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LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Identify the common types of lipid disorders.

  2. Identify the statin-benefit groups and intensity of statin therapy according to the American College of Cardiology/American Heart Association.

  3. Recommend appropriate therapeutic lifestyle changes (TLC) and pharmacotherapy interventions for dyslipidemia.

  4. Determine a patient’s atherosclerotic cardiovascular disease risk and corresponding treatment goals according to the National Lipid Association, American Association of Clinical Endocrinologist/American College of Endocrinology, and American College of Cardiology.

  5. Identify patients who are indicated for nonstatin therapy according to the American College of Cardiology.

  6. Describe components of a monitoring plan to assess effectiveness and adverse effects of pharmacotherapy for dyslipidemias.

  7. Educate patients about the disease state, appropriate TLC, and drug therapy required for effective treatment.

INTRODUCTION

Image not available. Hypercholesterolemia or dyslipidemia play a major role in atherosclerosis and plaque formation leading to coronary heart disease (CHD) as well as other forms of atherosclerotic cardiovascular disease (ASCVD), such as carotid and peripheral artery disease.1 CHD is the leading cause of death in adults in the United States and most industrialized nations. It is also the chief cause of premature, permanent disability in the US workforce.

EPIDEMIOLOGY AND ETIOLOGY

It is estimated that 94.6 million US adults have high cholesterol with a value of 200 mg/dL (5.17 mmol/L) or greater.2 Further, one out of every three US adults has a high level of low-density lipoprotein (LDL) cholesterol.2 Elevated cholesterol values are a major risk factor for the development of ASCVD. Annually, approximately 580,000 Americans experience a new heart attack and 210,000 will have a recurrent event.2 Lowering cholesterol reduces atherosclerotic progression and mortality from CHD and stroke. The development of CHD is a lifelong process. Except in rare cases of severely elevated serum cholesterol levels, years of poor dietary habits, sedentary lifestyle, and life-habit risk factors (eg, smoking, overweight/obesity) contribute to the development of atherosclerosis.3

PATHOPHYSIOLOGY

Cholesterol and Lipoprotein Metabolism

Cholesterol, an essential substance manufactured by most cells in the body, is used to maintain cell wall integrity and for the biosynthesis of bile acids and steroid hormones. Cholesterol, triglycerides, and phospholipids circulate in the blood as lipoproteins (Figure 12–1). The major lipoproteins are chylomicrons, very low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL), LDL, and high-density lipoprotein (HDL). Each lipoprotein has various proteins called apolipoproteins (Apos) embedded on the surface (Figure 12–1) that serve four main purposes: (a) required for assembly and secretion of lipoproteins; (b) serve as major structural components of lipoproteins; (c) act as ligands for binding to receptors on cell surfaces; and (d) can be cofactors for inhibition of enzymes involved in the breakdown of triglycerides from chylomicrons and VLDL.4

FIGURE 12–1.

Lipoprotein structure. Lipoproteins are a diverse group of particles with varying size and ...

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