Hyperlipidemia for PA
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Hyperlipidemia for the Physician Assistant Licensing Exam
Hyperlipidemia, or elevated blood lipid levels, is a significant risk factor for atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease and stroke. Management focuses primarily on reducing low-density lipoprotein (LDL) cholesterol to lower cardiovascular risk.
Lipoproteins and Their Roles
- Low-Density Lipoprotein (LDL): Known as “bad cholesterol,” LDL transports cholesterol to peripheral tissues, promoting plaque formation. Lowering LDL is the primary goal in managing hyperlipidemia.
- High-Density Lipoprotein (HDL): “Good cholesterol” that transports cholesterol from tissues back to the liver for excretion, providing some cardiovascular protection.
- Triglycerides (TG): High levels can increase the risk of pancreatitis and may also contribute to cardiovascular disease.
Classification of Hyperlipidemia
- Primary (Genetic) Hyperlipidemia: Genetic conditions, like familial hypercholesterolemia, cause very high LDL levels due to defective LDL receptors, increasing the risk of early ASCVD.
- Secondary (Acquired) Hyperlipidemia: Caused by lifestyle factors (e.g., high saturated fat intake, obesity) or medical conditions (e.g., diabetes, hypothyroidism, kidney disease).
Screening and Risk Assessment
- Screening: Baseline lipid panel starting at age 20 and repeated every 4–6 years in low-risk individuals; more frequent screening in high-risk patients.
- ASCVD Risk Score: A 10-year risk assessment that helps guide treatment decisions by factoring in age, sex, blood pressure, cholesterol levels, smoking status, and diabetes.
Management of Hyperlipidemia
Lifestyle Modifications
- Diet: A heart-healthy diet, such as the Mediterranean or DASH diet, focusing on low saturated fats and high fiber intake.
- Exercise: 150 minutes per week of moderate aerobic exercise can improve HDL and reduce triglycerides.
- Weight Management: Reducing weight lowers LDL and triglycerides, especially beneficial for overweight patients.
- Smoking Cessation: Improves HDL and reduces cardiovascular risk.
Pharmacologic Therapy
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Statins
- Mechanism: Inhibit cholesterol synthesis, lowering LDL and ASCVD risk.
- Intensity:
- High-Intensity: Atorvastatin (40–80 mg) and rosuvastatin (20–40 mg) for significant LDL reduction.
- Moderate-Intensity: Lower doses of atorvastatin or rosuvastatin for patients with moderate ASCVD risk.
- Side Effects: Myopathy and elevated liver enzymes; baseline liver function tests are recommended.
Ezetimibe and PCSK9 Inhibitors
- Ezetimibe: Reduces intestinal cholesterol absorption; often added to statins if LDL targets are not met.
- PCSK9 Inhibitors: Injectable antibodies that increase LDL clearance; used for familial hypercholesterolemia or high-risk patients needing further LDL reduction.
Key Points
- LDL Lowering: Primary goal in hyperlipidemia management, with statins as first-line treatment.
- Lifestyle Changes: Emphasize diet, exercise, and smoking cessation for all patients.
- Statin Therapy: High- and moderate-intensity statins are chosen based on ASCVD risk.
- Adjunctive Therapy: Ezetimibe or PCSK9 inhibitors may be added if statins alone are insufficient.
- Risk-Based Approach: The ASCVD risk score guides intensity of treatment in primary prevention.