Clin Med- Cardiology

Dyslipidemia

Abnormal levels of lipids (fats) in the blood that are divided on the basis of density

• HDL: good, more the better, (transport; most dense)

• LDL: bad, want less (less dense; triglyceride component)

• VLDL: bad, want less (least dense; triglyceride transport)

• Total cholesterol: HDL+LDL+VLDL

• Lipoprotein (a): key role in development of atherosclerosis (LDL-C)

Niacin

dyslipidemia medication that should be discontinued in all patients

HDL

• Good cholesterol 

• >40 mg/dL in men, >50 mg/dL in women

• Low HDL: insulin resistance, obesity, smoking, high carbs, drugs, decreased physical activity

• High HDL, low risk of coronary heart disease

LDL

• bad cholesterol

• Low LDL will decrease rate of MI, stroke, angina and need for CABG

• Primary prevention: decrease risk with reduction of LDL-C

• Secondary prevention: prevents future additional occurrences 

Triglycerides in the blood should be

<150 mg/dL

• diet and exercise (lifestyle) are key

Secondary causes of dyslipidemia

Alcohol use, diabetes, pancreatic and liver disease, hyper/hypothyroidism, drugs

Signs and symptoms of dyslipidemia 

• Most are non-specific and caught on routine lab screening

• >1000 mg/dL in triglyceride/VLDL- eruptive xanthomas (red-yellow papules on buttocks)

• High LDL- tendinous xanthomas (Achilles, patella, back of hand)

• Lipidemia retinalis (cream colored blood vessels in the fundus)

Screening for dyslipidemia should start

at 20 years old and continue once a year

Dyslipidemia Dx

Labs (lipid panel/profile)

Dyslipidemia Tx

1. Raise HDLs, improve diet, increase exercise (lifestyle changes)

2. If does not improve, go med route

   1. Statins (atorvastatin, fluvastatin), Ezetimibe (Zetia), PCSK9 inhibitors (Repatha, Praluent), Omega-3-fatty acids, Bempedoic acid (nexletol)

Pericarditis

Inflammation of the pericardial lining

• Acute: 2/4 criteria (chest pain, pericardial friction rub, ST changes, new or worsening effusion) and symptoms less than 4-6 weeks

• Incessant: Longer than 4-6 weeks, none at 3 months, no interruption

• Recurrent: longer than 4-6 weeks, has interruptions

• Chronic: lasting longer than 3 months, no breaks

Acute pericarditis

less than 2 weeks, inflammation of the pericardium

• Risks: idiopathic, infection, surgery, CT disease, radiation, pericardial injury. myxedema

• Infectious

  • Viral: coxsackie, echo, influenza, EBV, varicella, hepatitis, mumps, HIV, COVID

• Males <50 yo

• Bacterial: rare (TB)

• Uremic, neoplastic, post MI (Dressler syndrome), radiation, CT disease, drug induced

S/S of Acute Pericarditis 

chest pain (significant, continuous, sharp), dyspnea, fever, pericardial friction rub

• TB: TB symptoms

• Bacteria: inflammatory, toxic, critically ill (septic)

• Uremic: w/ or w/o symptoms, absent fever

• Neoplastic: Often painless, increase risk of pericardial effusion

Dx of acute pericarditis

• Viral: clinical diagnosis based on criteria, leukocytosis, echo is normal

• TB: TB testing

• Bacterial: pericardiocentesis

• Uremic: “shaggy pericardium”- irregular and thickened pericardium on ECHO or CT

• ECG: shows ST waves elevated in all ECG leads

• CXR: cardiac enlargement, masses (neoplastic)

• Neoplastic: cytologic examination

• Post MI: increased ESR, large pericardial effusion

• Myxedema: hypothyroidism, cholesterol crystals 

Acute Pericarditis Tx

• Tx of underlying cause

• NSAIDs

• Colchicine

Cardiac Tamponade 

Pressure that affects pericardial filling 

• Triad

1. Jugular venous distention (JVD)

2. Hypertension

3. Muffled heart sounds

DO NOT CONFUSE WITH TENSION PNEUMO

Tx of Cardiac Tamponade

• Restriction in activity (3 mo)

• ASA, NSAID

• Colchicine + NSAID (3 mo) for prevention (cyclophosphamide or azathioprine if not tolerated)

• Underlying cause

  • TB: TB drug therapy

  • Radiation: symptomatic tx

  • Uremic: dialysis (tamponade common)

  • Neoplastic (poor prognosis): drain effusion, chemo, tetracycline