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Tony Suhartono
TRIAD LIPID
Kol-total/ kol-LDL
Trigliserid (TG)
Kol-HDL.
Lipemia is normal , however dyslipidemia is abnormal. We need lipid for
normal body metabolism ? There are several kinds of lipids. Lipids are
hydrophobic therefore its must be transferred in a hydrophilic form as
lipoprotein 11
Bile Acids
Dietary + LIVER
Cholesterol 7 LDL
Fat
2 Apo, B-100
1
Endogenous
Cholesterol
INTESTINES EXTRAHEPATIC
10 TISSUES
3 5
NASCENT HDL
LPL LPL
4 6
HDL3
LDL
REMNANTS VLDL 8 9
CHYLOMICRONS Apo E, B-100
Apo E, B-48 Apo E, C-II, LCAT HTGL
Apo E, C-II, B-48 B-100
Cholest
AA
FA
Vessel wall
P,
glycerol
Digestion and metabolism of dietary fat
Endogenous Pathway of Lipid
Metabolism
HDL metabolism and reverse cholesterol transport
Mechanism of reverse
cholesterol transport
Esterified
cholesterol
Liver
Hepatic
Free catabolism
cholesterol Apo A-I
HDL
CETP
ABC-1
receptor Free
cholesterol VLDL
Apo A-II
Peripheral cell
Cholesterol
efflux
pre -HDL
HDL formation
Apo-CII and Apo E obtained from HDL by CMC and VLDL for
activation of LPL and receptor recognition respectively
LDL Oxidation and Atherosclerosis
Mechanism of Atherogenic
Dyslipidemia
Insulin resistance
Increased
increased NEFA and VLDL
glucose flux to liver
IR impairs
LDLR
Insulin resistance
Insulin
and decreased FCHL
resistance
apo-B and DM II
degradation decreased
LPL Metabolic
syndrome
Increased Atherogenicity of Small
Dense LDL
Direct Association Indirect Association
Longer residence time in Inverse relationship with HDL
plasma than normal sized LDL Marker for atherogenic TG
due to decreased recognition remnant accumulation
by receptors in liver Insulin resistance
Enhanced interaction with
scavenger receptor promoting
foam cell formation
More susceptible to oxidation
due to decreased antioxidants
in the core
Enter and attach more easily
to arterial wall
Endothelial cell dysfunction
High Density Lipoprotein and
Atherosclerosis
Reverse cholesterol transport
HMG-CoA
HMG-CoA X Statin
reductase
Mevalonate
Squalene
Geranylgeranyl-PP
Oxydative stress
Liao JK J Clin Invest 2002; 110:285-288
HMG-CoA Reductase Inhibitors
RhoA
MMPS hs-CRP
Adhesion molecules ROS NO
TF
Platelet Thrombotic Plaque Vascular SMC Endothelial SMC
Vasoconstriction
activation effect stability inflammation hypertrophy dysfunction proliferation
Atherosclerosis Hypertension
Cardiovascular
disease
- - 10 20 20 40 22 27
- 10 20 40 40 80 * 27 34
5 20 40 80 160 # 32 41
10 40 80 37 48
20 80 42 55
40 49 62
80 54 65
LDL-C low density lipoprotein TC=total cholesterol, 80mg XL formulation 2x80mg XL not yet approved
Comparable Efficacy of Statins
Special considerations:
No renal dosing: Atorvastatin and Fluvastatin
Use in chronic liver disease: pravastatin or rosuvastatin
Less drug interactions: pravastatin, fluvastatin, rosuvastatin
(not metabolized via CYP3A4)
Less muscle toxicity: Pravastatin and Fluvastatin
Cost-effectiveness: Rosuvastatin, atorvastatin, fluvastatin
Evidence in Primary Prevention
Name of Study Design Outcome
West of Scotland 6595 men 31 % risk reduction in
Coronary Prevention Mean TC 272; LDL>155 coronary deaths and
Study (WOSCOPS) diet + placebo nonfatal MI
Diet + pravastatin Benefit >treating mild
HTN but 3 x less than
that in 4S study
Air Force/Texas Coronary 5614 Men; 991 women 37 % risk reduction in
Atherosclerosis 45-73 y.o. coronary events
Prevention Study mean TC 221; LDL 150
(130-190)
Diet + placebo
Diet + lovastatin
Evidence in Secondary Prevention
Name of Study Design Outcome
Agents
Gemfibrozil- 600 mg po BID (11% raise in HDL). Modest LDL reduction but little effect in
combined hyperlipidemia. Can increase LDL in pure hypertriglyderidemia
Fenofibrate 200 mg capsules or iii caps 67 mg qd (renal dosing and can decrease Cyclosporin
levels). Better for LDL lowering
Side effects
Gallstone formation
Dyspepsia, diarrhea, nausea, vomiting, abdominal pain, eczema, rash, vertigo and myalgias
Available agents
Cholestyramine 8 grams/day. 24-30 grams/day can lower LDL up to 24%
Colestipol 10 grams/day
Colesevelam 1.5-4.5 grams/d
Adverse effects
Usually limit use
Mainly GI (nausea, bloating, cramping)- least problematic with colesevelam
Increased liver enzymes
Also drug interactions (impair absorption)
Digoxin, warfarin, and fat soluble vitamins (give one hour before or 4 hours after bile
acid sequestrant)
Contraindications: pts with elevated TG
Nicotinic Acid
Mechanism of Action
Inhibits hepatic VLDL production and its metabolite LDL
Raises HDL by reducing lipid transfer of cholesterol from HDL to VLDL and by delaying HDL
clearance
Increase in LDL size
Reduction in plasma fibrinogen levels
Side effects
Flushing (less common with controlled release) minimized with ASA 30 minutes before and
limited in 7-10 days
Nausea, paresthesias, pruritis (20% each)
Elevation of hepatocellular enzymes and possible hepatotoxicity, jaundice and fulminant
hepatitis (generally less common with Niaspan and crystalline niacin)
Insulin resistance and worsening hyperglycemia (less with crystalline Niaspan)
Hyperuricemia (AVOID IF H/O GOUT)
Hypotension in combination with other vasodialtors (can increase unstable angina)
NICOTINIC PERIPHERAL
ADIPOCYTE TISSUES
ACID
* Cholesterol
TG
HDL
HSL
Mechanisms of action of nicotinic acid on lipoprotein physiology. Nicotinic acid inhibits hepatic TG synthesis at the
level of fatty acid synthesis and esterification of diglyceride. Nicotinic acid also blocks apoAI-containing HDL
holoparticle uptake at the liver without altering the transport of cholesterol from HDL to the liver by way of SRB1.
Finally, nicotinic acid acutely inhibits adipocyte lipolysis, but the significance of this effect on lipoprotein physiology
is unclear. B100, apoprotein B100; CoA, coenzyme A; DG, diglyceride; HSL, hormone sensitive lipase; PL,
phospholipid. (Meyers. EMCNA 33 (2004):561)
Ezetimibe
(Zettia)
Mechanism:
impairs dietary and biliary cholesterol absorption at the brush border of the
intestines without affecting TG or fat-soluble vitamins
possible Niemann-Pick C1 like protein involved in cholesterol transport
LDL decrease 15-20%
Trivial effects on HDL and TG
Also adjunctive therapy to statins but same effect with higher dose of statin as in one
study 10 zettia and 10 atorvastatin same effect as 80 atorvastatin
Indications
Avoiding high doses of statins
Very high LDL (FCH) not sufficiently controlled on statins
Adverse effects
Only 20% absorption so lower side-effect profile
Higher incidence of myopathy and elevated transaminases when coadministered
with a statin
Exercise
In a prospective study of 111 sedentary men and women with dyslipidemia
randomized to different levels of exercise, decrease in VLDL TG and increase in
LDL size observed. Increase in HDL and size and largest effect on LDL seen with
high amount high intensity exercise
Mechanisms of benefit: reduction in CETP, elevation in LCAT, reduced hepatic
lipase and elevated LPL activity
Possible effect on LDL particle size
Moderate intensity exercise (3-4 mi/hr) for 30 minutes on most days of the week
Diet Supplements
Fish Oil (source of omega-3 polyunsaturated fatty acids)
Salmon, flaxseed, canola oil, soybean oil and nuts
At high doses > 6 grams/day reduces TG by inhibition of VLDL-TG synthesis and
apolipoprotein B
Possibly decreases small LDL (by inhibiting CETP)
Several studies have shown lower risk of coronary events
2 servings of fish/week recommended??
Pharmacologic use restricted to refractory hypertriglyceridemia
Number of undesirable side effects (mainly GI)
Soy
Source of phytoestrogens inhibiting LDL oxidation
25-50 grams/day reduce LDL by 4-8%
Effectiveness in postmenopausal women is questionable
Garlic
Mixed results of clinical trials
In combination with fish oil and large doses (900-7.2 grams/d), decreases in LDL observed
Cholesterol-lowering Margarines
Benecol and Take Control containing plant sterols and stanols
Inhibit cholesterol absorption but also promote hepatic cholesterol synthesis
10-20% reduction in LDL and TC however no outcome studies
AHA recommends use only in hypercholesterolemia pts or those with a cardiac event
requiring LDL treatment
Other agents include soluble fiber, nuts (esp. walnuts), green tea
Overall a combination diet with multiple cholesterol-lowering agents causes much more significant
LDL reductions
Measurement of Lipoproteins
Lipoprotein analysis 12-14 hours fasting
TC and HDL-C can be measured fasting or non-fasting
LDL-Cholesterol = Total cholesterol VLDL (1/5 TG)-HDL (Friedewalls)
Validity depends on TG <400 mg/dL
Measured directly if patients have profound hypertrig
Errors in TC, HDL, and TG can affect values
Non-HDL cholesterol= TC HDL-C
All cholesterol in atherogenic lipoproteins incl LDL, Lipoprotein (a), IDL, VLDL
Acute phase response (i.e. MI, surgical trauma or infection)
Can reduce levels of TC, HDL, LDL, apo A+B through impairment of hepatic
lipoprotein production and metabolism
Raise Lpa and TG
Lipoprotein analysis should be done as outpatient one month after event
Screening Recommendations
Adult Treatment Panel III (NCEP)
Fasting lipid profile at least once q 5 years for all
persons 20 y.o. or older
If non-fasting obtained and TC >200 or HDL <40, f/u
panel recommended
If no known CHD and serum LDL <160 (0-1 risk
factors) or LDL <130 (2 or more risk factors) then re-
screen in 5 years
Borderline high cholesterol and <2 risk factors, re-
screen in 1-2 years
Risk Assessment
CHD equivalents:
Symptomatic carotid artery disease
Peripheral arterial disease
AAA
DM
Multiple risk factors that confer a 10-year risk of CHD > 20%
Identify major risk factors other than LDL:
Smoking
HTN BP >140/90 or on anti-hypertensive medication
Low HDL <40 mg/dL
Family history premature CHD (CHD in men 1st degree relative <55;
women <65 y.o.)
Age (men > or =45; women >or =55)
Other potential risk factors
Chronic renal insufficiency (Cr > 1.5 mg/dL OR GFR <60 cc/min) per
Up-To-Date
Obesity, physical inactivity, impaired fasting glucose, markers for
inflammation
HDL > 60 mg/dL is a negative risk factor
If patient without CHD or equivalent has 2 or more major risk factors, then
calculate the Framingham risk (age,TC,HDL,smoking,SBP)
New Guidelines for LDL Goal
Risk category Goal LDL (mg/Dl)
CHD (CHD risk equivalent) <100
<70 optional
Apolipoprotein measurement
Apo B/ Apo A-I found to be a better predictor of events than LDL and total/HDL in AMORIS
study; best predictor of events on statins in AFCAPS/TexCAPS study
<0.7 considered target in Canadian guidelines
Most useful in the hypertriglyceridemic patient (elevated apoB levels)
Not universally available and much more expensive
Needs more cost-benefit analysis before routine use
May be useful for determining the efficacy of novel therapies
Hs-CRP
Intensity of atherosclerotic process
Recommendation of AHA, should be measured in the patient with intermediate Framingham
risk (10-20%) with LDL below the cutoff point for tx
Would not add much to those already at high risk
questionable correlation with LDL levels
Investigational Issues
To what extent should plasma levels of LDL-C be
lowered by therapy to afford optimal risk reduction?
Can risk assessment be improved by using novel risk
measures (such as hs-CRP) to indicate patients at higher
risk who may benefit from more aggressive intervention?
Should the metabolic syndrome be considered a high risk
state warranting aggressive intervention irrespective of
risk categorization using current scoring methods?
Awaiting prospective trials investigating the preventive
benefits of lipid-altering treatment in metabolic
syndrome (COMETS trial)
Laki-laki 45 tahun. TB 170 cm BB 87 kg
(BMI=30). Tensi 140/80 m Hg. Cor &
pulmo dbn. Laboratorium: Glukosa darah
puasa 286 mg/dl. Glukosa darah 2 jam
post prandial 359. A1C 10,1%. Kolesterol
210 mg/dl. HDL 30 mg/dl. LDL 155 mg/dl.
TG 596 mg/dl. Riwayat DM 16 tahun.
Riwayat stroke (hemiparesis dextra) 8
bulan yang lalu.
a. diagnosis?
b. tata laksana.
Gadis 27 tahun. Oedem anasarka. TB 155
cm. BB: 60 kg. BMI 25 kg/m2. Tensi:
130/80 mmHg. Protein total 6,3 gr%.
Albumin 2,8 gr%. Kolesterol 320 mg/dl.
HDL 50 mg/dl. LDL 170 mg/dl. TG 150
mg/dl. Urin: protein +4. Riwayat
kolesterol tinggi pada orang tuanya.
a. diagnosis
b. tata laksana.
References
Management of atherogenic dyslipidemia of the metabolic syndrome: evolving rationale for
combined drug therapy. Endocrinology and Metabolism Clinics of North America 33 (2004) 525-
544
Obesity and dyslipidemia. Endocrinology and Metabolism Clinics of North America 32 (2003) 855-
867
Management of Metabolic Sydrome: statins. Endocrinology and Metabolism Clinics of North
America 33 (2004) 509-523
Emerging therapeutic strategies for the management of dyslipidemia in patients with the
metabolic syndrome. The American Journal of Cardiology June 3, 2004
Past, Present and Future Standards for Management of Dyslipidemia. The American Journal of
Medicine March 22, 2004
Cardiovascular Endocrinology: Special Features. Medical Management of
Hyperlipidemia/Dyslipidemia. Journal of Clinical Endocrinology and Metabolism, June 2003
Effects of Lipid-Altering Treatment in DM and the Metabolic Syndrome. American Journal of
Cardiology June 3, 2004
Statins as the cornerstone of drug therapy for dyslipidemia: Monotherapy and combination
therapy options
Use of combination Therapy for Dyslipidemia: A Lipid Clinic Approach
Clinical relevance of the biochemical, metabolic, and genetic factors that influence low-density
lipoprotein heterogenity. The American Journal of Cardiology October 2002
Up-To-Date
Emerging Lipoprotein Goal
Trials
Validation study
found Framingham
CHD predictor
worked well in
white and black
population but
overestimated risk
in Japanese
American,
Hispanic men and
native American
women and other
studies have
shown possible
overestimation in
European and
Asian populations
Cholesterol efflux and reverse cholesterol
transport is modulated by two receptors
Atherogenicity of small dense LDL