History

Fact Explanation
Most patients are asymptomatic Most are incidental findings in high risk patients. Following are some examples for High risk conditions.(Ex- cardiovascular disease, family history of cardiovascular disease <65 years old, diabetes, hypertension, smoking, obesity, smoking and indian asian ethnicity) Hyperlipidemia can be classified in to three main categories (predominant hypercholesterolaemia, predominant hypertriglyceridemia and mixed hyperlipidaemia) based on biochemical testing. [1],[3]
Chest pain on exertion Hyperlipidemia is a major modifiable risk factor for coronary artery disease. Dyslipidemia causes increased oxidative stress, endothelial dysfunction and progression of atherosclerosis, resulting in a major cardiovascular event. [2],[3]
Headache Dyslipidemia causes endothelial damage and loss of physiological vasomotor activity. This damage can manifest as elevated systemic blood pressure(Cross-sectional studies have shown a relationship between dyslipidemia and hypertension).Sometimes severe hypertension is associated with headache. [10],[11]
Polyuria and polydipsia Polyuria and polydipsia are predominant symptoms of uncontrolled diabetes mellitus. Uncontrolled diabetes mellitus causes mixed hyperlipidemia (Both LDL cholesterol and triglycerides are elevated). [2],[3]
Constipation, malaise and cold intolerance Constipation, malaise and cold intolerance are predominant symptoms of hypothyroidism. Thyroid hormone is known to play a role in regulating the synthesis, metabolism, and mobilization of lipids.This is a cause for secondary hyperlipidemia. Usually in this condition, only LDL cholesterol level is elevated. [6],[9]
Facial puffiness and frothy urine Facial puffiness and frothy urine are common symptoms of nephrotic syndrome. Patients with nephrotic syndrome have characteristic secondary changes in lipoprotein metabolism (enzymes involved in cholesterol metabolism slip through the glomeruli, which results in high blood cholesterol). Nephrotic syndrome is a cause for secondary hyperlipidemia. In this condition, only LDL cholesterol level is elevated. [4],[12]
Yellowish discoloration of eyes and ankle oedema Yellowish discoloration of eyes and ankle oedema are common symptoms of hepatic dysfunction. It is a cause for secondary hyperlipidemia. [16].
Rapid weight gain, easy bruising, difficulty in combing hair and climbing stairs These are predominant symptoms of Cushing's syndrome. Cortisol increases lipoprotein lipase in adipose tissues (particularly in visceral fat where lipolysis is activated) resulting in the release of free fatty acids into the circulation. This is a cause for secondary hyperlipidemia. In this condition, only LDL cholesterol level is elevated. [13]
Recurrent episodes of epigastric pain Their may be a history of recurrent episodes of acute pancreatitis. This is commonly associated with hypertriglyceridemia. Some of them have a co-existing history of gallstone disease. [15]
Recurrent episodes of right upper quadrant pain after a fatty meal. Their may be a history of recurrent episodes of right upper quadrant pain after a fatty meal. This is the characteristic symptom of acute cholecystitis (due to cholesterol stones). [6], [14]
Weakness, anorexia, pruritis and bone pain Weakness, anorexia, pruritus and bone pain are symptoms of chronic renal failure. Patients with a history of chronic renal failure and patients undergoing renal replacement therapy has an increased risk of dyslipidemia (Chronic renal failure causes mixed hyperlipidemia). [4],[7]
Drug history Drugs such as oral contraceptive pills, Diuretics, Beta blockers, Corticosteroids, Retinoids, Sirolimus, Atypical antipsychotics, Cyclosporin, Antiretroviral therapy are secondary causes of hyperlipidemia. [6],[9]
Family history of coronary heart disease Family history of coronary heart disease (especially below 50 years of age) is a risk factor for hyperlipidemia. [1],[2],[3]
Family history of lipid disorders There are multiple phenotypes. Familial combined hypercholesterolemia is the most common primary lipid disorder. It is characterized by moderate elevation of plasma triglycerides and cholesterol with reduced plasma HDL cholesterol. Other familial lipid disorders are relatively rare. [1],[2],[3]
Dietary history Dietary history provides information on amount of fat, carbohydrate and fiber intake per day. Fat intake per total calories greater than 40% , saturated fat intake per total calories greater than 10% and cholesterol intake greater than 300 mg per day are major criteria to identify a high fat diet. [2],[3],[5],[6]
Sedentary life style History of sedentary lifestyle with limited physical activity increases the risk of dyslipidemia. [2],[3],[6]
Excessive alcohol consumption Habitual excessive alcohol consumption causes mixed hyperlipidemia (Both LDL cholesterol and triglycerides are elevated). [2],[3]
References
  1. AEKPLAKORN WICHAI, TANEEPANICHSKUL SURASAK, KESSOMBOON PATTAPONG, CHONGSUVIVATWONG VIRASAKDI, PUTWATANA PANWADEE, SRITARA PIYAMITR, SANGWATANAROJ SOMKIAT, CHARIYALERTSAK SUWAT. Prevalence of Dyslipidemia and Management in the Thai Population, National Health Examination Survey IV, 2009. Journal of Lipids [online] 2014 December, 2014:1-13 [viewed 01 July 2014] Available from: doi:10.1155/2014/249584
  2. YIN XY, ZHENG FP, ZHOU JQ, DU Y, PAN QQ, ZHANG SF, YU D, LI H. Central obesity and metabolic risk factors in middle-aged Chinese. Biomed Environ Sci [online] 2014 May, 27(5):343-52 [viewed 01 July 2014] Available from: doi:10.3967/bes2014.059
  3. JOSHI SR, ANJANA RM, DEEPA M, PRADEEPA R, BHANSALI A, DHANDANIA VK, JOSHI PP, UNNIKRISHNAN R, NIRMAL E, SUBASHINI R, MADHU SV, RAO PV, DAS AK, KAUR T, SHUKLA DK, MOHAN V, ICMR– INDIAB COLLABORATIVE STUDY GROUP. Prevalence of Dyslipidemia in Urban and Rural India: The ICMR-INDIAB Study. PLoS One [online] 2014, 9(5):e96808 [viewed 01 July 2014] Available from: doi:10.1371/journal.pone.0096808
  4. BANACH M, SERBAN C, ARONOW WS, RYSZ J, DRAGAN S, LERMA EV, APETRII M, COVIC A. Lipid, blood pressure and kidney update 2013. Int Urol Nephrol [online] 2014 May, 46(5):947-61 [viewed 01 July 2014] Available from: doi:10.1007/s11255-014-0657-6
  5. HA V, SIEVENPIPER JL, DE SOUZA RJ, JAYALATH VH, MIRRAHIMI A, AGARWAL A, CHIAVAROLI L, MEJIA SB, SACKS FM, DI BUONO M, BERNSTEIN AM, LEITER LA, KRIS-ETHERTON PM, VUKSAN V, BAZINET RP, JOSSE RG, BEYENE J, KENDALL CW, JENKINS DJ. Effect of dietary pulse intake on established therapeutic lipid targets for cardiovascular risk reduction: a systematic review and meta-analysis of randomized controlled trials. CMAJ [online] 2014 May 13, 186(8):E252-62 [viewed 01 July 2014] Available from: doi:10.1503/cmaj.131727
  6. PHAN BA, TOTH PP. Dyslipidemia in women: etiology and management. Int J Womens Health [online] 2014:185-94 [viewed 01 July 2014] Available from: doi:10.2147/IJWH.S38133
  7. LIU DW, WAN J, LIU ZS, WANG P, CHENG GY, SHI XZ. Association between dyslipidemia and chronic kidney disease: a cross-sectional study in the middle-aged and elderly Chinese population. Chin Med J (Engl) [online] 2013 Apr, 126(7):1207-12 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23557545
  8. YOGARATNAM J, BISWAS N, VADIVEL R, JACOB R. Metabolic complications of schizophrenia and antipsychotic medications--an updated review. East Asian Arch Psychiatry [online] 2013 Mar, 23(1):21-8 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23535629
  9. RAZA SA, MAHMOOD N. Subclinical hypothyroidism: Controversies to consensus. Indian J Endocrinol Metab [online] 2013 Dec, 17(Suppl 3):S636-42 [viewed 01 July 2014] Available from: doi:10.4103/2230-8210.123555
  10. KAUR J. A comprehensive review on metabolic syndrome. Cardiol Res Pract [online] 2014:943162 [viewed 01 July 2014] Available from: doi:10.1155/2014/943162
  11. GULATI ASHISH, DALAL JAMSHEDJ, PADMANABHAN T. N. C., JAIN PIYUSH, PATIL SHIVA, VASNAWALA HARDIK. Lipitension: Interplay between dyslipidemia and hypertension. Indian J Endocr Metab [online] 2012 December [viewed 01 July 2014] Available from: doi:10.4103/2230-8210.93742
  12. KRONENBERG F. Dyslipidemia and nephrotic syndrome: recent advances. J Ren Nutr [online] 2005 Apr, 15(2):195-203 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15827892
  13. MARINA, APPOLLONI GLORIA, BOSCARO MARCO. Pathophysiology of Dyslipidemia in Cushing’s Syndrome. Neuroendocrinology [online] 2010 December, 92(1):86-90 [viewed 01 July 2014] Available from: doi:10.1159/000314213
  14. PREMKUMAR M, SABLE T. Obesity, dyslipidemia and cholesterol gallstone disease during one year of Antarctic residence. Rural Remote Health [online] 2012:2186 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23157579
  15. KOTA SUNILK, KOTA SIVAK, KRISHNA S. V. S., MODI KIRTIKUMARD, JAMMULA SRUTI. Hypertriglyceridemia-induced recurrent acute pancreatitis: A case-based review. Indian J Endocr Metab [online] 2012 December [viewed 02 July 2014] Available from: doi:10.4103/2230-8210.91211
  16. CHATRATH HEMANT, VUPPALANCHI RAJ, CHALASANI NAGA. Dyslipidemia in Patients with Nonalcoholic Fatty Liver Disease. Semin Liver Dis [online] December, 32(01):022-029 [viewed 02 July 2014] Available from: doi:10.1055/s-0032-1306423

Examination

Fact Explanation
Weight and height Measure weight and height to calculate Body Mass Index (BMI). Obesity is commonly associated with hyperlipidemia. [2],[3],[5]
Blood pressure Hypertension is commonly associated with hyperlipidemia. Therefore undiagnosed hypertension can be noticed during examination. [1],[7],[5]
Xanthelasma "Xantho" is yellow in greek and "elasma" means plate. Xanthelasma are lipid laden yellow plaques, typically a few mm wide. They congregate around the lids or just below the eyes. Onset of xanthelasma before the age of 40 is a important sign of hyperlipidemia. Predominantly associated with hypercholesterolaemia. In later ages it may be nonspecific. [8]
Corneal arcus Corneal arcus is a greyish-white ring (or part of a ring) opacity occurring in the periphery of the cornea, in middle and old age. It is due to a lipid infiltration of the corneal stroma. Onset of corneal arcus before the age of 40 is a important sign of hyperlipidemia. Predominantly associated with hypercholesterolaemia. In later ages it may be nonspecific. [8]
Xanthoma Xanthomas are well circumscribed lesions in the connective tissue of the skin, tendons or fascia. They are predominantly consist of foam cells. These specific cells are formed from macrophages as a result of an excessive uptake of LDL particles and their oxidation. Extensor digitorum tendons, achilles tendon, pre patellar tendons are common sites of xanthoma. Tendon, tuberous (on elbows and knee) and planar (orange streaks in palmar creases) xanthoma predominantly associated with hypercholesterolaemia. Eruptive xanthoma are itchy nodules in crops. It is predominantly associated with hypertriglyceridemia. [8]
Hepato splenomegaly Predominantly associated with hypertriglyceridemia. Hepatomegaly occurs due to fatty liver. Splenomegaly is rarely seen. Icterus may be noticed in few patients. [9],[13]
Lipaemia retinalis Lipaemia retinalis is milky appearance of the veins and arteries of the retina. Predominantly associated with hypertriglyceridemia. [9]
Bradycardia and slow relaxing tendon reflexes Dry skin, lust less brittle hair, loss of hair on lateral 1/3 of eye brow, bradycardia and slow relaxing tendon reflexes are characteristic signs of hypothyroidism. [6]
Pallor, half half nails and uremic breath Pallor, half half nails, uremic breath are important signs of chronic kidney disease. Signs of renal replacement therapy such as AV fistula must examined specifically in these patients. [1]
Peri orbital edema and pitting ankle edema Periorbital edema, pitting ankle edema are predominant signs of nephrotic syndrome. Pleural effusion and ascites may be noticed in some patients. [10]
Moon face, buffalo hump, central obesity, purple abdominal striae and proximal myopathy Moon face, buffalo hump, central obesity, purple abdominal striae and proximal myopathy are some important signs of cushing's syndrome. [11]
Right upper quadrant or epigastric tenderness Right upper quadrant or epigastric tenderness and fever may be present in acute cholecystitis. Murphy's sign can be positive. [12]
References
  1. BANACH M, SERBAN C, ARONOW WS, RYSZ J, DRAGAN S, LERMA EV, APETRII M, COVIC A. Lipid, blood pressure and kidney update 2013. Int Urol Nephrol [online] 2014 May, 46(5):947-61 [viewed 01 July 2014] Available from: doi:10.1007/s11255-014-0657-6
  2. YIN XY, ZHENG FP, ZHOU JQ, DU Y, PAN QQ, ZHANG SF, YU D, LI H. Central obesity and metabolic risk factors in middle-aged Chinese. Biomed Environ Sci [online] 2014 May, 27(5):343-52 [viewed 01 July 2014] Available from: doi:10.3967/bes2014.059
  3. PAN S, YU ZX, MA YT, LIU F, YANG YN, MA X, FU ZY, LI XM, XIE X, CHEN Y, CHEN B, HE CH. Appropriate body mass index and waist circumference cutoffs for categorization of overweight and central adiposity among Uighur adults in Xinjiang. PLoS One [online] 2013, 8(11):e80185 [viewed 01 July 2014] Available from: doi:10.1371/journal.pone.0080185
  4. LIU DW, WAN J, LIU ZS, WANG P, CHENG GY, SHI XZ. Association between dyslipidemia and chronic kidney disease: a cross-sectional study in the middle-aged and elderly Chinese population. Chin Med J (Engl) [online] 2013 Apr, 126(7):1207-12 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23557545
  5. KAUR J. A comprehensive review on metabolic syndrome. Cardiol Res Pract [online] 2014:943162 [viewed 01 July 2014] Available from: doi:10.1155/2014/943162
  6. RAZA SA, MAHMOOD N. Subclinical hypothyroidism: Controversies to consensus. Indian J Endocrinol Metab [online] 2013 Dec, 17(Suppl 3):S636-42 [viewed 01 July 2014] Available from: doi:10.4103/2230-8210.123555
  7. GULATI ASHISH, DALAL JAMSHEDJ, PADMANABHAN T. N. C., JAIN PIYUSH, PATIL SHIVA, VASNAWALA HARDIK. Lipitension: Interplay between dyslipidemia and hypertension. Indian J Endocr Metab [online] 2012 December [viewed 01 July 2014] Available from: doi:10.4103/2230-8210.93742
  8. ZAK A, ZEMAN M, SLABY A, VECKA M. Xanthomas: clinical and pathophysiological relations. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub [online] 2014 Apr 29 [viewed 01 July 2014] Available from: doi:10.5507/bp.2014.016
  9. BOUAZIZ ABED A, MAALOUL I, MUSTAPHA R, CHIHA M, AISSA K. [Primary hypertriglyceridemia type IV : early presentation of a severe case]. Tunis Med [online] 2013 Nov, 91(11):683 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24343502
  10. KRONENBERG F. Dyslipidemia and nephrotic syndrome: recent advances. J Ren Nutr [online] 2005 Apr, 15(2):195-203 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15827892
  11. ARNALDI GIORGIO, SCANDALI VALERIO MATTIA, TREMENTINO LAURA, CARDINALETTI MARINA, APPOLLONI GLORIA, BOSCARO MARCO. Pathophysiology of Dyslipidemia in Cushing’s Syndrome. Neuroendocrinology [online] 2010 December, 92(1):86-90 [viewed 01 July 2014] Available from: doi:10.1159/000314213
  12. PREMKUMAR M, SABLE T. Obesity, dyslipidemia and cholesterol gallstone disease during one year of Antarctic residence. Rural Remote Health [online] 2012:2186 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23157579
  13. CHATRATH HEMANT, VUPPALANCHI RAJ, CHALASANI NAGA. Dyslipidemia in Patients with Nonalcoholic Fatty Liver Disease. Semin Liver Dis [online] December, 32(01):022-029 [viewed 02 July 2014] Available from: doi:10.1055/s-0032-1306423

Differential Diagnoses

Fact Explanation
Obstructive liver disease Stigmata of liver disease, such as jaundice and abdominal tenderness, may be seen. Usually there is a significant elevation of bilirubin level. Most of the patient may also complain of pruritus.[4]
Nephrotic syndrome Periorbital edema, facial puffiness, frothy urine are characteristic features of nephrotic syndrome. [2]
Chronic renal insufficiency Signs of chronic kidney disease such as pallor,half half nails and uremic breath may be present. Patients undergoing peritoneal dialysis are more likely to have an atherogenic lipid profile than those undergoing hemodialysis. [3]
Hypothyroidism Presents with lethargy, cold intolerance, constipation, dry hair or skin, goiter, bradycardia or delayed return of deep tendon reflexes. [1]
Cushing's Syndrome Presents with rapid weight gain, central obesity, buffalo hump, easy bruising, purple abdominal striae and proximal myopathy [5]
Side effect of drug Drugs such as oral contraceptive pill, Diuretics, Beta blockers, Cortecostroids, Retinoids, Sirolimus, Atypical antipsychotics, Ciclosporin, Anti retroviral therapy are secondary causes of hyperlipidemia. [6],[7]
References
  1. RAZA SA, MAHMOOD N. Subclinical hypothyroidism: Controversies to consensus. Indian J Endocrinol Metab [online] 2013 Dec, 17(Suppl 3):S636-42 [viewed 01 July 2014] Available from: doi:10.4103/2230-8210.123555
  2. KRONENBERG F. Dyslipidemia and nephrotic syndrome: recent advances. J Ren Nutr [online] 2005 Apr, 15(2):195-203 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15827892
  3. LIU DW, WAN J, LIU ZS, WANG P, CHENG GY, SHI XZ. Association between dyslipidemia and chronic kidney disease: a cross-sectional study in the middle-aged and elderly Chinese population. Chin Med J (Engl) [online] 2013 Apr, 126(7):1207-12 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23557545
  4. CHATRATH HEMANT, VUPPALANCHI RAJ, CHALASANI NAGA. Dyslipidemia in Patients with Nonalcoholic Fatty Liver Disease. Semin Liver Dis [online] December, 32(01):022-029 [viewed 02 July 2014] Available from: doi:10.1055/s-0032-1306423
  5. MARINA, APPOLLONI GLORIA, BOSCARO MARCO. Pathophysiology of Dyslipidemia in Cushing’s Syndrome. Neuroendocrinology [online] 2010 December, 92(1):86-90 [viewed 01 July 2014] Available from: doi:10.1159/000314213
  6. YOGARATNAM J, BISWAS N, VADIVEL R, JACOB R. Metabolic complications of schizophrenia and antipsychotic medications--an updated review. East Asian Arch Psychiatry [online] 2013 Mar, 23(1):21-8 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23535629
  7. PHAN BA, TOTH PP. Dyslipidemia in women: etiology and management. Int J Womens Health [online] 2014:185-94 [viewed 01 July 2014] Available from: doi:10.2147/IJWH.S38133

Investigations - for Diagnosis

Fact Explanation
Lipid profile Screening of plasma lipids is recommended in adult men ≥ 40 and women ≥ 50 years of age or postmenopausal. Patients with modifiable CVD risk factors (smoking, diabetes, arterial hypertension, obesity) are screened for lipids at any age. Levels of Total cholesterol (TC), triglyceride (TG), and HDL cholesterol (HDL C) need to be obtained after a 12 hour fast to permit accurate calculation of LDL cholesterol (LDL C) according to Friedewald formula. [LDL C= TC- HDL C- (TG/2.2)mmol/L] [1],[2]
Fasting lipid profile : LDL C Polygenic hypercholesterolaemia is the most common cause o f mild to moderate increase in LDL C. The Risk of cardiovascular disease is proportional to the degree of LDL C elevation, but is modified by other major risk factors such as low HDL C. Depending on LDL C level below severity assessment can be done. Optimal: <100 mg/dL (<2.58 mmol/L) Near or above optimal: 100 to 129 mg/dL (2.58 to 3.33 mmol/L) Borderline high: 130 to 159 mg/dL (3.36 to 4.11 mmol/L) High: 160 to 189 mg/dL (4.13 to 4.88 mmol/L) Very high: ≥190 mg/dL (≥4.91 mmol/L). [1],[2]
Fasting lipid profile: Total cholesterol Total cholesterol level can be tested in non fasting samples also. Depending on TC level below severity assessment can be done. Desirable: <200 mg/dL (<5.17 mmol/L) Borderline high: 200 to 239 mg/dL (5.17 to 6.18 mmol/L) High: ≥240 mg/dL (≥6.20 mmol/L). [1],[2]
Fasting lipid profile: HDL C HDL C removes cholesterol from tissues to liver, where it is metabolized and excreted in bile. Depending on HDL C level below severity assessment can be done. Low: <40 mg/dL (<1.03 mmol/L) High: ≥60 mg/dL (≥1.55 mmol/L). [1],[2]
Fasting lipid profile: Triglycerides Elevated TG is common in obesity, diabetes and insulin resistance, and is frequently associated with low HDL and increased "small, dense" LDL. Under these circumstances LDL C may underestimate risk. This is one situation which measurement of Apo B may provide additional useful information. [1],[2]
Fasting blood sugar Uncontrolled diabetes mellitus causes mixed hyperlipidemia. Therefore this is important to identify undiagnosed patients and to see the control of diagnosed diabetic patients. [3]
Serum TSH level To identify hypothyroidism this is done. [4]
ECG Hyperlipidemia regardless of cause, is a major modifiable risk factor for coronary artery disease. Therefore ECG must performed. [1]
Liver function tests Chronic liver diseases causes dyslipidemia. Also dyslipidemia causes fatty liver. Some cholesterol lowering drugs affect liver functions. Therefore performing liver function assessment is important. [5]
Blood urea and serum creatinine Chronic kidney disease causes dyslipidemia. If blood urea and serum creatinine level are elevated more specific tests such as creatinine clearence must be performed. [7]
Serum electrolytes Electrolyte imbalance can be seen in chronic kidney disease and cushing's syndrome. If found specific tests have to be performed. [7],[8]
USS abdomen USS abdomen is useful to identify fatty liver, acute cholecystitis, acute pancreatitis, ascitis and chronic kidney disease. [5],[6],[7],[9]
References
  1. ANDERSON TJ, GRéGOIRE J, HEGELE RA, COUTURE P, MANCINI GB, MCPHERSON R, FRANCIS GA, POIRIER P, LAU DC, GROVER S, GENEST J JR, CARPENTIER AC, DUFOUR R, GUPTA M, WARD R, LEITER LA, LONN E, NG DS, PEARSON GJ, YATES GM, STONE JA, UR E. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol [online] 2013 Feb, 29(2):151-67 [viewed 02 July 2014] Available from: doi:10.1016/j.cjca.2012.11.032
  2. YIN XY, ZHENG FP, ZHOU JQ, DU Y, PAN QQ, ZHANG SF, YU D, LI H. Central obesity and metabolic risk factors in middle-aged Chinese. Biomed Environ Sci [online] 2014 May, 27(5):343-52 [viewed 01 July 2014] Available from: doi:10.3967/bes2014.059
  3. BOSOMWORTH NJ. Approach to identifying and managing atherogenic dyslipidemia: a metabolic consequence of obesity and diabetes. Can Fam Physician [online] 2013 Nov, 59(11):1169-80 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24235189
  4. RAZA SA, MAHMOOD N. Subclinical hypothyroidism: Controversies to consensus. Indian J Endocrinol Metab [online] 2013 Dec, 17(Suppl 3):S636-42 [viewed 01 July 2014] Available from: doi:10.4103/2230-8210.123555
  5. CHATRATH HEMANT, VUPPALANCHI RAJ, CHALASANI NAGA. Dyslipidemia in Patients with Nonalcoholic Fatty Liver Disease. Semin Liver Dis [online] December, 32(01):022-029 [viewed 02 July 2014] Available from: doi:10.1055/s-0032-1306423
  6. KRONENBERG F. Dyslipidemia and nephrotic syndrome: recent advances. J Ren Nutr [online] 2005 Apr, 15(2):195-203 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15827892
  7. LIU DW, WAN J, LIU ZS, WANG P, CHENG GY, SHI XZ. Association between dyslipidemia and chronic kidney disease: a cross-sectional study in the middle-aged and elderly Chinese population. Chin Med J (Engl) [online] 2013 Apr, 126(7):1207-12 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23557545
  8. MARINA, APPOLLONI GLORIA, BOSCARO MARCO. Pathophysiology of Dyslipidemia in Cushing’s Syndrome. Neuroendocrinology [online] 2010 December, 92(1):86-90 [viewed 01 July 2014] Available from: doi:10.1159/000314213
  9. KOTA SUNILK, KOTA SIVAK, KRISHNA S. V. S., MODI KIRTIKUMARD, JAMMULA SRUTI. Hypertriglyceridemia-induced recurrent acute pancreatitis: A case-based review. Indian J Endocr Metab [online] 2012 December [viewed 02 July 2014] Available from: doi:10.4103/2230-8210.91211
  10. PREMKUMAR M, SABLE T. Obesity, dyslipidemia and cholesterol gallstone disease during one year of Antarctic residence. Rural Remote Health [online] 2012:2186 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23157579

Investigations - Fitness for Management

Fact Explanation
Liver function tests Presence of active liver disease is a contraindication to statin therapy. Therefore prior to statin therapy liver function tests must be performed. [1]
References
  1. ANDERSON TJ, GRéGOIRE J, HEGELE RA, COUTURE P, MANCINI GB, MCPHERSON R, FRANCIS GA, POIRIER P, LAU DC, GROVER S, GENEST J JR, CARPENTIER AC, DUFOUR R, GUPTA M, WARD R, LEITER LA, LONN E, NG DS, PEARSON GJ, YATES GM, STONE JA, UR E. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol [online] 2013 Feb, 29(2):151-67 [viewed 02 July 2014] Available from: doi:10.1016/j.cjca.2012.11.032

Investigations - Followup

Fact Explanation
Lipid profile Monitoring lipid levels is useful to assess compliance and response to therapy. Usually this is performed six monthly in patients with cardiovascular risk factors. [1]
Creatinine kinase (CK) CK is important to monitor the side effects. Must interrupt statin treatment if CK >5-10 times the upper limit of normal or if elevated with muscle symptoms such as myalgia. [1]
Alanine aminotransferase (ALT) ALT is important to monitor the side effects. Must interrupt statin treatment if ALT>2-3 times the upper limit of normal. [1]
References
  1. ANDERSON TJ, GRéGOIRE J, HEGELE RA, COUTURE P, MANCINI GB, MCPHERSON R, FRANCIS GA, POIRIER P, LAU DC, GROVER S, GENEST J JR, CARPENTIER AC, DUFOUR R, GUPTA M, WARD R, LEITER LA, LONN E, NG DS, PEARSON GJ, YATES GM, STONE JA, UR E. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol [online] 2013 Feb, 29(2):151-67 [viewed 02 July 2014] Available from: doi:10.1016/j.cjca.2012.11.032

Management - General Measures

Fact Explanation
Educate the patient. Educate the patient about the condition, possible complications such as myocardial infarction and stroke. Effectively communicate with the patient about available non pharmacological and pharmacological management modalities. Explain about types of fat. Saturated fats increase Low Density Lipoproteins (bad cholesterol) & Very Low Density Lipoproteins. Sources are meat, refined carbohydrate, such as white sugar and flour. Unsaturated fats increase High-Density Lipoprotein (good cholesterol) and decrease Low Density Lipoproteins (bad cholesterol). Unsaturated fats also high in antioxidants. Sources of HDL include onions and Omega-3 fatty acids like flax oil, fish, foods rich in fiber like grains. [1],[2],[3],[4],[5]
Advise on Mediterranean diet. The principal aspects of a Mediterranean diet include proportionally high consumption of olive oil, legumes, unrefined cereals, fruits, and vegetables, moderate to high consumption of fish, moderate consumption of dairy products (mostly as cheese and yogurt), moderate wine consumption, and low consumption of meat and meat products. [7],[8]
Reduce total fat intake. Dairy products and meat are the main sources of saturated fat in the diet. Therefore intake of those products must be reduced, and fish and poultry should be substituted. Visible fat and skin should be removed before cooking. Sausages and reconstituted meat should be avoided as concentration of fat is often high. Baking and grilling meats reduces the fat content and is preferred to frying. Low fat cheese or skimmed milk should be substituted for full cream milk. Cakes and pastries contains large amount of fat and should be avoided. [1],[2],[3],[4],[5]
Use monosaturates and polysaturates. Monosaturate oils such as olive oil and polyunsaturated oil such as sunflower, corn and soya oil should be used instead of saturated fat rich alternatives such as butter. [1],[2],[3],[4],[5]
Reduce dietary cholesterol intake. Liver, chinese rolls should be avoided. Although eggs and prawns are rich in cholesterol their total contribution to the body's cholesterol pool is small and they can still be part of a balanced lipid lowering diet. [1],[2],[3],[4],[5],[6]
Increase intake of fiber. Food high in soluble fiber such as pulses legumes, leafy vegetables and unprocessed cereals reduce circulating lipid content. [1],[2],[3],[4],[5]
Increase intake of food containing stanol esters. Plant stanols reduce the absorption of cholesterol from the intestine by competing for space in the micelles that deliver lipid to mucosal cells of the gut. They are largely unabsorbed and excreted in the stool. There are margarines containing added stanol esters such as Benecol. They lowers LDL cholesterol level. [1],[2],[3],[4],[5]
Restrict alcohol consumption. Excess alcohol is a cause of secondary hyperlipidemia. Alcohol should be eliminated or restricted. [1],[2],[3],[4],[5]
Maintain ideal BMI. Achieving ideal body weight and maintaining BMI < 25kg/m2 help the dyslipidemia itself and reduce the cardiovascular risk. [1],[2],[3],[4],[5]
Increase aerobic exercises. Advice to engage aerobic physical activity such as brisk walking at least 30 min per day, most days of the week. Aerobic exercises help to reduce weight and increase HDL cholesterol level. [1],[2],[3],[4],[5]
References
  1. JENSEN MD, RYAN DH, APOVIAN CM, ARD JD, COMUZZIE AG, DONATO KA, HU FB, HUBBARD VS, JAKICIC JM, KUSHNER RF, LORIA CM, MILLEN BE, NONAS CA, PI-SUNYER FX, STEVENS J, STEVENS VJ, WADDEN TA, WOLFE BM, YANOVSKI SZ. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. J Am Coll Cardiol [online] 2014 Jul 1, 63(25 Pt B):2985-3023 [viewed 01 July 2014] Available from: doi:10.1016/j.jacc.2013.11.004
  2. BOSOMWORTH NJ. Approach to identifying and managing atherogenic dyslipidemia: a metabolic consequence of obesity and diabetes. Can Fam Physician [online] 2013 Nov, 59(11):1169-80 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24235189
  3. AEKPLAKORN WICHAI, TANEEPANICHSKUL SURASAK, KESSOMBOON PATTAPONG, CHONGSUVIVATWONG VIRASAKDI, PUTWATANA PANWADEE, SRITARA PIYAMITR, SANGWATANAROJ SOMKIAT, CHARIYALERTSAK SUWAT. Prevalence of Dyslipidemia and Management in the Thai Population, National Health Examination Survey IV, 2009. Journal of Lipids [online] 2014 December, 2014:1-13 [viewed 01 July 2014] Available from: doi:10.1155/2014/249584
  4. JAQUES H. NICE guideline on lipid modification. Eur Heart J [online] 2013 Feb, 34(7):481-2 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23534074
  5. ANDERSON TJ, GRéGOIRE J, HEGELE RA, COUTURE P, MANCINI GB, MCPHERSON R, FRANCIS GA, POIRIER P, LAU DC, GROVER S, GENEST J JR, CARPENTIER AC, DUFOUR R, GUPTA M, WARD R, LEITER LA, LONN E, NG DS, PEARSON GJ, YATES GM, STONE JA, UR E. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol [online] 2013 Feb, 29(2):151-67 [viewed 02 July 2014] Available from: doi:10.1016/j.cjca.2012.11.032
  6. HA V, SIEVENPIPER JL, DE SOUZA RJ, JAYALATH VH, MIRRAHIMI A, AGARWAL A, CHIAVAROLI L, MEJIA SB, SACKS FM, DI BUONO M, BERNSTEIN AM, LEITER LA, KRIS-ETHERTON PM, VUKSAN V, BAZINET RP, JOSSE RG, BEYENE J, KENDALL CW, JENKINS DJ. Effect of dietary pulse intake on established therapeutic lipid targets for cardiovascular risk reduction: a systematic review and meta-analysis of randomized controlled trials. CMAJ [online] 2014 May 13, 186(8):E252-62 [viewed 01 July 2014] Available from: doi:10.1503/cmaj.131727
  7. MEKKI KHEDIDJA, BOUZIDI-BEKADA NASSIMA, KADDOUS ABBOU, BOUCHENAK MALIKA. Mediterranean diet improves dyslipidemia and biomarkers in chronic renal failure patients. Food & Funct. [online] 2010 December [viewed 04 July 2014] Available from: doi:10.1039/c0fo00032a
  8. TURCINOV D, STANLEY C, CANCHOLA JA, RUTHERFORD GW, NOVOTNY TE, BEGOVAC J. Dyslipidemia and adherence to the Mediterranean diet in Croatian HIV-infected patients during the first year of highly active antiretroviral therapy. Coll Antropol [online] 2009 Jun, 33(2):423-30 [viewed 04 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19662759

Management - Specific Treatments

Fact Explanation
Treatment priorities Using statins in primary prevention cause side effects and expensive. Give top priority to treat those with known cardiovascular disease. Patients with diabetes mellitus must be treated as second priority. Those with 10 year risk of cardiovascular disease >20%, irrespective of baseline lipid levels must be treated as third Priority. [1],[2],[3],[4]
Predominant hypercholesterolaemia First line treatment with Statin. Give Ezetimibe if intolerant to statin. [1],[2],[3],[4]
Predominant hypertriglyceridaemia First line treatment with Fibrate. Give fish oil if intolerant to Fibrate. [1],[2],[3],[4]
Mixed hyperlipidaemia Combination treatment preferred if TG and LDL >4 mmol/L. [1],[2],[3],[4]
Statins They inhibit HMG CoA reductase enzyme at the rate limiting step in cholesterol synthesis, thereby up regulating the activity of LDL receptor. This increases clearance of LDL and its precursor resulting In a secondary reduction in LDL synthesis. Statins are the most widely used drugs. They cause 30-60% reduction of LDL cholesterol and modest triglyceride lowering. Statins are generally well tolerated and serious side effects are rare. Liver function abnormalities and muscle problems are the most common. Statins are contraindicated in active liver disease, pregnancy and lactation. Simvastatin, atorvastatin, rosuvastatin are some examples. [1],[2],[3],[4]
Cholesterol absorption inhibitors They inhibit gut absorption of cholesterol from food and also from bile, thereby increasing de novo bile acid synthesis from hepatic cholesterol. Reduce LDL cholesterol by additional 10-15% if give with statin. Triglyceride concentrations reduced by 10%. Increase HDL cholesterol by 5%. Ezetimibe is an example.[1],[2],[3],[4]
Cholesterol binding resins They bind bile acids in gut preventing enterohepatic circulation. Reduce LDL cholesterol by 8-15%. Cause 5-15% rise in triglyceride concentration. Cholestyramine is an example. [1],[2],[3],[4]
Fibric acid derivatives They activate peroxisome proliferator activated nuclear receptors, which controls the expression of gene products that mediate the metabolism of triglyceride and HDL . Reduce LDL cholesterol by 10-15% and triglyceride by 25-35%. HDL cholesterol increase by10-50%. Gemfibrozil is an example.[1],[2],[3],[4]
Nicotinic acid (vitamin B3) derivatives In pharmacological doses, this reduces peripheral fatty acid release with the result that cholesterol and triglyceride decline whilst HDL C increases. Reduce LDL cholesterol by 5-10%. Reduce triglycerides by 15-20%. HDL cholesterol increase by10-20%. Acimi Pox is an example. [1],[2],[3],[4]
Fatty acid compounds Reduce hepatic VLDL secretion. They reduce triglycerides in severe hypertriglyceridemia. No favourable change on other lipids. Omega-3 acid ethyl ester is an example. [1],[2],[3],[4]
Cholesteryl ester transfer protein inhibitor This is still under development drug. Anacetrapib is an example. [1],[2],[3],[4]
References
  1. The New Cholesterol Treatment Guidelines. N Engl J Med [online] 2014 May, 370(20):1957-1957 [viewed 01 July 2014] Available from: doi:10.1056/NEJMc1403438
  2. AEKPLAKORN WICHAI, TANEEPANICHSKUL SURASAK, KESSOMBOON PATTAPONG, CHONGSUVIVATWONG VIRASAKDI, PUTWATANA PANWADEE, SRITARA PIYAMITR, SANGWATANAROJ SOMKIAT, CHARIYALERTSAK SUWAT. Prevalence of Dyslipidemia and Management in the Thai Population, National Health Examination Survey IV, 2009. Journal of Lipids [online] 2014 December, 2014:1-13 [viewed 01 July 2014] Available from: doi:10.1155/2014/249584
  3. JAQUES H. NICE guideline on lipid modification. Eur Heart J [online] 2013 Feb, 34(7):481-2 [viewed 01 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23534074
  4. ANDERSON TJ, GRéGOIRE J, HEGELE RA, COUTURE P, MANCINI GB, MCPHERSON R, FRANCIS GA, POIRIER P, LAU DC, GROVER S, GENEST J JR, CARPENTIER AC, DUFOUR R, GUPTA M, WARD R, LEITER LA, LONN E, NG DS, PEARSON GJ, YATES GM, STONE JA, UR E. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol [online] 2013 Feb, 29(2):151-67 [viewed 02 July 2014] Available from: doi:10.1016/j.cjca.2012.11.032