What is Dyslipidemia?

Dyslipidemia refers to abnormal levels of lipids (fats) in the blood, including cholesterol and triglycerides. It is a major risk factor for atherosclerosis (plaque buildup in arteries), leading to heart attacks, strokes, and peripheral artery disease.

Understanding Lipid Panel Results:

1. Total Cholesterol:

• Desirable: <200 mg/dL
• Borderline High: 200-239 mg/dL
• High: ≥240 mg/dL

2. LDL Cholesterol ("Bad" Cholesterol):

• Builds up in arteries → plaques → heart attacks/strokes
• Optimal: <100 mg/dL
• Near Optimal: 100-129 mg/dL
• Borderline High: 130-159 mg/dL
• High: 160-189 mg/dL
• Very High: ≥190 mg/dL

3. HDL Cholesterol ("Good" Cholesterol):

• Removes cholesterol from arteries, protective
• Low (Increased Risk): <40 mg/dL (men), <50 mg/dL (women)
• Desirable: ≥60 mg/dL (protective)

4. Triglycerides:

• Type of fat in blood; high levels increase cardiovascular risk
• Normal: <150 mg/dL
• Borderline High: 150-199 mg/dL
• High: 200-499 mg/dL
• Very High: ≥500 mg/dL (pancreatitis risk)

5. Non-HDL Cholesterol (Total - HDL):

• Includes all "bad" cholesterol (LDL + VLDL + remnants)
• Goal: <130 mg/dL (varies based on risk)

Types of Dyslipidemia:

• Hypercholesterolemia: High total cholesterol or LDL
• Hypertriglyceridemia: High triglycerides (addressed separately)
• Low HDL: "Good" cholesterol too low
• Mixed/Combined Dyslipidemia: High LDL + high triglycerides + low HDL

Causes:

Primary (Genetic):

• Familial Hypercholesterolemia (FH): Very high LDL from birth
• Familial Combined Hyperlipidemia: High LDL + high triglycerides
• Polygenic hypercholesterolemia

Secondary (Lifestyle/Medical):

• Diet: High saturated fat, trans fats, cholesterol
• Obesity, Sedentary Lifestyle
• Diabetes, Metabolic Syndrome
• Hypothyroidism: Low thyroid → high cholesterol
• Chronic Kidney Disease, Nephrotic Syndrome
• Medications: Steroids, thiazide diuretics, beta-blockers, estrogen, retinoids
• Alcohol Abuse: Raises triglycerides
• Smoking, Stress

Cardiovascular Risk Assessment:

Treatment goals depend on overall cardiovascular risk, not just cholesterol numbers.

Risk Categories:

• Very High Risk:
  • History of heart attack, stroke, PAD, or other cardiovascular disease
  • LDL goal: <70 mg/dL (or even <55 mg/dL)
• High Risk:
  • Diabetes + other risk factors, CKD, 10-year ASCVD risk ≥20%
  • LDL goal: <70-100 mg/dL
• Moderate Risk:
  • 10-year ASCVD risk 7.5-20%
  • LDL goal: <100-130 mg/dL
• Low Risk:
  • 10-year ASCVD risk <7.5%< /li>
  • LDL goal: <130 mg/dL

Treatment:

1. Lifestyle Modifications (FIRST-LINE):

Diet:

• Reduce Saturated Fat: <7% of total calories (avoid fatty meats, full-fat dairy, butter)
• Eliminate Trans Fats: Fried foods, baked goods with partially hydrogenated oils
• Increase Soluble Fiber: Oats, beans, fruits, vegetables (lowers LDL)
• Add Plant Sterols/Stanols: Fortified foods, supplements (lower LDL by 5-10%)
• Healthy Fats: Olive oil, nuts, avocados, fatty fish (omega-3s)
• Limit Dietary Cholesterol: <200 mg/day (eggs, organ meats)

Exercise:

• 150+ minutes/week of moderate aerobic activity
• Raises HDL, lowers triglycerides

Weight Loss:

• Improves all lipid parameters

Quit Smoking, Limit Alcohol

2. Medications:

Statins (First-Line for High LDL):

• High-Intensity: Atorvastatin 40-80 mg, Rosuvastatin 20-40 mg (lower LDL by ≥50%)
• Moderate-Intensity: Atorvastatin 10-20 mg, Simvastatin 20-40 mg, Pravastatin, Lovastatin (lower LDL 30-50%)
• Low-Intensity: Simvastatin 10 mg, Pravastatin 10-20 mg (lower LDL <30%)< /li>
• Side Effects: Muscle aches (myalgias - 10-15%), rare severe myopathy/rhabdomyolysis, elevated liver enzymes

Ezetimibe (Zetia®):

• Blocks cholesterol absorption in intestines
• Lowers LDL by 15-25%
• Often combined with statin if statin alone insufficient

PCSK9 Inhibitors (Very High Risk or Statin-Intolerant):

• Evolocumab (Repatha®), Alirocumab (Praluent®)
• Subcutaneous injections every 2-4 weeks
• Lower LDL by 50-60%
• Very expensive; reserved for very high-risk patients or familial hypercholesterolemia

Bempedoic Acid (Nexletol®):

• Oral alternative if statin-intolerant
• Lowers LDL by 15-25%

Bile Acid Sequestrants:

• Cholestyramine, Colesevelam
• Lower LDL by 15-25%
• GI side effects limit use

Fibrates (for High Triglycerides):

• Fenofibrate, Gemfibrozil
• Lower triglycerides 30-50%, raise HDL 10-20%

Omega-3 Fatty Acids (High-Dose Prescription):

• Icosapent ethyl (Vascepa®), EPA/DHA formulations
• For high triglycerides

Monitoring:

• Lipid Panel: 4-12 weeks after starting/changing medication, then every 3-12 months
• Liver Enzymes: Baseline and as clinically indicated (not routine for statins)
• CK (Creatine Kinase): If muscle symptoms develop

Special Considerations:

• Hypothyroidism: Check TSH; treat thyroid disorder first—cholesterol often improves
• Diabetes: Higher cardiovascular risk; lower LDL goals
• Family History: Screen for familial hypercholesterolemia if LDL >190 mg/dL or strong family history of early heart disease