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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