HYPERLIPIDEMIA Liz Grant, MD. UNM Department of Family and Community Medicine July 2012

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1 HYPERLIPIDEMIA Liz Grant, MD UNM Department of Family and Community Medicine July 2012

2 Objective To be familiar with and able to apply screening and treatment guidelines to patients.

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4 Components of cholesterol screening: Total cholesterol: goal <200 can be non-fasting for screening

5 Components of cholesterol screening: Triglycerides (TG) goal <150 must be fasting Unclear if independent cardiac risk factor Treated for non CHD reasons (prevention of pancreatitis) Extreme variability based on diet

6 Components of cholesterol screening: HDL ( healthy or good ) goal >40 can be nonfasting Carries cholesterol away from the arteries >60 protects against heart attack <40 increases risk for heart attack

7 Components of cholesterol screening: LDL ( lousy or bad ): goal depends on risk factors must be fasting Major cholesterol carrier in the blood and causes build-up of plaques LDL = total cholesterol (HDL + TG/5)

8 Who should we screen for high cholesterol? Guidelines

9 Screening Guidelines United States Preventative Services Task Force (USPSTF) Women >/= 45 yrs and Men >/= 35 yrs Total cholesterol and HDL cholesterol every 5 yrs (nonfasting) If total cholesterol is >200 or HDL <40 then a fasting panel should be obtained Women and Men at 20 yrs if: multiple CV risk factors diabetes family history of hyperlipidemia or premature CV disease epss (Electronic Preventive Services Selector)

10 Screening Guidelines Adult Treatment Panel (ATP III) of the National Cholesterol Education Program (NCEP) Women and Men at age 20 Fasting lipid profile Repeat every 5 yrs

11 Screening Guidelines New guideline supported by AAP: Screen ALL kids between the ages of 9-11

12 Who should we treat?

13 ATP III Guidelines for Treatment Step 1: obtain fasting lipid panel Step 2: ID Coronary Heart Disease (CHD) or equivalent*: Diabetes Symptomatic CAD Peripheral artery disease Abdominal aortic aneurysm Chronic renal disease (Cr >1.5/ GFR<60) Step 3: ID other major risk factors **: Cigarette smoking HTN (BP >140/90) or on anti-htn medication Low HDL (<40) Family h/o premature coronary heart disease (CHD) CHD in 1 st degree male relative <55 or female relative <65 Age (men >/=45, women >/=55) (If HDL >60, then one risk factor is removed) Step 4: * If CHD (or equivalent) in step 2 then consider high risk ** If >/= 2 risk factors in step 3, then use risk calculator to determine category If 0 or 1 risk factor, then consider low risk

14 Risk Calculators Framingham: adults 30-74yo Men: general-cardiovascular-disease-in-men paper?source=see_link&utdpopup=true Women: of-general-cardiovascular-disease-in-women paper?source=see_link&utdpopup=true NCEP/ATP III: adults >20 yo without heart disease or diabetes Others

15 NCEP/ATP III (National Cholesterol Education Program) Guidelines RISK per 10yrs LDL Goal Initiate Drug Treatment HIGH >20% INTERMEDIATE 10-20% LOW <10% < >100 < > 130 < >

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18 Cases

19 Cases: #1 S.R. is a 58 yo male here to establish care PAST MEDICAL HISTORY: 1. Kidney stone 2. Plantar fasciitis Surgical/Family/Social Hx: noncontributory MEDS: multivitamin VITALS: P 50, BP 110/80, Wt 98kg 1. Should we screen? Lipids: Total chol 165, TG122, HDL 41, LDL Should we treat?

20 Cases: #2 J.R. is a 25 yo male who presents to establish care PAST MEDICAL HISTORY: 1. HTN 2. H/o congenital hydronephrosis and UTIs as a child 3. Sleep apnea requiring CPAP Social Hx: Tobacco: pipe (1/wk), ETOH: 2 drinks/week Family Hx: Noncontributory Meds: None VITALS: P 61, BP 150/98, Wt kg, Ht 5 10, BMI Should we screen? Lipids: total chol 260, TG 299, HDL 29, LDL Should we treat?

21 Cases: #3 G.G. is a 70 yo male here for follow up PAST MEDICAL HISTORY: - CAD, CHF, HTN, Hyperlipidemia, COPD, Tobacco use Social Hx: Tobacco: ½ ppd; ETOH: quit >25 yrs ago; Other drugs: quit >15 yrs ago Medications: simvastatin 40 mg (and many others) VITALS: P 82, R 14, BP 120/64, Wt 100kg 1. Should we check cholesterol? - Lipids: Total chol 166, TG 190, HDL 32, LDL Should we change treatment?

22 Cases: #4 J.B. is a 74 yo woman here to follow up hip pain PAST MEDICAL HISTORY: 1. Hypothyroidism 2. Osteopenia/osteoporosis 3. Degenerative joint disease of left knee and right hip MEDICATIONS: 1. Natural thyroid hormone replacement 2. Calcium, vitamin D 3. Ibuprofen and tylenol 4. Multiple over the counter supplements VITALS: HR 55, BP 120/60, Weight 65.5 kg 1. Should we screen? Lipids: total cholesterol 260, TG 105, HDL 46, LDL Should we treat?

23 Cases: #5 KB is a 62 yo male who presents for rash PAST MEDICAL HISTORY: 1. GERD 2. Alcoholic cirrhosis 3. Tobacco use Surgical Hx/Family Hx: noncontributory Social Hx: tobacco: 1ppd, ETOH: 6-12 beers per day, no other drug use MEDICATIONS: omeprazole Vitals and exam normal 1. Should we screen? Lipids: total cholesterol 184, TG 134, HDL 28, LDL Should we treat?

24 Cases: #6 32 yo male presents with 4 days of abdominal pain Past Medical History/Past Surgical History: none Family Hx: Diabetes in Mother and Father; Uncle had an MI at age 46 Social Hx: Tobacco: 1 ppd x 9 yrs. No alcohol or drugs MEDS: none VITALS: T 38.1; HR 103; BP 130/66, wt 146 kg ABDOMEN: Soft and nondistended with bowel sounds present. No masses. Mild tenderness in the epigastric area to deep palpation

25 Cases: #6 continued Labs: CBC, CMP: normal Lipase: mildly elevated Glucose high (295) CT abdomen/pelvis: Inflammation of the region of the pancreatic head and duodenum ASSESSMENT: Pancreatitis, unknown etiology 1. Should we check lipids? Lipids: total cholesterol 286, TG 864, HDL 18, LDL unable to calculate 2. Should we treat?

26 Cases: #6 continued Started on statin and fenofibrate total cholesterol 130, TG 319, HDL 27, LDL 36 (from total chol 286, TG 864, HDL 18, LDL?) No further episodes of pancreatitis

27 Case 7 M.S. is a 65 yo woman with intermittent claudication who presents for follow up PAST MEDICAL HISTORY: 1. Asthma 2. Chronic renal disease Surgical Hx/Family Hx: noncontributory Tobacco, alcohol, drugs: none MEDICATIONS: albuterol 1. Should we screen? Lipids: total cholesterol 296, TG 215, HDL 56, LDL Should we treat?

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29 Top 10 Ways Dave Will Lower His Cholesterol 10. Use skim milk in my coffee instead of mayonnaise. 9. Have my private nurse discontinue the intravenous liquid cheese feedings. 8. Pay a 10-year-old kid to take my test for me. 7. Cancel my annual "Cool Hand Luke" egg-eating contest. 6. Visit a quack nutritionist in Guatemala who for $1,000 will play with the numbers and give me a low count. 5. Instead of sitting in my chair and telling my assistant to run my errands, I'll walk over to her desk and tell her to do them. 4. Replace cholesterol-clogged arms and legs with cool bionic limbs. 3. No more fooling around on weekends answering door in sculpted beard of butter. 2. No longer use blacking-out as signal to stop at all-you-can-eat fried clam bars. 1. Use my wealth and power to pressure the A.M.A. to dangerously lower their standards.

30 Resources American Heart Association Blaha MJ, Nasir K, Blumenthal RS. Statin therapy for healthy men identified as "increased risk". JAMA Apr 11;307(14): Gillman MW, Daniels SR. Is universal pediatric lipid screening justified? JAMA Jan 18;307(3): Goldfine, AB. Statins: is it really time to reassess benefits and risks? NEJM 366;19. May Gupta A, Guyomard V, Zaman MJ, Rehman HU, Myint PK. Systematic review on evidence of the effectiveness of cholesterol-lowering drugs. Adv Ther Jun;27(6): Last, AR, et. al. Pharmacologic treatment of hyperlipidemia. AAFP 84:5. Sept Lughetti L, Bruzzi P, Predieri B. Evaluation and management of hyperlipidemia in children and adolescents. Curr Opin Pediatr Aug;22(4): Manktelow BN, Potter JF. Cochrane Review: Interventions in the management of serum lipids for preventing stroke recurrence. 8 JUL Minder CM, Blaha MJ, Horne A, Michos ED, Kaul S, Blumenthal RS. Evidence-based use of statins for primary prevention of cardiovascular disease. Am J Med May;125(5): Prescriber s Letter Redberg RF, Katz MH. Healthy men should not take statins. JAMA Apr 11;307(14): Wagner, LK. Hyperlipidemia lecture. Apr 2012.