Yasar Kucukardali Professor Yeditepe University Department of Internel Medicine Objectives To learn correct management of hyperlipidemia Review NCEP ATP III Guidelines Discuss laboratory monitoring Relation between plasma cholesterol concentration and six-year coronary heart disease risk in 361,662 men (ages 35 to 57) screened during the MRFIT study. There is a continuous, positive, graded correlation between the plasma cholesterol concentration and coronary risk. Data from Stamler, J, Wentworth, D, Neaton, JD, JAMA 1986; 256:2823. Cholesterol Essential component of the cell membrane Precursor molecule from which steroid hormones, bile salts, and vitamin D are synthesized Derived from the diet synthesized within the body,mainly in the liver. Dietary sources of Cholesterol Type of Fat Main Source Effect on Cholesterol levels Monounsaturated Olives, olive oil, canola oil, peanut oil, cashews, almonds, peanuts and most other nuts; avocados Lowers LDL, Raises HDL Polyunsaturated Corn, soybean, safflower and cottonseed oil; fish Lowers LDL, Raises HDL Saturated Whole milk, butter, cheese, and ice cream; red meat; chocolate; coconuts, coconut milk, coconut oil, egg yolks, chicken skin Raises both LDL and HDL Trans Most margarines; vegetable shortening; partially hydrogenated vegetable oil; deep-fried chips; many fast foods; most commercial baked goods Raises LDL Doymu yalar: Tereya, sade ya, krema, kaymak, st, peynir ve etlerin bileiminde bulunan yalar oklu doymam YAlar: Msr, ayiek, soya, susam, fndk, keten tohumu Tekli doymam yalar: zeytinya Cholesterol circulates as a component of lipoproteins The principal plasma lipoproteins chylomicrons (CMs) very low density lipoproteins (VLDL) low-density lipoproteins (LDL) high-density lipoproteins (HDL) The principal fat in the diet is the triglycerides (TG), which are absorbed in the intestine The lipoproteins are transported in combination with apoproteins (apo), like apo-A, apo-B, and apo-C Causes of Sec. Hyperlipidemia Diet Hypothyroidism Nephrotic syndrome Anorexia nervosa Obstructive liver disease Obesity Diabetes mellitus Pregnancy Acute hepatitis AIDS (protease inhibitors) Pancreatitis Hematopoietic diseases (myeloma, Waldenstrom's macroglobulinemia, cryoglobulinemia, hemochromatosis Systemic lupus erythematousus drugs like estrogens, corticosteroids, and retinoids Clasification Hyperlipidemias are classified as primary or secondary Primary hyperlipidemia have been classified into 5 major groups according to plasma lipoprotein patterns Genetic primary hyperlipidemias Symptoms of Hyperlipidemia Hyperlipidemia usually has no noticeable symptoms and tends to be discovered during routine examination or evaluation for atherosclerotic cardiovascular disease. Deposits of cholesterol (known as xanthomas) may form under the skin Individuals with hypertriglyceridemia may develop numerous pimple-like lesions across their body. ** Extremely high levels of triglycerides may also result in pancreatitis, a severe inflammation of the pancreas that may be life-threatening. Dermatologic Markers of Lipid Derangement Abnormalities of lipid metabolism may favor lipid deposition in the skin and present as xanthomas Xanthelasma palpebrarum is the commonest type of cutaneous xanthoma The major lipid stored in xanthomas is esterified cholesterol However, only about half of the patients with xanthelasma are hyperlipidemic The most frequent hyperlipidemia associated with xanthelasma is type IIa Isolated xanthelasmata are often treated with destructive modalities, like trichloroacetic acid, electrocautery, surgical excision, carbon dioxide laser, pulsed dye laser, and erbium:YAG laser Disorders of lipid storage Individuals with hypertriglyceridemia may develop numerous pimple-like lesions across their body NCEP Guidelines The NCEP Adult Treatment Panel (ATP) first published guidelines for managing hypercholesterolemia in 1988 (ATP I) Revised them in 1993 (ATP 2) The latest NCEP report (ATP III) has been published in 2001. managing hypercholesterolemia The first step is to determine lipoprotein levels after a 9- to 12-hour fast Next, coronary heart disease (CHD) risk equivalents and major risk factors should be established. CHD risk equivalents include clinical CHD symptomatic carotid artery disease peripheral arterial disease abdominal aortic aneurysm diabetes Major risk factors (exclusive of LDL cholesterol) cigarette smoking hypertension low HDL cholesterol (45 years; women >55 years) CHD risk equivalents and risk factors are then used to determine the risk category of the patient Coronary Equivalents Abdominal Aortic Aneurysm Peripheral Artery Disease Renal Artery Stenosis Carotid Artery Stenosis Cerebral Vascular Disease Diabetes Mellitus Risk Factors Hypertension HDL 60 mg/dl negative risk factor) Family history of premature CAD (male 55 Cigarette Smoking Checking lipids Nonfasting lipid panel measures HDL and total cholesterol Fasting lipid panel Measures HDL, total cholesterol and triglycerides LDL cholesterol is calculated: LDL cholesterol = total cholesterol (HDL + triglycerides/5) When to check lipid panel Two different Recommendations Two different Recommendations Adult Treatment Panel (ATP III) of the National Cholesterol Education Program (NCEP) Beginning at age 20: obtain a fasting (9 to 12 hour) serum lipid profile consisting of total cholesterol, LDL, HDL and triglycerides Repeat testing every 5 years for acceptable values United States Preventative Services Task Force Women aged 45 years and older, and men ages 35 years and older undergo screening with a total and HDL cholesterol every 5 years. If total cholesterol > 200 or HDL