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 at least 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 between 20 and 45 years

Age > 45 years to 65 years

Age > 65 years

Age between 20 years and 55 years

Age > 55 years to 65 years

Age > 65 years

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

Complete Diagnostic Approach

Boxes in red signify that an urgent management is needed.

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

Obtain a detailed history

Assess for CAD risk factors

Screen for possible causes of secondary dyslipidemia

Evaluate the patient's 10-year global risk of CAD

Examine the patient

Order tests to rule out secondary causes of dyslipidemia

Order fasting lipid profile

Total cholesterol

LDL-C

HDL-C

Triglycerides

Non HDL-C

Additional tests