Hypercholesterolemia Disease

BASICS

DESCRIPTION

Serum cholesterol > 200 mg/dL (5.18 mmol/L). High risk > 240 mg/dL (6.22 mmol/L)
High density lipoprotein fraction of cholesterol (HDL) - protective
Low density lipoprotein (LDL) - atherogenic
System(s) affected: Endocrine/Metabolic, Cardiovascular
Genetics: Heterozygous familial. Hypercholesterolemia, 1 in 500 cases. Autosomal dominant hypercholesterolemia 1 in 1 million.
Incidence/Prevalence in USA: 120 million people with cholesterol 200 mg/dL (5.18 mmol/L) or more, 60 million with 240 mg/dL (6.22 mmol/L) or more
Predominant age: Prevalence increases with age
Predominant sex: Male > Female

SIGNS AND SYMPTOMS

Corneal arcus before 50
Xanthomata
Xanthelasma
Arterial bruits
Claudication
Angina pectoris
Stroke
Myocardial infarction

CAUSES

Primary
- Diet
- Heredity
- Obesity
- Sedentary life-style
- Stress
Secondary
- Hypothyroidism
- Diabetes mellitus
- Nephrotic syndrome
- Obstructive liver disease
- Progestins
- Anabolic steroids
- Diuretics except indapamide (Lozol)
- Beta blockers except those with intrinsic sympathomimetic activity (ISA)
- Some immunosuppressants

RISK FACTORS

Obesity
Heredity

DIAGNOSIS

LABORATORY

High density lipoprotein fraction of cholesterol (HDL), low density lipoprotein (LDL), triglycerides must be checked fasting
Cholesterol is considered elevated if > 200 mg/dL (5.18 mmol/L)
TSH initially because hypothyroidism may cause hypercholesterolemia

Drugs that may alter lab results: Caffeine may increase cholesterol
Disorders that may alter lab results:

Hypothyroidism
Nephrotic syndrome
Obstructive liver disease

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

N/A

IMAGING

N/A

DIAGNOSTIC PROCEDURES

N/A

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient, except for complicating emergencies, e.g., myocardial infarction

GENERAL MEASURES

Requires intervention: HDL less than 35 mg/dL (0.78 mmol/L), LDL greater than 160 mg/dL (4.14 mmol/L)
Cholesterol 200-240 mg/dL (5.18-6.22 mmol/L) without coronary artery disease or two risk factors (male, smoking, HDL less than 35 mg/dL [0.91 mmol/L], severe obesity, diabetes, hypertension, strong family history) - prudent diet and recheck in one year
Cholesterol 200-240 mg/dL (5.18-6.22 mmol/L) with coronary artery disease or two or more risk factors (as above) - lipoprotein analysis with further action based on HDL and LDL
Cholesterol over 240 mg/dL (6.22 mmol/L) - lipoprotein analysis with further action based on HDL and LDL

SURGICAL MEASURES

N/A

ACTIVITY

Walking or other sustained cardiovascular exercise for 2.5 hours per week or more. Important for increasing HDL, lowering total cholesterol, and losing weight.

DIET

If not uremic, no restriction
When uremic - protein, salt, potassium restriction as needed
For stone-formers, increased oral fluids

PATIENT EDUCATION

Reduce all dietary fats. Olive oil should be preferentially used.
Increase fiber, increase intake of fruits, vegetables, whole grains, and garlic
Emphasize vegetarian, meatless, eggless, cheese-less meals, with poultry, fish, and nonfat milk or yogurt
Minimal daily alcohol use may increase HDL
Dietary adherence to low fat and cholesterol generally may be expected to result in a 10% LDL reduction
Intake of too many carbohydrates with a high glycemic index, e.g., bread, rice, pasta, potatoes, will make weight loss and cholesterol reduction more difficult

FOLLOW UP

PREVENTION/AVOIDANCE

Prudent diet, frequent exercise and weight control for all

POSSIBLE COMPLICATIONS

Coronary heart disease, cerebrovascular disease, generalized arteriosclerosis

EXPECTED COURSE AND PROGNOSIS

1% decrease in cholesterol results in 2% decreased risk of coronary heart disease
Goals:
- LDL < 160 if 0-1 risk factors
- LDL < 130 if 2 or more risk factors
- LDL < 100 if known coronary, cerebral or peripheral vascular disease, or diabetes mellitus
- Risk factors:
  - Smoking
  - Male over 45
  - Female over 55 not on hormonal replacement
  - HDL less than 35
  - Hypertension
  - MI or stroke in first degree relative under (male under 55 and female under 65)

MISCELLANEOUS

ASSOCIATED CONDITIONS

Hypertension
Obesity
Diabetes mellitus
Hypothyroidism
Coronary artery disease
Cerebrovascular disease
Peripheral vascular disease

AGE-RELATED FACTORS

Pediatric:

Screening every five years beginning as early as 12. (Childhood screening is controversial because no studies have shown a clear link between hypercholesterolemia in childhood to hypercholesterolemia in adulthood. Furthermore, the risks of reducing cholesterol in childhood are not known.)
If total cholesterol greater than 170 mg/dL (4.40 mmol/L), check HDL and LDL levels. If LDL is 110-125 mg/dL (2.85-3.24 mmol/L) = moderate risk. If LDL is greater than 125 mg/dL (3.24 mmol/L) = high risk

Geriatric: The benefit of cholesterol reduction in preventing coronary disease diminishes steadily beyond age 80
Others: N/A

PREGNANCY

Fetal nutritional demands may alter diet and drug treatment; statins contraindicated

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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