DYSLIPIDEMIA   17A

A 47-year-old man presents to his primary care provider for a routine checkup. The patient denies any symptoms but is worried about his weight and diet, which consists of many saturated fats. On physical examination, his blood pressure is 153/102 mm Hg, and his body habitus reveals a large amount of abdominal obesity. Blood tests reveal a serum triglyceride level of 321 mg/dL, high-density lipoprotein (HDL) cholesterol level of 24 mg/dL, low-density lipoprotein (LDL) of 132 mg/dL, and hemoglobin A_1c of 6.2%.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Obese man; large waist circumference; elevated blood pressure; elevated serum triglyceride level; low HDL cholesterol level; insulin resistance consistent with the metabolic syndrome

How to think through: Serum LDL and HDL cholesterol, along with triglycerides, are important markers of risk for coronary artery disease (CAD). Elevated LDL cholesterol is associated with increased CAD, and LDL is the primary target of lipid-lowering therapies. This patient has a different, but equally important, pattern of dyslipidemia: low HDL and elevated triglycerides. The degree to which these abnormalities are independent predictors of CAD is debated because they so often travel with other metabolic abnormalities, collectively termed the metabolic syndrome. What are the elements of this syndrome? What other secondary causes of hypertriglyceridemia should be considered? (Alcohol abuse, hypothyroidism, nephrotic syndrome, familial disorders of triglyceride metabolism, and medications [e.g., corticosteroids].) What is an important complication of elevated triglycerides, and is this patient likely to experience this complication? (Pancreatitis, which typically occurs with levels greater than 2000 mg/dL.) Should he receive targeted therapy to lower his triglycerides? (Not necessarily.) Weight loss and reduction of CAD risk factors known to improve outcomes is the primary treatment strategy for dyslipidemia. The first interventions should be diet, exercise, blood pressure control, and a statin medication. Targeted triglyceride-lowering therapies are recommended for patients with levels above 500 mg/dL. What medications lower triglycerides? (Fibric acid derivatives [e.g., gemfibrozil, fenofibrate].) What downside might there be to prescribing nicotinic acid for this patient? (Worsened glucose intolerance.)

DYSLIPIDEMIA   17B

What are the essentials of diagnosis and general considerations regarding dyslipidemia?

Essentials of Diagnosis

Elevated serum total cholesterol or LDL cholesterol, low serum HDL cholesterol, or elevated serum triglycerides

In severe cases associated with metabolic abnormalities, superficial lipid deposition occurs

General Considerations

Cholesterol and triglycerides are the two main circulating lipids.

Elevated levels of LDL cholesterol are associated with increased risk of atherosclerotic heart disease; high level of HDL cholesterol are associated with a lower risk.

Familial genetic disorders are an uncommon, but often lethal, cause of elevated cholesterol.

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