SIU School of Medicine

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Department of Internal Medicine

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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