Dyslipidemia

1) Disease Description (Causes and Pathophysiology, Main Symptoms)

• Definition: Dyslipidemia refers to a condition in which blood lipid levels are abnormally high due to metabolic abnormalities of lipoproteins, which transport blood lipids (mainly cholesterol and triglycerides).
• Causes
  • Primary (genetic): Genetic predisposition, such as familial hypercholesterolemia.
  • Secondary: Hypothyroidism, chronic liver disease, nephrotic syndrome, diabetes, obesity, alcohol consumption, certain medications (e.g., diuretics, beta-blockers, antiretroviral agents, etc.), pregnancy, and others.
  • Lifestyle: Excessive intake of saturated fat and calories, lack of exercise, smoking, and others.
• Pathophysiology (summary): LDL (low-density lipoprotein) deposits in the vascular intima → macrophages ingest it, forming foam cells → lipid plaque formation → atherosclerosis and narrowing and instability of the vascular lumen → increased risk of coronary artery disease, cerebrovascular disease, and others.
• Main symptoms: Usually asymptomatic (detected through health screening). In familial forms, skin or eye findings such as xanthomas and corneal arcus may occur, or abdominal pain may develop when triglycerides are very high (with a risk of pancreatitis).

2) Treatment Methods (Standard Treatment, Medications, Procedures/Surgery, Lifestyle Management, Precautions)

• Treatment goal: Lowering LDL cholesterol is the primary goal, and the target level is determined according to the individual’s 10-year cardiovascular risk (underlying diseases, age, smoking, hypertension, diabetes, etc.). (Discuss specific targets and treatment intensity with the attending physician.)
• Lifestyle management (first-line recommendation for all patients)
  • Diet: Control total calorie intake, reduce saturated and trans fats, limit dietary cholesterol, increase dietary fiber (especially soluble fiber), and avoid excessive alcohol consumption.
  • Exercise: At least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous exercise per week is recommended.
  • Weight loss (if obese), smoking cessation, and control of blood pressure and blood glucose.
• Pharmacological treatment
  • Statins: First-line medications. Their effects in reducing LDL and preventing cardiovascular events have been confirmed. The dose and intensity are determined according to risk.
  • Ezetimibe: Used in combination with or as an alternative to a statin when the response to a statin is insufficient.
  • PCSK9 inhibitors (e.g., evolocumab, alirocumab): Additional use may be considered in high-risk groups (refractory hypercholesterolemia, familial hypercholesterolemia, etc.).
  • Fibrates: Used primarily to treat hypertriglyceridemia (especially when triglycerides are very high). When combined with a statin, the risk of muscle toxicity needs to be managed.
  • High-dose omega-3 (prescription EPA/DHA): May be used to treat hypertriglyceridemia (depending on the product and indication).
  • Bile acid sequestrants, niacin (less commonly used these days), and others: Considered in specific situations.
• Procedures/Other
  • Complications caused by atherosclerosis (such as coronary artery disease) are treated according to indications with procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG).
  • Plasma component separation (apoB apheresis) may be used to remove LDL in conditions such as homozygous familial hypercholesterolemia.
• Monitoring
  • Before treatment: Fasting lipid testing (nonfasting testing may be possible in some situations), liver function tests, and clinical history (including muscle pain, etc.).
  • Check the treatment response with lipid testing within 4–12 weeks after starting medication, and thereafter follow up every 3–12 months once stable.
  • Additional tests (such as CK) if liver enzyme elevations or muscle symptoms occur.
• Precautions
  • Some medications, including statins, are contraindicated during pregnancy and breastfeeding.
  • Check for drug interactions (e.g., the risk of myopathy when statins are used with CYP3A4 inhibitors or certain fibrates).
  • When triglycerides are very high (TG ≥ 500 mg/dL), prompt treatment is necessary because of the risk of acute pancreatitis.

3) Checkpoints Before an Outpatient Visit (Including Preparation and Example Questions)

• Items/Documents to bring
  • A list of all currently used medications, supplements, herbal medicines, and OTC products (including doses and administration times).
  • Recent blood test results (lipid tests, with fasting status indicated, blood glucose/HbA1c, liver function, etc.) or information on whether testing can be scheduled.
  • Past medical history (myocardial infarction, stroke, peripheral artery disease, etc.) and family history (especially premature cardiovascular disease and familial hypercholesterolemia).
  • Records of lifestyle habits (diet, exercise, smoking, and alcohol consumption) and notes on changes in symptoms (chest pain, shortness of breath, muscle pain, etc.).
• Examples of information to tell the doctor first during an outpatient visit
  • Whether you are currently pregnant or may become pregnant, and whether you are breastfeeding.
  • Medications recently started or discontinued.
  • New symptoms such as muscle pain, muscle weakness, or jaundice.

4) Examples of General Questions to Ask the Doctor

• "What is my LDL target? (Based on my overall cardiovascular risk)"
• "What are the expected effects of the recommended treatment (lifestyle management and medication), and when will the results be checked after starting it?"
• "What are the main side effects of this medication (e.g., a statin), and how should I respond if they occur?"
• "Are there any other medications or foods I should be cautious about while taking this medication?"
• "How much does treatment reduce my risk of cardiovascular disease?"

5) Examples of Disease-Specific Questions (1–2)

• If there is a family history or familial hypercholesterolemia is suspected due to very high LDL: "Could I have familial hypercholesterolemia? Would genetic testing (or testing of family members) be necessary?"
• If triglycerides are very high: "If my triglyceride level is 500 mg/dL or higher (or close to that level), what acute and long-term treatment is needed to prevent pancreatitis? How should hospitalization, medication (fibrates and omega-3), or dietary therapy be planned?"

Reference (Summary)

• Dyslipidemia is usually asymptomatic but increases the risk of cardiovascular disease and pancreatitis (when triglycerides are high). The key to treatment is lifestyle improvement and LDL-focused pharmacological treatment (with statins as the first choice), and it is important to set targets according to individual cardiovascular risk and undergo regular testing.