What Is Lipidemia?
Lipidemia, technically, is the presence of lipids in the blood. The term dyslipidemia is used to describe abnormalities in lipids, primarily cholesterol and triglycerides.
Hypercholesterolemia is often a genetic disease within families (“familial hypercholesterolemia”) in which there is reduced clearance of LDL-C.
Types of Dyslipidemia
Is is a simplistic notion that high-density lipoprotein cholesterol (HDL-C) is the “good” cholesterol and that low-density lipoprotein cholesterol (LDL-C) is the “bad” cholesterol. Clinical relevance in cardiovascular disease, however, follows these motifs in that low amounts of “good” HDL-C and high amounts of “bad” LDL-C, with elevations above normal of triglycerides, or in a combination of these, create increased risk for premature coronary heart disease, the most common form of cardiovascular disease (CVD).
The values determined by testing lipids in a “lipid profile” usually measures the following:
- Total cholesterol
- LDL cholesterol
- HDL cholesterol
- Non-HDL cholesterol (total cholesterol minus HDL-C)
- Triglycerides (not cholesterol, but another type of fat)
Lipid profiles are done to determine the the risk of developing the complications of cardiovascular disease, including coronary artery disease and neurological stroke.
Connection with Diabetes
Those with diabetes already have a major risk factor for cardiovascular disease and atherosclerosis. Poor glycemic control is associated with elevations in triglycerides and LDL-C levels.
How Is Lipidemia Diagnosed?
All patients over 20 years of age should have an assessment for risk of cardiovascular disease (CVD). Those with an elevated risk of having a CVD event in the next 10 years, statistically, prompt a decision to treat.
As a risk group for cardiovascular disease, any dyslipidemia is determined by lipid profiles from diabetic patients to determine their relative risk for developing complications of cardiovascular disease, including coronary artery disease and neurological stroke.
Besides determinations of their glycemic control via glucose measurements, periodic lipid tests are done that assess total cholesterol, LDL-C, HDL-C, non-HDL cholesterol (Total Cholesterol minus HDL-C), and triglycerides.
The values determined by testing lipids in a lipid profile usually measures the following:
- Total cholesterol (normal < 200)
- cholesterol (levels > 130 raise the risk for heart attacks, strokes, and other cardiovascular complications)
- HDL cholesterol (levels > 60 lower the risk of cardiovascular complications)
Alternately, HDL-C levels < 60 raise the risk of cardiovascular complications
- Non-HDL cholesterol (total cholesterol minus HDL-C; normal is <160)
- Triglycerides (another type of fat, should have a level <150; >150 raises the risk of cardiovascular disease
Elevations, especially in LDL-C and triglycerides, and/or low HDL-C, create high risk for cardiovascular events and such patients are evaluated/treated for other risk factors such as hypertension, glycemic control, peripheral artery disease, and other warning signals. The diabetic patient at higher risk due to dyslipidemia is evaluated like any high-risk cardiovascular patient, with EKGs, echocardiogram, and stress testing.
Management and Treatment of Lipidemia
With elevated levels of LDL-C, evidence has shown that lowering it results in a reduction of cardiovascular disease (CVD) events. Among these events, myocardial infarction (MI) was reduced the most, making treatment mandatory.
Treatment is based on the risk of suffering a CV event within 10 years, predicted by an assessment of the lipid panel and consideration of other risk factors.
When the normal balance of production and clearance is upset and cholesterol increases abnormally in the blood to pose a risk of CVD, statins are used to bring levels back into a normal balance. Statins lower cholesterol by reducing the production of cholesterol by the liver.
For starter therapy, one of the moderate-intensity statins is begun:
- Lovastatin (Mevacor, Altoprev), 40 mg.
- Pravastatin (Pravachol), 40 mg.
- Simvastatin (Zocor), 40 mg.
- Atorvastatin (Lipitor), 10 to 20 mg.
- Rosuvastatin (Crestor), 5 to 10 mg
When moderate intensity statins fail, high-intensity statin therapy is used:
- Atorvastatin (Lipitor), 40 to 80 mg
- Rosuvastatin (Crestor), 20 to 40 mg
Decision to Treat
Current guidelines recommend that any adults aged 40-75 without CVD but with an LDL-C between 70-189 mg/dL should be treated: treatment with moderate-intensity statin therapy is recommended for those with an estimated 10-year CVD risk between 5.0-7.5%; those with an estimated 10-year CVD risk ≥7.5% are treated with moderate-to-high intensity statin therapy.
For patients at high risk, which is the group to which diabetics belong, the LDL-C should be lowered to <100 mg/dL, or at least 50% of their baseline levels.
For very high-risk patients, LDL-C should be lowered to <70 mg/dL, or a reduction of at least 50 percent of their baseline levels.
Measuring LDL-C response to statins at the 6-week mark, followed by lipid panels yearly, is the protocol used to assess appropriate lowering of LDL-C from a treatment regimen.
Prevention of Lipidemia
Dyslipidemia–elevated LDL-C, low HDL-C, high triglycerides, and the accompanying risk of cardiovascular disease, especially in diabetics, requires treatment with statins. The relationship between dyslipidemia and cardiovascular disease (CVD) means that reducing any of the risk factors will reduce the entire risk for CVD as a group. The best strategy for preventing a risk from becoming a reality is to assess all of the risk factors and address each one–not just the dyslipidemia:
- Education: Understanding one’s risks and the possible outcomes is an important part of reducing risk. It also increases patient compliance with the treatment methods and goals.
- Diet: A nutritional assessment into caloric reduction as well as the types of different foods that contribute to dyslipidemia, obesity and the metabolic syndrome, hypertension, and poor glycemic control can be used to formulate a better diet for prevention of dyslipidemia and CVD risk.
- Smoking: If a patient is a smoker, this must stop. Counseling and even medication is available to assist in smoking cessation.
- Physical inactivity: The mutually beneficial aspects of physical exercise and diet are important. Joining an athletic club can help ensure compliance.
- Hypertension: If diet and exercise do not reduce blood pressure, there are medications that are used to do this.
- Hyperglycemia: Patients with diabetes already understand hyperglycemia and its repercussions, but they should be made aware that diabetic risk overshadows all of the other risks and why this puts them in greater danger.
Prevention of dyslipidemia can be challenging, since it often is a genetic disease. Looking at the risks collectively will address all of the risk factors globally to offer a diabetic patient the best chance of reducing the CVD risk.