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Hyperlipidemia

Brief Overview: Hyperlipidemia is a chronic metabolic condition characterized by elevated levels of lipids in the blood, most commonly low-density lipoprotein cholesterol (LDL-C), total cholesterol, triglycerides, and/or low high-density lipoprotein cholesterol (HDL-C). It is typically asymptomatic but plays a major role in the development of atherosclerotic cardiovascular disease (ASCVD), including heart attack and stroke. Management focuses on long-term cardiovascular risk reduction through lifestyle modification and medication when indicated.

Prevalence: According to Cleveland Clinic, “Hyperlipidemia is very common. Ninety-three million American adults (age 20 and older) have a total cholesterol count above the recommended limit of 200 mg/dL.”

Etiology: According to Cleveland Clinic, “Various hyperlipidemia causes include:

Risk Factors:

  • Increasing age
  • Family history of hyperlipidemia or premature ASCVD
  • Diet high in saturated fat, processed foods, or added sugars
  • Physical inactivity
  • Overweight or obesity
  • Diabetes mellitus
  • Hypertension
  • Tobacco use
  • Excess alcohol intake

Commonly Associated Conditions:

  • Coronary artery disease
  • Myocardial infarction (heart attack)
  • Stroke or transient ischemic attack (TIA)
  • Peripheral arterial disease
  • Metabolic syndrome
  • Type 2 diabetes mellitus
  • Nonalcoholic fatty liver disease (NAFLD)

Common Medications:

Medication choice depends on ASCVD risk, LDL levels, age, comorbidities, and tolerance.

  • First-line therapy:
    • Statins: atorvastatin, rosuvastatin, simvastatin, pravastatin
      • Lower LDL cholesterol and reduce cardiovascular events
    • Additional or alternative agents (selected patients):
      • Ezetimibe – reduces intestinal cholesterol absorption
      • PCSK9 inhibitors: alirocumab, evolocumab (high-risk or familial hypercholesterolemia)
      • Bempedoic acid – LDL lowering in statin-intolerant patients
      • Fibrates: fenofibrate, gemfibrozil (primarily for high triglycerides)
      • Omega-3 fatty acids: prescription EPA/DHA formulations (hypertriglyceridemia)

Common Labs, Imaging, and Tests:

  • Fasting or non-fasting lipid panel:
    • Total cholesterol, LDL-C, HDL-C, triglycerides
  • ASCVD risk calculation (10-year risk estimate)
  • Liver function tests (baseline and monitoring with statins)
  • May be indicated: High sensitivity C-reactive protein (hs-CRP0, lipoprotein (a), apolipoprotein B
  • Hemoglobin A1c or fasting glucose (metabolic risk)
  • TSH if secondary causes suspected
  • Coronary artery calcium (CAC) score (selected patients to guide therapy decisions)

Common Symptoms:

  • Usually asymptomatic
  • Rare physical findings in severe or genetic cases:
    • Xanthomas or xanthelasmas
    • Corneal arcus (younger patients)
  • Symptoms typically occur only after cardiovascular complications develop

Common Treatments:

  • Lifestyle modification (foundation of therapy)
    • Exercise, as tolerated, and approved by healthcare provider
    • Smoking cessation
    • Adequate sleep
    • Stress management
    • Healthy diet
    • Limit alcohol consumption
    • Maintain optimal body weight
  • Medication (see above)
  • Management of contributing conditions (diabetes, hypothyroidism)
  • Regular monitoring and long-term follow-up

Physical Findings:

  • Often normal physical exam
  • Possible xanthomas or xanthelasmas in severe cases
  • Signs of cardiovascular disease in advanced disease (bruits, diminished pulses)

Potential Complications and Contraindications:

  • Potential complications:
    • Atherosclerosis
    • Heart attack
    • Stroke
    • Peripheral arterial disease
    • Pancreatitis (very high triglycerides)
  • Contraindications / cautions:
    • Statins contraindicated in pregnancy
    • Monitor liver enzymes and muscle symptoms with statins
    • Drug–drug interactions (important during medication reconciliation)
    • Caution combining statins and fibrates (myopathy risk)

General Health and Lifestyle Guidance:

  • Follow a heart-healthy diet (Mediterranean or DASH-style), as recommended by healthcare provider
  • Reduce saturated fat, trans fat, and added sugars
  • Increase fiber intake (fruits, vegetables, whole grains)
  • Engage in regular aerobic physical activity, as tolerated, and as approved by healthcare provider
  • Achieve and maintain a healthy weight, as directed by healthcare provider
  • Avoid tobacco use
  • Limit alcohol intake
  • Encourage medication adherence and routine lab monitoring

Suggested Questions to Ask Patients:

  1. Have you had a recent cholesterol or lipid panel?
  2. Are you taking your cholesterol medication as prescribed?
  3. Any side effects such as muscle pain or weakness?
  4. Do you have a history of heart disease, stroke, or diabetes?
  5. What does a typical day of eating look like for you?
  6. How often do you exercise?
  7. Do you smoke or use tobacco products?

Suggested Talking Points:

  • High cholesterol usually has no symptoms, but it increases heart attack and stroke risk.
  • Statins and lifestyle changes work together to lower risk.
  • Taking medication consistently is important—even when you feel well.
  • Diet and physical activity can significantly improve cholesterol levels.
  • Lowering cholesterol is a long-term investment in heart and brain health.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.