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Hyperlipidemia

Lipedema

Hyperlipidemia is a term used to describe increased levels of lipids in blood, be that in the form of cholesterol (HDL, LDL, IDL or VLDL) or triglycerides. Though not a disease itself, hyperlipidemia has the potential to predispose to several diseases.


Presentation

The most common presentation of hyperlipidemia is a cardiovascular event. Patients are typically overweight, lethargic and may have one or multiple xanthomas on their skin. They may also be suffering from other diseases like diabetes or pancreatitis. In case of homozygous familial types, presentation is often similar to that of ischemic heart disease. In heterozygous types, the patients are often asymptomatic.

There may also be tendon xanthomas, xanthelasmas (yellow coloured lesions on eyelids) and corneal arcus (gray coloured opacity on periphery of cornea). The most commonly found ophthalmologic abnormalities occurring in patients with hyperlipidemia include corneal arcus, lipemia retinalis, and xanthelasma [7]. Patients may also complain of abdominal pain, nausea, vomiting and sometimes dyspnea.

Coronary Atherosclerosis
  • atherosclerosis. remnant hyperlipidemia a form in which the accumulated lipoproteins are normally transient intermediates, chylomicron remnants, and intermediate-density lipoproteins; a generic descriptor for the type III hyperlipoproteinemia phenotype[medical-dictionary.thefreedictionary.com]
  • Definition / general Term used to denote excess of lipids, mainly cholesterol and triglycerides (TG), in the blood Strong relationship between high plasma lipids and coronary heart disease Lowering LDL and raising HDL decrease the progression of coronary[pathologyoutlines.com]
  • Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomised controlled trial. JAMA 2004 ; 291 : 1132 –4. Cannon CP, Braunwald E, McCabe CH, et al.[doi.org]
  • Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomised controlled trial. JAMA 2004; 291 :1132–4. [ PubMed ] [ Google Scholar ] 17. Cannon CP, Braunwald E, McCabe CH, et al.[ncbi.nlm.nih.gov]
Splenectomy
  • Long-term follow-up (37 years) of the first patient revealed hypothyroidism at diagnosis requiring thyroxine replacement, palmar xanthomas requiring surgical removal, splenomegaly requiring splenectomy, 18 episodes of pancreatitis and premature coronary[dx.doi.org]
Noncompliance
  • Overestimation of the actual ingested dosage may occur due to some degree of noncompliance. Furthermore, in this study, the dosage, total treatment length, and comparison of the effects of different kinds of statins use were not available.[journals.plos.org]
Poor Feeding
  • Poor feeding, lethargy, hyperglycemia, and hyperlipidemia were resolved with the normalization of triglyceride level. References Raupp P, Keenan C, Dowman M, Nath R, Hertecant J.[web.archive.org]
Lipemia Retinalis
  • The most commonly found ophthalmologic abnormalities occurring in patients with hyperlipidemia include corneal arcus, lipemia retinalis, and xanthelasma. Patients may also complain of abdominal pain, nausea, vomiting and sometimes dyspnea.[symptoma.com]
  • Complications include retinal vein occlusion, acute pancreatitis, steatosis, and organomegaly, and lipemia retinalis.[en.wikipedia.org]
Stroke
  • CONCLUSIONS: Preexisting hyperlipidemia is an independent predictor of new-onset AD in patients with tSCI, especially in those who are younger, male, have a higher CCI score, and have stroke. Copyright 2017 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • Hyperlipidemia (High levels of lipids in the blood) is one of the main risk factors for coronary heart disease and stroke. Hyperlipidemia (high levels of lipids in the blood) is one of the main risk factors for coronary heart disease and stroke.[healthhub.sg]
  • Left untreated, hypercholesterolemia can eventually lead to a heart attack due to CHD or a stroke due to narrowed arteries supplying the brain.[healthcommunities.com]
  • Other risk factors Family history of early stroke or heart disease Complications Heart disease – angina and heart attack Stroke and transient ischemic attack Peripheral arterial disease Diagnosis A blood test called the serum lipid profile measures the[news-medical.net]

Workup

Laboratory tests

  • Complete blood count
  • Complete lipid panel
  • Resting and fasting blood sugar levels
  • Thyroid function tests
  • Renal function tests

Imaging 

Test results

All potential underlying diseases should be tested and methodically excluded with the help of history and laboratory tests. The elevated lipids should be checked with the help of a lipid analysis and imaging studies should be conducted to reveal the extent of damage to the vasculature and other organs.

Hypercholesterolemia
  • One is associated with a deficiency of δ-aminoadipic semialdehyde synthase. hyperlipidemia /hy·per·lip·id·emia/ ( -lip″ĭ-de me-ah ) elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia[medical-dictionary.thefreedictionary.com]
  • (p CONCLUSION: The prevalence of hypercholesterolemia and hyperglycemia were increased significantly from 2009 to 2016.[ncbi.nlm.nih.gov]
  • Hyperlipidemias are also classified according to which types of lipids are elevated, that is hypercholesterolemia, hypertriglyceridemia or both in combined hyperlipidemia.[en.wikipedia.org]
Hypertriglyceridemia
  • Abstract Fasting hypertriglyceridemia is positively associated with the morbidity of coronary heart disease (CHD), and postprandial (non-fasting) hypertriglyceridemia is also correlated with the risk status for CHD, which is related to the increase in[ncbi.nlm.nih.gov]
  • One is associated with a deficiency of δ-aminoadipic semialdehyde synthase. hyperlipidemia /hy·per·lip·id·emia/ ( -lip″ĭ-de me-ah ) elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia[medical-dictionary.thefreedictionary.com]
Lactescent Serum
  • He had a lactescent serum and hypertriglyceridemia. Lethargy, hepatomegaly, and hyperglycemia increased with time. Increasing hyperglycemia in spite of having insulin therapy indicated the existence of insulin-resistant diabetes type.[web.archive.org]
Lactescent Serum
  • He had a lactescent serum and hypertriglyceridemia. Lethargy, hepatomegaly, and hyperglycemia increased with time. Increasing hyperglycemia in spite of having insulin therapy indicated the existence of insulin-resistant diabetes type.[web.archive.org]
Liver Biopsy
  • The liver biopsy at one month showed massive steatosis. Poor feeding, lethargy, hyperglycemia, and hyperlipidemia were resolved with the normalization of triglyceride level. References Raupp P, Keenan C, Dowman M, Nath R, Hertecant J.[web.archive.org]

Treatment

Primary medication used to effectively treat the condition is statins. Statins are a class of drugs that lower circulating cholesterol levels by inhibiting HMG-CoA reductase , which is the rate-limiting enzyme in hepatic cholesterol biosynthesis [8]. Other drugs include fibrates, to control high triglyceride levels, bile resins and sequestrants for hypercholesterolemia, and niacin. Lipid apheresis may also be used to treat patients with severe hyperlipidemia by reducing low-density lipoprotein cholesterol (LDL-C) levels [9]. The parallel mode of treatment includes lifestyle modifications and a carefully controlled diet.

Prognosis

Prognosis depends heavily on management. If the hyperlipidemia, be it familial or secondary, is appropriately managed with drugs, appropriate diet and lifestyle modifications, the prognosis is fairly positive. However, if the condition is not managed, there is a negative prognosis and a high rate of mortality. Epidemiologic studies found a direct relationship between the total cholesterol levels and risk of coronary disease [6]. Indeed the high mortality can be attributed to cardiovascular diseases.

Etiology

Hyperlipidemia may be primary [1], for example familial hyperlipidemia (FH), or secondary meaning it occurs as a consequence of other diseases that disturb lipid metabolism [2], for example diabetes mellitus. Hyperlipidemia in association with insulin resistance is a common occurrence in patients suffering from diabetes mellitus type II (DM 2) [2].

In case of FH, the causative factors are inherited mutations in genes like APOB, APOC2 etc, deficiency of the lipoprotein lipase enzyme (LPL) or disturbed functioning of LDL receptors. Acquired hyperlipidemias are caused by diseases that interfere with lipid metabolism and uptake into cells.

Epidemiology

Incidence

CDC conducted a survey of the prevalence of hyperlipidemia with respect to body mass index (BMI) between 1999 and 2006 and it reported a prevalence of 14.2% in normal weight individuals, 22.3% in overweight individuals and 42.9% in the obese [3].

Age

Hyperlipidemia may present in the youth in familial cases but non-familial cases usually present much later in life.

Sex

Hyperlipidemia tends to be slightly more common in men than women.

Sex distribution
Age distribution

Pathophysiology

Primary hyperlipidemias can be classified on the basis of the type of elevated lipoproteins found in the blood, using the Fredrickson criteria [4]:

  • Type I hyperlipoproteinemia: It is of three subtypes: A, b and c. All three result in elevation of chylomicrons in the blood. It is a rare type of hyperlipidemia with an incidence of only 1 out of 1000,000 births and can be easily managed with a controlled diet and regular exercise.
  • Type II hyperlipoproteinemia: It is of two subtypes: Type IIa has increased levels of LDL and Type IIb has elevated LDL as well as VLDL. It is much more common with an incidence of 1 out of 500 births for Type IIa and 1 out of 100 births for TYPE IIb.
  • Type III hyperlipoproteinemia: It has no subtype. It results in elevated IDL in blood and occurs in 1 out of 10,000 births.
  • Type IV hyperlipoproteinemia: It is an autosomal-dominant condition that results in increased levels of VLDL in the blood and is estimated to occur in 1 out of 10,000 births (approximately 1% of the population) [5].
  • Type V hyperlipoproteinemia: It is a rare type which results in elevated chylomicrons and VLDL in the blood.

Secondary hyperlipidemias or acquired hyperlipidemias are a consequence of underlying disease such as hypothyroidism, renal failure, excessive intake of alcohol, diabetes, metabolic syndrome or chronic pancreatitis. The elevated lipids are either a consequence of direct damage to the liver, and thus the lipid metabolism, or due to nonenzymatic glycosylation of blood vessel as in diabetes, pancreatitis due to alcoholism or high absorption from the gut due to increased intake as in obese individuals.

Prevention

Hyperlipidemia can easily be prevented by exhibiting a healthy lifestyle. Good cholesterol (HDL) should be kept elevated and bad cholesterol (LDL) should be kept in reduced limits. Exercise and moderate consumption of ethanol raise HDL levels, whereas obesity and smoking lower it [10]. So a healthy lifestyle demonstrated by regular exercise, controlled diet and avoiding smoking and excessive alcohol can go a long way in both preventing the occurrence of, as well as the progress of hyperlipidemia.

Summary

Hyperlipidemia is a disorder of increased lipid or lipoprotein levels and is the most common form of dyslipidemia. Lipids are a group of biological organic compounds that are insoluble in water but soluble in organic solvents. For the purpose of adhering strictly to the human body and the phenomenon of hyperlipidemia, lipids are classified into 6 types. They are: High density lipids (HDL), low density lipids (LDL), Intermediate density lipids (IDL), very low density lipids (VLDL), triglycerides and cholesterol. If any one or more of these types become abnormally elevated in the blood, it is known as hyperlipidemia.

Patient Information

Definition

Hyperlipidemia is a group of conditions where there is an abnormally increased level of lipids (fats) in the blood.

Cause

It can be genetic, known as primary or familial hyperlipidemia due to inherited mutations or it can be acquired; as a consequence of an extravagant lifestyle or underlying disease.

Signs and symptoms

It may be asymptomatic initially and typically presents late in the form of a cardiovascular event. Infants may present with signs similar to ischemic heart disease and small raised yellow coloured lesions on the skin (xanthomas). Adults may also have xanthomas either on the skin or in their tendons.

Diagnosis

Diagnosis is based on excluding or identifying underlying disease, and measuring lipid levels in the blood. A detailed history also helps in diagnosing familial types.

Treatment

Treatment includes dietery and lifestyle modifications and drugs.

References

Article

  1. Chait A, Brunzell JD. Acquired hyperlipidemia (secondary dyslipoproteinemias). Endocrinol. Metab. Clin. North Am. June 1990, 19 (2): 259–78. PMID 2192873.
  2. Zavaroni I, Dall'Aglio E, Alpi O, et al. Evidence for an independent relationship between plasma insulin and concentration of high density lipoprotein cholesterol and triglyceride. Atherosclerosis 1985; 55:259.
  3. Centers for Disease Control and Prevention. Prevalence of abnormal lipid levels among youths: United States, 1999–2006. MMWR Morb Mortal Wkly Rep. 2010;59:29–33.
  4. Fredrickson DS, Lees RS. A system for phenotyping hyperlipoproteinemia (PDF). Circulation, 1965, 31 (3): 321–7.
  5. Boman H, Hazzard WR, AlbersJJ, et al. Frequency of monogenic forms of hyperlipidemia in a normal population. Am J ttum Genet 27:19A,1975. 
  6. Wallis EJ, Ramsay LE, Ul Haq I, et al. Coronary and cardiovascular risk estimation for primary prevention: validation of a new Sheffield table in the 1995 Scottish health survey population. BMJ 2000; 320:671.
  7. Wu CW, Lin PY, Liu YF, Liu TC, Lin MW, Chen WM, et al. Central corneal mosaic opacities in Schnyder's crystalline dystrophy. Ophthalmology. Apr 2005;112(4):650-3
  8. Glassberg H, Rader D. Management of lipids in the prevention of cardiovascular events. Annu Rev Med 59:79-94, 2008
  9. Lui M, Garberich R, Strauss C, Davin T, Knickelbine T. Usefulness of lipid apheresis in the treatment of familial hypercholesterolemia. J Lipids. 2014;2014:864317. 
  10. Ridker P, Libby P. Risk factors for atherothrombotic disease. In Zipes D, et al (eds). Braunwald’s Heart Disease, 7th ed. Philadelphia, ElsevierSaunders, 2005, p 939. 

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Last updated: 2019-07-11 22:04