Dyslipidemia

DYSLIPIDEMIA

Rationale

Hypercholesterolemia is a common, important, and treatable cardiovascular risk factor. Its pathophysiology is increasingly understood, diagnostic tests are readily available, and treatment modalities range from diet and exercise to a multitude of pharmacotherapies. Competency in the evaluation and management of this problem helps develop skills in rational test selection, patient education, and design of cost-effective treatment strategies. It also draws attention to the importance of community health education and nutrition.

Prerequisites

Knowledge of basic biochemistry of cholesterol and lipoprotein metabolism

Knowledge of the role of dyslipidemia in atherogenesis

Knowledge

Students should be able to define, describe and discuss:

the contribution of lipoproteins to atherogenicity and coronary heart disease (CHD) risk, including the importance of elevations in total cholesterol and LDL cholesterol, a decrease in HDL cholesterol, elevation of the ratio of total to HDL cholesterol, and Lipoprotein (a)

the classification and etiologies of primary dyslipidemias,

etiologies and underlying pathophysiology of secondary dyslipidemias

nephrotic syndrome, hypothryroidism

screening recommendations for dyslipidemias in adults

the available diagnostic studies and their use, particularly determinations of HDL, LDL and total cholesterol, as well as the need to test for other cardiovascular risk factors

the current National Cholesterol Education Program (NCEP, ATP III) guidelines for risk factor assessment, diagnosis and management of dyslipidemias

basic management of the common dyslipidemias, including diet, fiber, exercise, smoking cessation, and use of statins, resins, fibratesl, and other agents;

the risks, benefits, and expense of the various pharmacologic agents

the evolution of medical knowledge of the diagnosis and treatment of hypercholesterolemia based on landmark studies (Framingham data, MRFIT, angiographic studies, HERS trial, CARE, 4S and MIRACLE trials)

gender and age differences that affect the diagnosis, prognostic significance, and treatment of dyslipidemias

diagnosis and implications of metabolic syndrome

Skills

Students should demonstrate specific skills, including:

History-Taking Skills:History-Taking Skills: Students should be able to obtain, document, and present an age-appropriate medical history, that includes a pertinent history for diagnosis of lipid disorders and the presence of other cardiovascular risk factors, including:

family history of early cardiovascular disease

dietary fat, saturated fat, fiber, and cholesterol intake

exercise patterns

alcohol use

presence of defined risk factors (smoking, hypertension, diabetes)

presence of symptoms of angina, peripheral vascular disease, TIA and stroke

past history of established coronary artery disease, cerebral vascular disease, and other vascular disease

history of renal and/or hepatic disease

Physical Exam Skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including assessing for:

blood pressure elevation

xanthomata

atherosclerotic fundoscopic changes

carotid or femoral bruits

femoral bruits

diminished peripheral pulses

Differential Diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest primary or secondary causes of dyslipidemia.

Laboratory Interpretation: Students should be able to recommend when to order and know how to interpret the following diagnostic and laboratory tests:

lipoprotein fractions

TSH

serum glucose, BUN, creatinine, LFT’s , uric acid, CBC, urinalysis

Communication Skills: Students should be able to:

counsel a patient on dietary measures to reduce cholesterol, saturated fats, fiber selection.

counsel a patient on ways to increase exercise.

communicate the diagnosis, treatment plan, and implications of Metabolic Syndrome to patients.

address the other identified cardiovascular risk factors.

Management Skills: Students should be able to:

design a treatment plan that incorporates the NCEP recommendations, includes a program of dietary modification, exercise, attends to cost considerations, and takes into account the patient’s life-style.

monitor the patient’s response to therapy and adherence.

monitor the patient for side effects of drug therapy.

Attitudes and Professional Behaviors

Students should be able to:

appreciate the importance of encouraging patients to assume responsibility for modifying their diet and increasing their exercise level.

identify barriers that prevent patients from adhering to recommended dietary, exercise, and pharmacologic plans and assist patients in overcoming these barriers.

appreciate the difficulties and frustrations that patients and health care providers face with recommended dietary changes.

appreciate the importance of identifying and treating asymptomatic patients at high risk for CAD as aggressively as those with symptomatic disease.

Resources

Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Cholesterol in Adults (Adults Treatment Panel 111).

Clerkship Articles, Week 7:"Drug Treatment of Lipid Disorders", Robert Knopp, MD, The New England Journal of Medicine, August 12, 1999,Volume 341 Number 7, 498-511

Clerkship Seminar, “Hyperlipoproteinemia”, Stuart Frank, MD

Internal Medicine Clerkship Guide, Paauw et al, Mosby 2003, 257-264

"Low HDL Cholesterol Levels", M. Dominique Ashen, Ph.D., C.R.N.P., and Roger S. Blumenthal, M.D., N Engl J Med 2005;353:1252-60.

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