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Introduction   

Hyperlipidemia is a very common issue for people around the world because of several factors that we will explore in this course. Hyperlipidemia relates to high fats in the blood. We will discuss the differences in the two lipids involved, what causes them, what they do in the body, and how they are treated by lifestyle, good dietary habits, and medications. 

We will also look at how nurses can contribute to assisting these patients through education and support. In addition, we will discuss newer medications for patients who cannot tolerate pharmacological treatments or need adjunct therapy.  

Definition 

The medical term for high fats (lipids) in the blood is called hyperlipidemia. There are two specific types of lipids that the medical community is concerned with. These are cholesterol and triglycerides. Hyperlipidemia can either be inherited or developed from poor lifestyle habits (3).  Cholesterol is the most common of the lipids that become elevated. There is also mixed hyperlipidemia which occurs when both triglycerides and cholesterol are elevated.  Hyperlipidemia is easy to manage if caught early.  

The two types of cholesterol are high density lipidemia (HDL) and low density lipidemia (LDL).  Contrary to what it may seem, a higher HDL is preferable to a low HDL and in contrast a higher LDL is more dangerous. We know that cholesterol forms plaques in the arteries reducing blood flow and oxygen to the body and hardening the arteries (atherosclerosis) (3). These plaques can eventually obstruct the arteries, which may cause heart attack, stroke, blood clots, and/or peripheral vascular disease (PVD) (2). 

Assessment 

During a medical history, the patient’s general health and lifestyle should be evaluated. High cholesterol does not generally show symptoms unless plaque buildup has begun to obstruct the vessel and the patient presents with chest pain, severe headache, or dyspnea (3). It is very important to know family history for cardiovascular disease, high cholesterol, and if these problems began prior to the age of 50 because high cholesterol may be inherited (3). If high cholesterol is not inherited, it is most likely caused by poor lifestyle, such as smoking, unhealthy diet, sedentary lifestyle, obesity, and heavy alcohol intake (3). Other health conditions may lead to high cholesterol, such as diabetes, liver disease, low thyroid levels, psoriasis, and inflammatory bowel disease (3). 

It is also important to know which medications the patient takes as some medications could possibly contribute to high cholesterol.  

Some of these medications may include (4): 

• Cardiac drugs, such as, B-blockers, amiodarone, furosemide, and high dose thiazides 
• Hormones, such as estrogen, certain progestins, growth hormones, anabolic steroids, and corticosteroids 
• Antivirals 
• Immunosuppressants 
• First-and second-generation antipsychotics 
• Anticonvulsants 
• Retinoids 

Epidemiology 

As we know, hyperlipidemia is very common in the U.S. and increasing around the world. The Center for Disease Control and Prevention (CDC) states that 73.5 million, or 31.7% of adults have high LDL which makes their risk of cardiac disease twice of those with normal LDL levels (5). Of the 73.5 million people with high LDL, only 48.1% are receiving treatment. The CDC also states that familial or inherited high cholesterol has a prevalence of 1 person in 300,000, whereas in other countries this number could be 1 person in 100. (5)  

According to the Journal of Medical Association (JAMA), LDL is higher in whites than Blacks or Hispanics/Latinx with females having lower LDLs than males (3). In countries with healthier diets, such as the Mediterranean diet (which encourages lean meats, in-season fruits and vegetables, nuts, and legumes), hyperlipidemia may be less of a concern (3). 

Pathophysiology 

According to the National Institutes of Health (NIH), among the people with familial high LDLs, there is a missing receptor for LDL, or the receptor is problematic. Since the liver processes about two-thirds of LDL, this missing or damaged receptor causes the liver to be unable to receive the LDL for processing (5). When there is too much circulating LDL in the blood, the tiny particles form plaques on the inner walls of the arteries causing narrowing or obstruction. This is called atherosclerosis. Atherosclerosis can also occur from endothelial damage of the arteries, inflammation, immunologic issues, hypertension, and smoking (3). Once the endothelial lining is compromised, increased inflammation occurs and the lipids land in the innermost lining of the epithelium. “Foam cells” (where the cholesterol builds), cause dysfunction which eventually leads to necrosis of the underlying tissue (3).   

Plaque rupture and thrombosis can cause obstruction of the artery. The buildup of plaque in the artery is not usually known until the artery is 70% to 80% occluded and the patient is symptomatic (3). This is when angina, heart attack, or stroke might occur (3).  

In my husband’s case, he had 10 out of 10 chest pain and was in the hospital for three days on heparin. Cardiac catheterization and stenting for a non-ST elevated heart attack was done and we were told every other artery was clear. About three months later while on vacation in Florida, he had more chest pain and had a second non-ST elevated attack in his left anterior descending artery which was 90% occluded. How could this happen when he was told everything was clear?  We were told by the cardiologist that a piece of plaque must have broken off the artery and caused an occlusion. 

Signs, Symptoms, and Etiology 

There are no clinical signs and symptoms of high cholesterol. It is a silent disease that can only be detected by a blood test to determine cholesterol levels (1). If the patient presents with chest pain or stroke, it may be caused by elevated cholesterol which created plaques and obstructed the artery, or plaque ruptured from another area. This is an emergency that must be taken care of immediately. 

There are some other diseases that can cause dyslipidemia because of their inflammatory processes. These include Crohn’s disease, inflammatory bowel disease, psoriasis, depression, chronic obstructive pulmonary disease (COPD), chronic pain, pediatric alopecia areata, and chronic kidney disease (3).  

Per the National Heart and Lung and Blood Institute (NHLBI), screening for cholesterol should occur (6, 9): 

• Every 5 years for people aged 19 or younger starting at age 9 – 11 and as early as age 2 if there is a family history of high blood cholesterol, heart attack, or stroke 
• Every 5 years for young adults 
• Every 1 to 2 years for males aged 45 – 65 and females aged 55 – 65 
• Yearly for people over the age of 65 

If beyond normal limits, cholesterol may be checked even more often, especially if there is a family history of cardiovascular disease (CVD), diabetes, or high blood pressure (6). 

Nursing Considerations 

If a patient comes to the hospital or clinic with shortness of breath, chest pain, lower tolerance of activity, or numbness and tingling, it is important to assess for hyperlipidemia. Patient and family history should be assessed for CVD, hyperlipidemia, and family history of CVD before age 50 for males and before 60 for females (5). Risk factors should also be assessed. Hyperlipidemia can increase with age so history of diet, exercise, smoking, obesity, alcohol, and diabetes should be assessed (5).  

If you are following a patient with high LDL, it is important to educate the patient on lowering their LDL by diet and exercise, alcohol modification, and managing other diseases that can cause a high LDL. You must also assess the patient’s desire and ability to make these changes and follow up closely (6). Be sure to check all peripheral pulses, carotid pulses, and femoral bruits and as abnormalities may be a sign of peripheral artery disease (PVD) which can also be related to hyperlipidemia (5). 

Recommending a heart-healthy diet is also important. Educating on the Mediterranean diet is important. This diet consists of fruits and vegetables, nuts, whole grains, fish, chicken, beans, soy (like tofu) and only vegetable oils (6). Some would argue that olive oil is best. Avoiding saturated fats found in red meat, sausage, bacon, whole milks, and cheeses which are high in fat, are also important. Fiber intake is important for good digestion and elimination and is found in fruits and vegetables (6). 

Losing weight can help lower total cholesterol along with increasing vitamin intake. One of the most important things a patient can do is quit smoking as this habit also causes many other issues (6). 

Treatment 

The first line in treating hyperlipidemia is lifestyle change. A provider may encourage the patient to enroll in a nutritional program to encourage a healthy diet and get active (7). The easiest way to get active is to get out and walk. As a case manager, I used to advise my patients to get out two to three times per day and walk briskly for 10 to 15 minutes each time. This also worked well for people who were employed as they could take a short break to do this. As they felt stronger, I would encourage them to lengthen the time or distance. Using the stairs instead of an elevator and parking the car further away from the store are also ways to increase activity. If the patient liked to swim, I would encourage them to engage in that activity as often as possible, for as long as possible each time. At one point in my career, I was able to ride my bike to work as I lived within two miles of my job.    

Of course, we always want to see our patients who smoke quit. There are many online and in-person programs to assist people to quit. A healthy diet as we have previously mentioned is also extremely important. I would ask the patient to write in a journal what they had to eat for a week and then review with them where changes could be made. It is difficult for some people to change their lifestyle, so I encourage them to start with small steps. 

If these approaches do not work, the first line medications are “statins,” for example, lovastatin. It is important to note that if the patient has low cardiac risk the provider may not prescribe a statin until it is recognized that the LDL has not been lowered with their lifestyle change (3). Depending on the cardiac risk the provider will decide which statin is best for each patient.  

Patient Safety Considerations 

We always want to be sure our patient is safe while making lifestyle changes to lower cholesterol. These are a few questions we need to get answers to. 

• Are they able to make lifestyle changes?   
• Do they have support from family and/or friends to assist them? 
• Do they know when and how to take their medications? 

Asking these questions is important so the patient has a safe environment in which to make the changes we are asking of them. It is also necessary to know all of their other medications to be sure there are no interactions with the statin they may be taking.   

If a patient is undiagnosed, undertreated, or unable to follow treatment protocols, they run the risk of vascular disease (3). This includes CVD, stroke, aneurysms, type II diabetes, hypertension, and vascular problems (3). 

Other considerations are the side effects of statins which include extremity discomfort, renal injury, myalgia, elevated liver tests and possibly death (3). These side effects should be reported to the prescribing provider so that assessments and possible medication changes may be initiated. 

Research Findings 

There is a new drug on the market that uses mRNA (messenger ribonucleic acid) therapy called Inclisiran (1). This drug is used for patients who are resistant or intolerant to statins. Inclisiran has shown to lower levels of LDL by 50% by blocking the function of mRNA. It blocks an enzyme which causes issues with the LDL receptors in the liver (1). This drug was approved in the U.S on December 22, 2021.  

Two other medications approved in 2020 in the U.S. are bempedoic acid and bempedoic acid-ezetimibe. They can be taken as an adjunct with statins but have significant side effects (8). One other drug approved in the U.S. is alirocumab. It also is used in combination with statins and acts like antibodies made by the body. Alirocumab is an injectable medication used every 2 – 4 weeks and also has major side effects (8). 

Conclusion

We have reviewed what high cholesterol is and whether it is familial or due to lifestyle. We have discussed how high cholesterol, specifically LDL, affects arteries in the body and what it can cause if left untreated. Nurses can help by developing care plans for high LDL and determining if the patient can make lifestyle changes to lower cholesterol.  

We have also looked at medications frequently used and newer medications that have a positive outlook for patients. Due to the western diet and lack of exercise, high cholesterol is now an issue for children. As nurses, we have a responsibility to assist these young patients. As noted, children need to be tested for high cholesterol early, especially if there is a family history. If you are interested, there are several patient questionnaires you can find on the internet that will assist you in caring for these patients.   

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