Dyslipidemia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Causes

Secondary causes of dyslipidemia may cause either an increase in total-cholesterol & low density lipoprotein-cholesterol (LDL-C) or an increase in total triglycerides & very low density lipoprotein cholesterol (VLDL-C). Common causes are listed below.

Increase in Total Cholesterol and LDL-C

• Hypothyroidism
• Nephrosis
• Dysgammaglobulinemia (systemic lupus erythematosus, multiple myeloma)
• Cholestatic hepatic diseases due to abnormal lipoproteins (e.g. primary biliary cirrhosis)
• Administration of protease inhibitors (treatment for HIV infection)
• Administration of progestin or anabolic steroids

Increase in Total Triglycerides and VLDL-C

• Chronic kidney disease
• Type 2 diabetes mellitus
• Obesity
• Excessive alcohol intake
• Hypothyroidism
• Administration of anti-hypertensive therapy (thiazide diuretics or B-blockers)
• Administration of corticosteroids
• Severe stress that increases endogenous corticosteroid concentration
• Elevated concentrations of estrogen (administration of oral (not transdermal) estrogen therapy, oral contraceptives, or pregnancy)
• Administration of protease inhibitors (treatment for HIV infection)

To view a comprehensive list of dyslipidemia causes, click here

Screening

Abbreviations: ASA: American society of anesthesiologists; BP: Blood Pressure; CCS: Canadian cardiovascular society; CrCl: Creatinine clearance; CXR: Chest X-ray; DNI: Do not intubate; DNR: Do not resuscitate; ECG: Electrocardiogram; eGFR: estimated glomerular filtration rate; HR:Heart rate; INR: International normalized ratio; LMWH: Low molecular weight heparin; LV: Left ventricle; LVED: Left ventricular ejection fraction; NOAC: Novel oral anticoagulant; NPO: Nothing per os; PMI: Point of maximal impulse; PT: Prothrombin time; RR: Respiratory rate; SpO2: Oxygen saturation; T: Temperature; VT: Ventricular tachycardia

Identify risk factors for CAD Major risk factors: ❑ Advanced age ❑ ↑ total serum cholesterol ❑ ↑ non-HDL-C (calculated by: total cholesterol minus HDL-C) ❑ ↑ LDL-C (either measured or calculated by: total cholesterol minus HDL-c minus (total triglycerides/5)) ❑ ↓ HDL-C ❑ Diabetes mellitus ❑ Hypertension ❑ Cigarette smoking ❑ Family history of CAD Additional risk factors: ❑ Obesity, especially abdominal ❑ Family history of hyperlipidemia ❑ Small, dense LDL-C ❑ ↑ Apo-B ❑ ↑ LDL particle number (measured by ApoB) ❑ Fasting/postprandial hypertriglyceridemia ❑ Polycystic ovarian syndrome ❑ Dyslipidemic triad Non-traditional risk factors: ❑ ↑ lipoprotein ❑ ↑ clotting factors ❑ Inflamamtory markers (e.g. hsCRP or Lipoprotein-associated phospholipase A2 (Lp-PLA2) ❑ Hyperhomocysteinemia ❑ ApoE4 isoform ❑ ↑ uric acid

Determine the 10-year risk of coronary event using ANY of the following assessment tools: ❑ Framingham Risk Assessment Tool (To be redirected to Framingham Risk Assessment Tool, click here) ❑ Reynolds Risk Score (To be redirected to Reynolds Risk Score website, click here)

High (Framingham 10-year global risk > 20%)

Intermediate (Framingham 10-year global risk between 10% and 20%)

Lower (Framingham 10-year global risk < 10%)

Optimal (Framingham 10-year global risk < 10% with optimal levels or risk factors and heart-healthy lifestyle)

Does the patient have type 2 diabetes mellitus?

Yes

No

Does the patient have ALL the following criteria for low-risk dyslipidemia during previous work-up? ❑ Low LDL-C < 100 mg/dL, AND ❑ HDL-C > 50 mg/dL, AND ❑ Triglycerides < 150 mg/dL

Adult patient

Pediatric patient (age > 2 years)

Yes. The patient has ALL of the criteria for low-risk dyslipidemia

Either unknown history of lipid profile or No, the patient does not have ALL of the criteria for low-risk dyslipidemia (at least 1 criterion is not met)

Does that patient have risk factors for CAD (listed above)?

Does the patient have risk factors for CAD (listed above)?

Screen every 2 years

Screen annually

No

Yes

Yes

No

Screen patient more frequently than patients with no risk factors based on clinical judgement (unknown optimal interval)

Male patient

Female patient

Screen every 3 to 5 years

Do not screen patient for dyslipidemia

Age 20 to 45 years

Age > 45 to 65 years

Age > 65 years

Age 20 to 55 years

Age > 55 to 65

Age > 65

Screen every 5 years More frequent screening is recommended for patients with risk factors for CAD (shown above)

Screen every 1 to 2 years More frequent screening is recommended for patients with risk factors for CAD (shown above)

Screen annually

Screen every 5 years More frequent screening is recommended for patients with risk factors for CAD (shown above)

Screen every 1 to 2 years More frequent screening is recommended for patients with risk factors for CAD (shown above)

Screen annually