Diabetes

•Poorly controlled diabetes increases cholesterol levels. Having control of your diabetes can cause your cholesterol levels to fall.

Deep vein thrombosis and Pulmonary embolism

•Presence of a thrombosis in a deep vein in the leg is a risk factor for PE, but a thrombosis in a superficial vein in the leg is not

Factors Affecting Cholesterol: Exercise

•Regular exercise can lower LDL and raise HDL. You should try to be physically active for at least 30 minutes on most days.

Infectious causes of vasculitis

•Rocky Mountain spotted fever •Syphilis •Aspergillosis •Herpes •Neisseria infections

Therapeutic target for Statin in those with a history of MI

•Therapeutic target level is <70 mg/dL for those with history of MI

Risk factors of Metabolic Syndrome

•Waistline: For men, greater than 40 in; for women, greater than 35 in •Elevated triglycerides: Equal to or greater than 150 mg/dL •Reduced HDL cholesterol: For men, less than 40 mg/dL; for women, less than 50 mg/dL •Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of a medication for hypertension •Elevated fasting glucose: Equal to or greater than 100 mg/dL or use of a medication for hyperglycemia

Factors Affecting Cholesterol: Heredity

•Your genes partly determine how much cholesterol your body makes. High blood cholesterol can run in families.

Total cholesterol level

•Your total blood cholesterol is a measure of LDL cholesterol, HDL cholesterol, and other lipid components. Your doctor will use your total cholesterol number when determining your risk for heart disease and how best to manage it.

Cholesterol

•a waxy, fat-like substance made in the liver and other cells. It's also found in certain foods, such as dairy products, eggs, and meat. Your body needs some cholesterol to function properly. Its cell walls, also known as membranes, need cholesterol to produce hormones, vitamin D, and the bile acids that help you digest fat. But the body only needs a limited amount of cholesterol. When there's too much, health problems, such as heart disease, may develop.

Low density lipoproteins (LDL)

•also called "bad" cholesterol because it can cause plaque buildup on the walls of arteries. The more LDL there is in the blood, the greater the risk of heart disease.

High density lipoproteins (HDL)

•also called "good" cholesterol. It helps the body get rid of LDL. Maintaining a higher level of HDL is good. If your HDL level is low your risk of heart disease goes up. •a higher number means lower risk. This is because HDL cholesterol protects against heart disease by taking the "bad" cholesterol out of your blood and keeping it from building up in your arteries. A statin can slightly increase your HDL, as can exercise.

Primary lipid disorders

•also known as primary hyperlipidemias, which result in an increase in cholesterol, triglyceride, or both in the plasma. Many of these disorders are a result of genetic mutations that perturb the metabolism of cholesterol. They are not uncommon.

Triglycerides

•another type of fat, are carried in the blood by VLDL. Excess calories, alcohol, or sugar in your body are converted into triglycerides and stored in fat cells throughout your body. Associated with chylomicrons Triglycerides are the form in which most fat exists in food and the body. A high triglyceride level has been linked to higher risk of coronary artery disease.

Non-lipid disorders

•cause elevations in the concentration of plasma lipids, usually cholesterol and/or triglyceride. •These are called secondary hyperlipidemias. Disorders or conditions that adversely affect lipid metabolism include hypothyroidism, nephrotic syndrome, liver disease, diabetes, obesity, and alcohol abuse. In addition, many medications can alter plasma lipid levels.

Very low density lipoproteins (VLDL)

•similar to LDL in that it contains mostly fat and not much protein.

DVT above the knee symptoms

•soft tissue swelling and discomfort •distention of the vein (a palpable "cord" on physical examination) •Homans sign (pain on dorsiflexion of foot) •erythema •Warmth