‫‪Cardiology_87 #Dyslipidemia_1#‬‬

‫أﻫﻢ ال ‪ lipids‬اﻟﻠ‪ ‬ﺑﻨﺤﺘﺎﺟﻬﺎ ﻫ‪ ‬ال ‪ cholesterol‬وال‪triglyceride‬‬

‫اﻟ‪‬ﻮﻟﺴﺘﺮول © ﺑﻴﺴﺘﺨﺪﻣﻪ ال ‪ liver‬ﻟﻠﺘﺼﻨﻴﻊ‬
‫ﻓﺒﻴﺪﺧﻞ ﻓ‪ ‬ﺗﺼﻨﻴﻊ ال‬
‫‪... VitD , corticosteroid, Bile acid ,sex hormones‬‬

‫أﻣﺎ ال ‪ (triglyceride ( TG‬ﻓﺒﻴﺴﺘﺨﺪﻣﻪ اﻟﺠﺴﻢ ﻟﻠﻄﺎﻗﺔ ‪،‬ﺑﻴﺘﺨﺰن ﻓ‪ ‬ال ‪ Adipose tissue‬وﻟﻤﺎ ﻧﺤﺘﺎﺟﻪ ﺑﻴﻨﺤﺮق ﺑﺎل ‪Beta -‬‬
‫‪ Oxidation‬وﺑﻴﻄﻠﻌﻠﻨﺎ ﻃﺎﻗﺔ ‪...‬‬

‫ﺑﻤﺎ إﻧﻪ اﻟ‪‬ﻮﻟﻴﺴﺘﻴﺮول وال ‪ TG‬ﻟﻴﺒﻴﺪات ‪،‬ﺑﺎﻟﺘﺎﻟ‪ ‬ﻣﺎ ﺑﻴﻘﺪرو ﻳﻤﺸﻮ ﺑﺎﻟﺪم ﻛﻮﻧﻪ ‪Aqueous media‬‬
‫ﻋﺸﺎن ﻫﻴﻚ ﺑﻴﻤﺸﻮ ﺑﺎﻟﺪم ﻣﺤﻤﻮﻟﻴﻦ ﻋﻠ‪ ‬ﺑﺮوﺗﻴﻦ ‪...‬‬
‫ﻓﺎﻟ‪‬ﻮﻟﻴﺴﺘﻴﺮول © وال ‪ TG‬ﺑﻴﺘﺤﻮﻃﻮ ب ‪Apolipoprotein‬‬
‫ﻳﺒﻘ‪ ‬ﺻﺎر ﻋﻨﺎ ‪ molecule‬ﺑﻴﺘ‪‬ﻮن ﻣﻦ ال © وال ‪ TG‬وﻣﻐﻠﻒ ب ‪ Apolipoprotein‬وﺑﻨﺴﻤﻴﻪ ‪ Lipoprotein‬وﻫﺎد اﻟﺸ‪‬ﻞ اﻟﻠ‪ ‬رح‬
‫ﻳﻤﺸ‪ ‬ﺑﺎﻟﺪم ‪...‬‬
‫⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪‬
‫ﻓ‪ ‬ﻋﻨﺎ ﺧﻤﺲ أﻧﻮاع ﻣﻦ ال ‪ Lipoprotein‬ﺑﻴﺨﺘﻠﻔﻮ ﺣﺴﺐ ال ‪ size‬وال ‪ density‬وﻣﺤﺘﻮﻳﺎت ال© & ‪TG ..‬‬

‫‪1⃣ chylomicrons‬‬
‫اﻛﺒﺮﻫﻢ ﺣﺠﻤﺎ و ‪ %90‬ﻣﻦ ﻣﺤﺘﻮﻳﺎﺗﻪ ‪ , TG‬و ‪ %10‬ﻛﻮﻟﻴﺴﺘﻴﺮول©‬

‫‪2⃣VLDL‬‬
‫ﺑﻴﺤﺘﻮي ﻋﻠ‪ %75 ‬ﻣﻦ ال ‪ TG‬و ‪ %25‬ﻛﻮﻟﻴﺴﺘﻴﺮول ©‬

‫⃣‪IDL 3‬‬
‫ﺑﻴﺤﺘﻮي ﻋﻠ‪ 50:50 ‬ﻣﻦ ال ‪ TG‬وال ©‬

‫⃣‪LDL ( bad cholesterol) 4‬‬

‫‪75% cholesterol ©+ 25% triglyceride‬‬

‫)‪5⃣HDL ( Good Cholesterol‬‬

‫‪75% cholesterol© + 25% triglyceride‬‬

‫⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪‬
‫ﻛﻴﻒ ﺑﺘ‪‬ﻮن رﺣﻠﺔ ال ‪ ©&TG‬ﻣﻦ أول ﻣﺎ ﻳﺪﺧﻠﻮ اﻟﺠﺴﻢ ‪..‬‬
‫ﺑﻌﺪ ﻣﺎ ﻳﺼﻞ ال ©وال ‪ TG‬ﻟﻞ ‪Intestine‬‬
‫ال ‪ TG‬ﺑﻴﺘﻔ‪‬ﻚ ل ‪ free fatty acid‬ﻋﺒﺮ ال ‪pancreatic Lipase‬‬

‫ال ‪ Bile acid‬ﺑﻴﺤﻮط ال ©وال ‪ TG‬وﺑﻴﺪﺧﻠﻬﻢ ﻟﻠﺨﻼﻳﺎ اﻟﻤﺒﻄﻨﺔ ﻟﻞ ‪ intestine‬اﻟﻠ‪ ‬ﺑﻨﺴﻤﻴﻬﺎ ‪Enterocyte‬‬

‫ال ‪ Enterocyte‬ﺑﺘﻐﻠﻒ ال ©وال ‪ TG‬ب ﺑﺮوﺗﻴﻦ وﺑﺘﺮﻣﻴﻬﻢ ﻋﻠ‪ ‬اﻟﺪم ﺑﺼﻮرة ‪chylomicrons‬‬
 ‫ال ‪ chylomicrons‬ﻃﻮل ﻣﺎ ﻫﻮ ﻣﺎﺷ‪ ‬ﺑﺎﻟﺪم ﺑﻴﻘﺎﺑﻠﻪ ال ‪ lipoptn lipase‬اﻟﻠ‪ ‬ﺑﻴﻄﻠﻊ ﻣﻦ ال ‪Vascular Endothelium‬‬
‫ﻫﺎد ال ‪ Lipase‬ﺑﻴﺄﻛﺴﺪ ال ‪ TG‬وﺑﻴﺤﻮﻟﻪ ل ‪FFA‬‬
‫ﻓﻌﻠ‪ ‬ﻣﺎ ﻳﻮﺻﻞ ال ‪ chylomicrons‬ﻟﻞ ‪ liver‬ﻫﺘ‪‬ﻮن ﻛﻞ ﺣﻤﻮﻟﺘﻪ © وال ‪ TG‬ﻓﻘﺪﻫﻢ ﺑﺎﻟﻄﺮﻳﻖ ﻋﺒﺮ ال ‪.. lipase‬‬

‫ال ‪ liver‬ﺑﻴﺠﻤﻊ ال‬

‫©اﻟﻠ‪ ‬واﺻﻠﻪ ﻣﻦ ال ‪ intestine‬وال‪ denovo cholesterol‬اﻟﻠ‪ ‬ﻫﻮ ﻣﺼﻨﻌﻪ ﻣﻊ ال ‪ TG‬وﺑﻴﺤﻮﻃﻬﻢ ﺑﺒﺮوﺗﻴﻦ وﻳﺮﻣﻴﻬﻢ ﻋﻠ‪ ‬اﻟﺪم‬
‫ﺑﺼﻮرة ‪VLDL‬‬

‫ال ‪ VLDL‬وﻫﻮ ﻣﺎﺷ‪ ‬ﺑﺎﻟﺪم ﻫﻴﻘﺎﺑﻞ ال ‪ lipoptn lipase‬وﻳﺤﺮق ال ‪TG‬‬

‫ﻟﻴﺤﻮل ال ‪ VLDL‬ل ‪ , IDL‬وﻣﻊ اﻟﻮﻗﺖ ال ‪ IDL‬ﻫﻴﺘﺤﻮل ل ‪LDL&HDL‬‬

‫ال ‪ LDL‬ﻗﺪاﻣﻪ ﻣﺴﺎرﻳﻦ‬

‫إﻣﺎ ﻳﺮﺟﻊ ﻟﻞ ‪ liver‬ﻋﺒﺮ ال ‪ LDL Receptor‬وﻳﺘﺨﻠﺺ ﻣﻨﻪ ال ‪liver‬‬
‫وﻫﺎد ﻟﻠﻨﺎس اﻟﻠ‪ ‬ﻋﻨﺪﻫﻢ ‪LDL Receptor‬‬
‫اﻣﺎ اﻟﻠ‪ ‬ﻣﺎ ﻋﻨﺪﻫﻢ ‪ LDL Receptor‬ف ﻫﻴﺮوح ال ‪ LDL‬ﻳﺘﺮاﻛﻢ ﺑﺎل ‪ vessel‬وﻳﺘﺎﻛﺴﺪ ﻣﻊ اﻟﻮﻗﺖ وﻳﺘﺮﺳﺐ ﻋﻠﻴﻪ ‪ ca‬وﻳﺘﺤﻮل ل‬
‫‪Atherosclerosis‬‬

‫ﻓ‪ ‬ﺣﻞ ﺗﺎﻧ‪ ‬ان ال ©اﻟﻠ‪ ‬ﺗﺮﺳﺐ ﺑﺎﻟﺸﺮاﻳﻴﻦ ﻳﺘﺠﻤﻊ ﺑﺼﻮرة ‪ HDL‬وﻳﺮﺟﻊ ﻋﻠ‪ ‬ال ‪ Liver‬ﺑﺪون اﻟﺤﺎﺟﻪ ل ‪.. Receptor‬‬

‫‪#‬ﻟﻌﻠ‪_‬أﻓﻴﺪك ❤‬
 Cardiology_88 #Dyslipidemia_2#

Lipoprotein ‫ ﻋﻨﺎ ﺧﻤﺲ اﻧﻮاع ﻣﻦ ال‬‫ﻓ‬، ‫زي ﻣﺎ ﺷﻔﻨﺎ اﻟﺒﻮﺳﺖ اﻟﺴﺎﺑﻖ‬

Chylomicron ,VLDL ,IDL ,LDL ,HDL
‫ وﻫﺪﻓﻨﺎ اﻧﻪ ﻧﻘﻠﻠﻪ‬atherosclerosis ‫ ﺑﻴﺘﺮﺳﺐ ﺑﺎﻟﺸﺮاﻳﻴﻦ وﺑﻴﺘﺄﻛﺴﺪ وﺑﻴﻌﻤﻞ‬‫ اﻟﻠ‬bad cholesterol ©‫ ﻫﻮ ال‬LDL ‫ال‬
.. ‫ ﻟﻴﺘﺨﻠﺺ ﻣﻨﻬﺎ‬liver ‫ ال‬‫ وﺑﻴﻮدﻳﻬﺎ ﻋﻠ‬vessel ‫ﻮﻟﻴﺴﺘﺮول ﻣﻦ ال‬‫ ﺑﻴﺤﻤﻞ اﻟ‬‫ اﻟﻠ‬Good cholesterol ‫ ﻓﻬﻮ ال‬HDL ‫أﻣﺎ ال‬
ApoB100 ‫ ﻣﺤﺎط ب‬LDL ‫ ﻓﺎل‬Apo B ‫ اﻟﻤﻐﻠﻔﻬﻢ‬lipoptn ‫ وﺑﻨﻤﻴﺰﻫﻢ اﻧﻪ ﻧﻮع ال‬LDL IDL.VLDL ‫ ﻫﻢ ال‬Non HDL ©‫ال‬
‫ال‬
ApoA1 ‫ ﻣﻐﻠﻒ ب‬HDL© ‫أﻣﺎ ال‬

LDL .. ‫ ﻓﺒﺘﺰﻳﺪ ﻗﻴﻤﺔ ال‬، ‫ﻮﻟﻴﺴﺘﻴﺮول‬‫ ﻣﻊ اﻟ‬Apo-B ‫ ﺑﻴﺰﻳﺪ اﺗﺤﺎد ال‬‫ﻓﺒﺎﻟﺘﺎﻟ‬، ‫ ﺑﺰﻳﺎدة‬Apo-B ‫ ﺑﻴﺼﻨﻊ ال‬liver ‫اﺣﻴﺎﻧﺎ ال‬
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
Level of Lipid interpretation :

●Total cholesterol

•<200 mg/dL (5.2 mmol/L): desirable

•200 to 239 mg/dL (5.2 to 6.1 mmol/L): borderline high

•>239 mg/dL (6.1 mmol/L): high

●LDL-C

•<100 mg/dL (2.6 mmol/L): optimal

•100 to 129 mg/dL (2.6 to 3.3 mmol/L): near optimal

•130 to 159 mg/dL (3.4 to 4.1 mmol/L): borderline high

•160 to 189 mg/dL (4.1 to 4.9 mmol/L): high

•>189 mg/dL (4.9 mmol/L): very high

●HDL-C

A low level is commonly defined:

•Women: <50 mg/dL (1.30 mmol/L)

•Men: <40 mg/dL (1.03 mmol/L)

.(●Triglycerides – A normal triglyceride level is <150 mg/dL (1.7 mmol/L

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_89 #Dyslipidemia_3#

‫ او‬LDL ‫ أو زﻳﺎدة ﺑﺎل‬Total© ‫ ﺑﻴﻨﺘﺞ ﻋﻨﻪ إﻣﺎ زﻳﺎدة ﺑﺎل‬lipoptn metabolism ‫ ال‬‫ ﻓ‬Disorder ‫ ﻋﺒﺎرة ﻋﻦ‬Dyslipidemia ‫ال‬
HDL ‫ او ﻧﻘﺺ ﺑﺎل‬TG ‫زﻳﺎدة ﺑﺎل‬

Dyslipidemia: A disorder of lipoprotein metabolism that may result in elevated total cholesterol,
elevated low density lipoprotein cholesterol, an elevated triglyceride level, or a low high density
.lipoprotein cholesterol

‫ ﺑﺘﻨﺪرج ﺗﺤﺖ ﻗﺴﻤﻴﻦ ؛‬Dyslipidemia ‫اﺳﺒﺎب ال‬

Primary ( Familial) Dyslipidemia

: ‫ أﺳﺒﺎب ﺟﻴﻨﻴﺔ وﻳﻨﺪرج ﺗﺤﺘﻬﺎ ﻛﺬا ﻧﻮع أﺷﻬﺮ اﻧﻮاع‬‫وﻫ‬

: 1⃣Type 1 Familial chylomicronemia

‫ﻟﺨﻠﻞ ﺟﻴﻨ‬، ‫ زﻳﺎدة ﺑﺎﻟﺪم‬Chylomicron ‫ﻮن ﻓﻴﻬﺎ ال‬‫وﺑﻴ‬

: 2⃣Type 2
⬇ ‫ وﺑﻨﺴﻤﻴﻬﺎ‬: Type2a ‫ﻓﻴﻬﺎ ﻧﻮﻋﻴﻦ‬
(Familial hypercholesterolemia ( Type 2a
‫ ﻟﺴﺒﺐ ﺧﻠﻞ ﺟﻴﻨ‬ApoB100 Receptor ‫ او ﻧﻘﺺ ال‬LDL Receptor ‫ ﺑﺴﺒﺐ ﻧﻘﺺ ال‬LDL Level ‫ زﻳﺎدة ﺑﺎل‬‫ﻮن ﻓ‬‫ﺑﻴ‬

Type2b : ‫و‬
Familial combined hyperlipidemia
lipoptn ‫ﻮﻳﻦ ال‬‫ ف زاد ﺗ‬ApoB100 ‫ أدى ﻟﺰﻳﺎدة ﺗﺼﻨﻴﻊ ال‬‫ وﻏﺎﻟﺒﺎ ﺳﺒﺒﻬﺎ ﺧﻠﻞ ﺟﻴﻨ‬VLDL ‫ وال‬LDL ‫ﻮن زﻳﺎدة ﺑﺎل‬‫ﺑﻴ‬

3⃣ Type 3: Familial dysbetalipoproteinemia

IDL ‫زﻳﺎدة ﺑﺎل‬

4⃣ Type 4: Familial hypertriglyceridemia

...‫ ﺑﺎﻟﺪم‬TG ‫ ﺑﻨﺴﺒﻪ ﻛﺒﻴﺮة ﻓﻬﻴﺰﻳﺪ ال‬TG ‫ ﺑﻴﺤﻤﻞ‬VLDL ‫ وﺑﻤﺎ اﻧﻪ ال‬VLDL ‫زﻳﺎدة ﺑﺎل‬

5⃣Type 5: Familial mixed hypertriglyceridemia

Chylomicron ‫ وال‬VLDL ‫زﻳﺎدة ﺑﺎل‬

Secondary causes
‫زي ال‬
DM ,CKD, Alcohol Consumption , obesity ,hypothyroidism ,Liver Disease ,drug induce ( as loop
diuretic ,Thiazide
 ⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

: (Familial hypercholesterolemia( FH ‫أﺷﻬﺮ وأﻫﻢ ﻧﻮع ﻫﻮ ال‬

early middle Age ‫ ﺑﺴﻦ ﺻﻐﻴﺮ‬CVD ‫ ب‬‫ ﺑﻴﺠ‬FH ‫ﻣﺮﻳﺾ ال‬

FH ‫ ﻟﺘﺸﺨﻴﺺ ال‬criteria ‫ ﻋﻨﺎ اﻛﺘﺮ ﻣﻦ‬‫ﻓ‬

AHA Criteria

Dutch Lipid Clinic Network diagnostic criteria for familial hypercholesterolaemia

Simon Broome Familial Hypercholesterolemia Register diagnostic criteria for familial

hypercholesterolemia

190mg/dl ‫ ﻣﻦ‬‫ ﻛﺎن أﻋﻠ‬LDL ‫ ﺑﺘﻘﻮل ﻟﻮ ال‬AHA Criteria ‫ال‬

190 ‫ ﻣﻦ‬‫ اﻋﻠ‬LDL ‫ ﺑﺮدو ال‬First degree relarive ‫وال‬
FH ‫ﻓﻬﻨﺎ اﻟﻤﺮﻳﺾ‬

preterm CVD ‫ ﻣﻊ وﺟﻮد‬190 ‫ ﻣﻦ‬‫ ﻋﻨﺪه اﻋﻠ‬LDL ‫او ﻟﻮ اﻟﻤﺮﻳﺾ ال‬

FH ‫ ( ﻓﻬﻨﺎ ﺑﺮدو‬Female ‫ ﻟﻞ‬60 ‫ وﻗﺒﻞ ال‬male ‫ ﻟﻞ‬55 ‫) ﻗﺒﻞ ال‬

‫ ﻣﺮﻓﻘﺎت ﺑﺎﻟﺼﻮر‬Simon ‫ وال‬Dutch ‫ال‬

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_90 #Dyslipidemia_4#

Management Guidelines of Dyslipidemia according to ACC/AHA

: ‫ ﻟﻘﺴﻤﻴﻦ‬Management ‫ﻫﻨﻘﺴﻢ ال‬
; Primary Prevention

TIA ‫ او‬Stroke ‫ زي ال‬Cerbrovascular Disease ‫ وﻣﺎ ﺑﺪﻧﺎ اﻳﺎﻫﻢ ﻳﺪﺧﻠﻮ ب‬Risk Factor ‫ ﻣﻌﻨﺪﻫﻤﺶ اﻻ‬primary ‫ال‬
..ACS ,Angina ‫ زي ال‬Coronary Disease ‫او‬
(Periphral Aretry disease (PAD ‫او‬
PAD .... ‫ او‬Cerebral ‫ او‬Coronary ‫ ﺳﻮاء ﻛﺎن‬Atherosclerotic Disease ‫ﻓﻬﺪﻓﻨﺎ ﻧﻤﻨﻊ أي‬

; Secondary Prevention

‫ و‬Very high risk ‫ وﻫﻨﻘﺴﻤﻬﻢ ﻟﻘﺪام ل‬Coronary ‫ او‬cerebro ‫ ﺳﻮاء‬Atherosclerotic Disease ‫ ﻋﻨﺪﻫﻢ‬Already ‫ﻫﺪول‬
High risk
Medical Management ‫وﻫﻴﺤﺘﺎﺟﻮ‬

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

; Primary Prevention Guideline

: ‫ ﻟﻨﻮﻋﻴﻦ‬ttt ‫ ﺑﺮدو ﻫﻨﻘﺴﻢ ال‬Primary prevention ‫ﺑﺎل‬

: Pt Require Medical ttt without Calculating any Score

medical ‫ﻓﺄي ﻣﺮﻳﺾ ﻣﻦ اﻟﺤﺎﻻت اﻟﺘﺎﻟﻴﺔ ﻫﺘﺒﺪأﻟﻪ‬, Score ‫ ﺑﺪون ﻣﺎ ﻧﺤﺴﺒﻠﻬﻢ أي‬Medical management ‫ ﻫﻴﺒﺪأو ﻋﻠ‬‫ﻣﺮﺿ‬
⬇ .. ‫ واﻧﺖ ﻣﻐﻤﺾ‬management

High Intensity Statin ‫ ﻫﻴﺒﺪأ ﻋﻠ‬190mg/dl ‫ او ﻳﺴﺎوي‬‫ ﻛﺎن اﻋﻠ‬LDL ‫ﺳﻨﻪ وال‬75-20 ‫أي ﺷﺨﺺ ﻋﻤﺮه‬1⃣
Rosuvastatin 20-40 mg ‫ أو‬Atorvastatin40-80mg ‫زي ال‬
%50 ‫ ﺑﻨﺴﺒﺔ‬LDL ©‫ ﺑﻴﻨﺰل ال‬High Intensity Statin ‫ال‬

190mg/dl ‫ وﻳﻨﺰل ﻋﻦ‬%50 ‫ ﻳﻨﺰل ﺑﻨﺴﺒﺔ‬LDL ‫ ﺗﺒﻌﻨﺎ اﻧﻪ ال‬Target ‫وال‬

‫ وﻟﺴﻪ ﻣﺎ‬Atorvastatin80mg ‫ ﻋﻠ‬‫ ﻣﺜﻼ ﻣﺸ‬Statin ‫ ﻣﻦ ال‬Maximum Tolerated dose ‫ ال‬‫ ﻋﻠ‬‫ﻃﻴﺐ ﻟﻮ اﻟﻤﺮﻳﺾ ﻣﺸ‬
Ezetimbe 10mg ‫ ﻓﺒﻴﻨﻀﺎﻓﻠﻪ‬Target ‫وﺻﻞ ﻟﻞ‬

Statin ‫ ﻟﻞ‬Ezetimbe ‫ﻟﻮ اﻟﻤﺮﻳﺾ ﺑﻌﺪ ﻣﺎ ﺿﻔﻨﺎﻟﻪ‬

220mg/dl ‫ ﻣﻦ‬‫ ﻛﺎن ﻟﺴﺎﺗﻪ أﻋﻠ‬LDL ‫ال‬
PCK9 Inhibitor ‫ﻫﻨﺎ ﺑﻴﻨﻀﺎﻓﻠﻪ دوا ﻣﻦ ﻋﻴﻠﻪ ال‬

‫ ﻋﻠ‬‫ ﻫﻴﻤﺸ‬75-40 ‫ ﻋﻤﺮه ﻣﻦ‬DM ‫ أي ﻣﺮﻳﺾ‬2⃣

 Moderate Intensity Statin as :

Atorvastatin 10-20 mg
Simvastatin 20-40 mg
Rosuvastatin 5-10 mg
Pravastatin 40-80 mg
Fluvastatin 80mg once if Extended Release or 40 mg Twice Daily
Pitavastatin 1-4 mg

High Intensity Statin ( class 2a) ‫ ﻫﻨﺎ ﻫﻴﺎﺧﺪ‬High risk ‫ وﻃﻠﻊ‬ASCVD Score ‫ ﺣﺴﺒﻨﺎﻟﻪ ال‬DM ‫ﻟﻮ ﻣﺮﻳﺾ ال‬

Moderate Intensity Statin ‫ ﻫﻴﺒﺪأو ب‬CKD ‫ ﻟﻮ اﻟﻤﺮﻳﺾ‬3⃣

Ezetimbe ‫ﻟﺤﺎﻟﻪ او ﻣﻊ ال‬

Familial Hypercholesterolemia ‫ ﺣﺎﻻت ال‬4⃣

ACC ‫ ﺣﺴﺐ ال‬70mg/dl ‫ ﻷﻗﻞ ﻣﻦ‬LDL ‫ ﻧﻨﺰل ال‬Target ‫ وال‬High Intensity Statin ‫ﻫﻴﺒﺪأو ع‬
Baseline ‫ اﻗﻞ ﻣﻦ ال‬%50 ‫او‬
Ezetimbe ‫ ﻫﻨﻀﻴﻒ‬Target ‫ وﻣﻮﺻﻠﺶ ال‬‫ ﻟﺴﺎﺗﻪ ﻋﺎﻟ‬LDL ‫ ﺷﻬﻮر ال‬3 ‫ﻟﻮ ﺑﻌﺪ‬
PCK9 Inhibitor ‫ ﺑﻴﻨﻀﺎﻓﻠﻪ‬Target ‫ﻟﻮ ﻣﻮﺻﻠﺶ ﻟﻞ‬

Sever Abnormal lipid profile ‫ ﺳﻨﻪ وﻋﻨﺪﻫﻢ‬19-0 ‫ ﻣﻦ ﻋﻤﺮ‬5⃣

‫ ﺷﻬﻮر وﻣﺤﺼﻠﺶ اﺳﺘﺠﺎﺑﺔ‬3 ‫ ﻟﻤﺪة‬life stylw management ‫ وﻣﺸﻴﻨﺎﻫﻢ ع‬Familial Hypercholesterolemia ‫او‬
Statin ‫ﻓﻬﻴﺒﺪأو ع‬

Medical ttt ‫ اي ﺣﺎﻟﻪ ﻣﻦ اﻟﺤﺎﻻت اﻟﺴﺎﺑﻘﺔ ﻫﻴﺒﺪأو‬‫ﻳﺒﻘ‬

Pt need to Calculate ASCVD Score to assess if They need medical ttt or not
‫ﻪ‬‫ﻤﻠﻪ اﻟﺒﻮﺳﺖ اﻟﻘﺎدم ان ﺷﺎء اﻟ‬‫ﻫﻨ‬
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_91 #Dyslipidemia_5#

... Management Guidelines of Dyslipidemia according to ACC/AHA Part 2

‫ ﺑﺪون ﻣﺎ ﻧﺤﺴﺒﻠﻬﻢ اي‬Statin ‫ ﻫﻴﺒﺪأو ﺑﺎل‬pt ‫ ﻓ‬Primary prevention of Dyslipidemia ‫ﺷﻔﻨﺎ اﻟﺒﻮﺳﺖ اﻟﺴﺎﺑﻖ اﻧﻪ ﺑﺎل‬
‫ زي ؛‬score
pt ( age 20-75) with Sever Hypercholesterolemia ( LDL>190) 1⃣
2⃣DM pt ( Age >40)
3⃣CKD
4⃣Familial Hypercholesterolemia
5⃣pt age (0-19 year) with Sever abnormal Lipid profile unresponsive to life style management
⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

medical ttt ‫ ﻫﻞ ﻫﻴﺤﺘﺎﺟﻮ‬189mg/dl-70 ‫ ﻗﻴﻤﺘﻪ‬LDL ‫ وال‬DM ‫ وﻣﻌﻨﺪﻫﻤﺶ‬75-40 ‫ ﻋﻤﺮﻫﻢ‬‫ﻃﻴﺐ ﺷﻮ ﺑﺎﻟﻨﺴﺒﻪ ﻟﻼﺷﺨﺎص اﻟﻠ‬
‫وﻻ ﻷ‬
‫ ﺳﻨﻮات‬10 ‫ ﺧﻼل ال‬ASCVD ‫ اﻧﻪ ﻳﺼﻴﺮ ﻣﻌﻬﻢ‬Risk ‫ ﻧﺤﺴﺒﻠﻬﻢ ال‬Score ‫ﻢ اﻟﻮﺿﻊ ﻟﻬﺪول اﻻﺷﺨﺎص ﻋﺸﺎن ﻫﻴﻚ ﺑﻨﺴﺘﺨﺪم‬‫ﻻزم ﻧﻘﻴ‬
‫اﻟﻘﺎدﻣﺔ‬
(ASCVD : Atherosclerotic Cardiovascular Disease )
Pooled cohort Equation ‫ ﺑﻴﺴﺘﺨﺪﻣﻮ ال‬American ‫ال‬

.. Pooled Cohort equation to estimate 10 year ASCVD

T© ‫ وال‬LDL ‫ وال‬sex ‫ وال‬Age ‫ ﺑﻨﺪﺧﻞ ﻓﻴﻬﺎ ﺑﻴﺎﻧﺎت اﻟﻤﺮﻳﺾ زي ال‬Medical calculator ‫ ﻣﻮﺟﻮدة ﺑﺄﻏﻠﺐ ال‬equation ‫ال‬
‫ وﺑﻴﻄﻠﻊ ﻗﻴﻤﻪ ﻣﻌﻴﻨﻪ ﺑﻨﺎء ﻋﻠﻴﻬﺎ ﺑﻨﻘﻴﻢ وﺿﻊ اﻟﻤﺮﻳﺾ ؛‬Smoking ‫ او‬DM ‫ او‬HTN ‫ﻫﻞ اﻟﻤﺮﻳﺾ‬
ASCVD Risk ; ‫ اﺣﺘﻤﺎﻻت ﻟﻞ‬4 ‫ﻋﻨﺎ‬

1⃣ Low Risk pt
%5 ‫ اﻗﻞ ﻣﻦ‬ASCVD Risk ‫ﻟﻮ ﻃﻠﻌﺖ ﻗﻴﻤﺔ ال‬
medical ttt ‫ وﻣﺎ ﺑﻴﺤﺘﺎﺟﻮ‬Life style ‫ ال‬‫ﻫﺪول ﺑﺲ ﻳﺤﺎﻓﻈﻮ ﻋﻠ‬

2⃣Pt at Borderline Risk ( ASCVD :5-7.5%)

3⃣pt at Moderate Risk ( ASCVD : 7.5-20%)

(4⃣Pt at High Risk ( ASCVD :>20%

.. Baseline ‫ ﻣﻦ ال‬%50 ‫ ﺑﻘﻴﻤﻪ‬LDL ‫ وﻫﺪﻓﻨﺎ ﻧﻘﻠﻞ ال‬High Intensity statin ‫وﻫﺪول ﻫﻴﺤﺘﺎﺟﻮ‬

High intensity Statin ‫ ﻫﻴﺤﺘﺎج‬high risk ‫أﻣﺎ ﻟﻮ‬،، medical ttt ‫ ﻣﺶ ﻫﻴﺤﺘﺎج‬low risk ‫ ﻟﻮ‬‫ﻳﺒﻘ‬

Borderline ⬇ ‫ وال‬moderate ‫ﺑﻴﻀﻞ ﻋﻨﺎ ال‬

ASCVD 5-20%
‫ﺘﻔﻮ ﺑﺎل‬‫ وﻻ ﻫﻴ‬ttt ‫ﻋﺸﺎن ﻧﺤﺪد ﻫﻞ ﻫﻴﺎﺧﺪو‬
life style modification
Moderate intensity ‫ﻟﻮ ﻟﻘﻴﺘﻬﺎ ﻋﻨﺪه ﻫﻴﺎﺧﺪ‬، ‫ ﺣﺎﺟﻪ ﺗﺎﻧﻴﻪ ﻋﻨﺪ اﻟﻤﺮﻳﺾ‬‫ﻓﻬﺄدور ﻋﻠ‬، Risk Inhancer ‫ﻋﺸﺎن ﻧﺤﺪد زودوا ال‬
Statin
 Risk Inhancer :

Family history of premature ASCVD Persistently elevated LDL-C ≥160 mg/ dL (24.1 mmol/L)

Chronic kidney disease

Metabolic syndrome

Conditions specific to women (e.g., preeclampsia, premature menopause)

Inflammatory diseases (especially rheumatoid arthritis, psoriasis, HIV)

Ethnicity (e.g., South Asian ancestry)

Lipid/Biomarkers:

Persistently elevated triglycerides (2175 mg/dL, (≥2.0 mmol/L)) In selected individuals if measured:

hs-CRP 22.0 mg/L

Lp(a) levels >50 mg/dL or >125 nmol/L apoB ≥130 mg/dL

Ankle-brachial index (ABI) <0.9

... Moderate Intensity Statin ‫ ﻫﻴﺎﺧﺪ‬Risk enhancer ‫ وﻋﻨﺪه ﺣﺎﺟﻪ ﻣﻦ ال‬%20-5 ‫ ﻣﻦ‬ASCVD ‫ ال‬‫ﻓﺎﻟﻤﺮﻳﺾ اﻟﻠ‬

170 ‫ﻓﻮق ال‬LDL ‫ وال‬75-40 ‫ وﻋﻤﺮه ﻣﻦ‬Risk enhancer ‫ وﻣﻌﻨﺪوش‬%20-5 ‫ ﻣﻦ‬ASCVD ‫ﻃﻴﺐ ﻓﺮﺿﺎ اﻟﻤﺮﻳﺾ ﻛﺎن ال‬
190 ‫واﻗﻞ ﻣﻦ‬
CAC Score( Cotonary Aretry Calcium) ‫ﺑﻴﻨﺤﺴﺒﻠﻬﻢ ال‬

If risk decision is uncertain Consider measuring CAC in selected adults:

CAC-0 (lowers risk; consider no statin, unless diabetes,

family history of premature CHD, or cigarette smoking are present)

CAC-1.99 favors statin (especially after age 55)

CAC-100+ and/or >=75th percentile, initiate statin

therapy

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_92 #Dyslipidemia_6#

(Management Guidelines of Dyslipidemia according to ACC/AHA Part 3... ( Secondary Prevention

CABG ‫ او‬PCI ‫ او ﺳﺒﻖ وﻋﻤﻠﻮ‬Angina ‫ او‬ACS ‫ ﻋﻨﺪﻫﻢ‬‫اﻟﻨﺎس اﻟﻠ‬

PAD ‫ او‬TIA ‫ او‬Stroke ‫او ﻋﻨﺪﻫﻢ‬
Secondary Prevention ‫ ك‬Statin ‫ﻫﺪول ﻫﻴﻚ ﻫﻴﻚ ﻫﻴﻤﺸﻮ ﻋﻠ‬
‫ﺑﻨﻘﺴﻤﻬﻢ ل ﻗﺴﻤﻴﻦ ؛‬
Very High Risk pt

Very high-risk includes;

A history of multiple major ASCVD events

(hx MI, hx ischemic stroke, recent ACS, symptomatic PAD)

or
1 major ASCVD event and multiple high-risk Condition
(Age ≥ 65 y, heterozygous FH, prior CABG or PCI, DM, hypertension, CKD, current smoking, hx
CHF, persistently elevated LDL-C ≥ 100 mg/dL).

Not at very High Risk Pt

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

%50 ‫ او اﻗﻞ ب‬70mg/dl ‫ ﻻﻗﻞ ﻣﻦ‬LDL ‫ واﻟﻬﺪف اﻧﻨﺎ ﻧﻘﻠﻞ ال‬High Intensity Statin ‫ ﻫﻴﺒﺪأو ﻋﻠ‬Very high Risk Pt ‫ال‬
Baseline ‫ﻣﻦ ال‬
Ezetimibe ‫ اﻟﻤﻄﻠﻮب ﺑﻨﻀﻴﻔﻠﻪ‬Target ‫ وﻣﺎ وﺻﻞ ﻟﻞ‬Highly Tolerated Max dose of statin ‫ ع ال‬‫ﻟﻮ ﻣﺸ‬
‫ ﺑﻴﻨﻀﺎﻓﻠﻪ اﺣﺪ ادوﻳﺔ ﻣﺠﻤﻮﻋﺔ ال‬Target ‫وﻟﻮ ﻟﺴﻪ ﻣﺎ وﺻﻞ ﻟﻞ‬
PCK9 Inhibitor
Very high risk ‫ ﺗﺼﻨﻴﻔﻬﻢ ﻣﺶ‬‫ اﻟﻠ‬pt ‫ال‬
High intensity statin ‫ ﻫﻴﺒﺪأو ع‬, 75 ‫ﻟﻮ اﻟﻌﻤﺮ اﻗﻞ او ﻳﺴﺎوي‬
Moderate Intensity ‫ ﻓﺒﻴﺘﺸﻔﺖ ع‬Tolerated ‫وﻟﻮ ﻣﺶ‬

Ezetimibe ⬇ ‫ ﺑﻴﻨﻀﺎف‬70 ‫ ﻣﻦ‬‫ اﻋﻠ‬LDL ‫وﻟﻮ ﻟﺴﺎﺗﻪ ال‬

( (Weak Recommendation class 2b

Moderate - High Intensity ‫ ﺑﻴﺒﺪأ ع‬75 ‫ﻟﻮ اﻟﻌﻤﺮ اﻛﺒﺮ ﻣﻦ‬

Tolerated ‫وﻳﺴﺘﻤﺮ ﻋﻠﻴﻪ ﻟﻮ ﻛﺎن‬
(( Class 2a

ESC Dyslipidemia management ‫ﻪ ﻫﻨﺸﻮف ال‬‫اﻟﺒﻮﺳﺖ اﻟﻘﺎدم ان ﺷﺎء اﻟ‬

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_93 #Dyslipidemia_7#

(Management Guidelines of Dyslipidemia according to ESC ( part 1

European ‫ ﻫﻨﺒﺪأ ﺑﺎل‬American Guideline ‫ﺧﻠﺼﻨﺎ ﺳﺎﺑﻘﺎ ال‬

‫ ﻣﺤﺘﺎﺟﻴﻦ ﻧﻌﻤﻠﻠﻬﻢ‬‫ ﻣﻴﻦ اﻻﺷﺨﺎص اﻟﻠ‬ESC ‫ﺣﺴﺐ ال‬

? Risk assessment for Cardiovascular Event
‫ وﻻ ال‬FH ‫ وﻻ‬CKD ‫ وﻻ‬Known CVD ‫ وﻻ‬DM ‫ﻮﻧﻮش‬‫ ﺳﻨﻪ ﺑﺸﺮط ﻣﻴ‬40 ‫ اﻻﻛﺒﺮ ﻣﻦ‬Asymptomatic ‫ ال‬Adult ‫ﻛﻞ ال‬
190mg/dl ‫ ﻣﻦ‬‫ اﻋﻠ‬LDL
‫ﻻﻧﻪ اي ﺷﺨﺺ‬
DM ,hx CVD ,CKD ,FH ,LDL<190mg/dl

risk assessment ‫ وﻣﺶ ﻫﻴﺤﺘﺎﺟﻮ‬High Risk ‫ﻫﻨﻌﺘﺒﺮﻫﻢ ﻣﻦ اﻟﺒﺪاﻳﺔ ﺧﺎﻟﺺ‬

... CV Risk Stratification ‫ﻛﻴﻒ ﺑﻨﻌﻤﻞ‬

Pooled cohort score ‫ ﻛﺎﻧﻮ ﻳﺴﺘﺨﺪﻣﻮ ال‬American ‫ﺷﻔﻨﺎ ﺑﺎل‬
SCORE .. ‫ﻮر اﺳﻤﻪ‬‫ ﻓﺒﻴﺴﺘﺨﺪﻣﻮ ﺳ‬European ‫أﻣﺎ ال‬

SCORE estimate 10-year Risk the First Fatal Atherosclerotic Event

Coronary ‫ او‬Cerebro ‫ﺳﻮاء‬
HDL ‫ وال‬Total cholesterol ‫ وال‬SBP ‫ وال‬Smoking ‫ وال‬Gender ‫ وال‬Age ‫ ال‬‫ ﻋﻠ‬SCORE ‫ﺑﻴﻌﺘﻤﺪ ال‬
pt Risk‫ ) ﻣﺮﻓﻘﻪ ﺑﺎﻟﺼﻮر ( ﻣﻦ ﺧﻼﻟﻬﺎ ﺑﻨﺤﺪد ال‬Chart ‫ﻓﻌﻤﻠﻮ‬

High risk country ‫ ﻟﻞ‬‫ وﻓ‬low risk country ‫ ﻟﻞ‬Chart ‫ﻓ‬

‫ وﻧﻄﻠﻊ ﻗﻴﻤﻪ ال‬SCORE ‫ﺑﻌﺪ ﻣﺎ ﻧﺤﺴﺐ ﻟﻠﻤﺮﻳﺾ ال‬

year of Fatal Atherosclerotic Event-10

Risk ‫ وﻋﺪﻣﻬﺎ ﺑﻴﻘﻠﻞ ال‬RISK ‫ ﺣﺎﺟﺎت ﺗﺎﻧﻴﻪ ﻻزم ﻧﺴﺄل ﻋﻠﻴﻬﺎ وﺟﻮدﻫﺎ ﺑﻴﺰود ال‬‫ﻓ‬

Factors modifying SCORE risks ;

Social deprivation- the origin I many of the causes of CVD

Obesity and central obesity as measured by the body mass index and waist circumference,
respectively.

Physical inactivity.

Psychosocial stress including vital exhaustion.

Family history of premature CVD (men: <55 years; women: <60 years).

Chronic immune-mediated inflammatory disorder,

 Major psychiatric disorders.

Treatment for human immunodeficiency virus (HIV) infection.

Atrial fibrillation.

Left ventricular hypertrophy.

Chronic kidney disease.

Obstructive sleep apnoea syndrome.

. Non-alcoholic fatty liver disease

... CVD ‫ ﻟﻞ‬Pt risk ‫ ﻣﻦ ﻫﺪول ﺑﻴﺰود ال‬Factor ‫أي‬

Risk Category ‫ ﺑﻨﺸﻮف اﻟﻤﺮﻳﺾ ﺑﺄي‬Factors modifying SCORE risks ‫ وﻧﺸﻮف ال‬SCORE ‫ﺑﻌﺪ ﻣﺎ ﻧﺤﺴﺐ ال‬
Very high Risk
High Risk
Moderate Risk
Low Risk
‫ﻪ‬‫ اﻟﻴﻮﺳﺖ اﻟﺠﺎي ان ﺷﺎء اﻟ‬Risk category ‫ﻤﻞ ﺗﻔﺎﺻﻴﻞ ال‬‫ﻫﻨ‬
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_94 #Dyslipidemia_8#
(Management Guidelines of Dyslipidemia according to ESC ( part 2

Cardiovascular Event ... ‫ ﻟﻞ‬Risk category ‫ ﻋﻨﺎ أرﺑﻊ‬‫ ﻓ‬ESC ‫ﺣﺴﺐ ال‬
Very High Risk
55mg/dl (1.4mmol/L) ‫ﻮن اﻗﻞ ﻣﻦ‬‫ اﻧﻪ ﻳ‬LDL ‫ ﻟﻞ‬Target ‫وال‬

High Risk
70mg/dl(1.8mmol/L) ‫ﻮن اﻗﻞ ﻣﻦ‬‫ ﻳ‬LDL target ‫وال‬

Moderate Risk
LDL targey <100mg/dl (2.6mmol/L)

Low Risk
LDL target <116mg/dl (3 mmol/L) class 2b

‫ ؛‬‫ ﻋﻨﺪه اﻟﺘﺎﻟ‬‫ ﻫﻮ اﻟﻤﺮﻳﺾ اﻟﻠ‬very High Risk ‫ ال‬1⃣

Documented ASCVD ‫اي ﻣﺮﻳﺾ ﻋﻨﺪه‬

( previous ACS {MI or Unstable angina }

,Angina ,Previous Revascularization { PCI Or CABG } ,Stroke ,TIA ,PAD ,Significant Plaque on
coronary angiography or CT Scan , multivessel coronary disease with 2 major epicardial aretry
( having >50% stenosis or on Carotid Ultrasound

‫ او‬Neuropathy ‫ او‬Retinopathy ‫ﻮن ﻣﻌﻪ‬‫ زي ﻣﺜﻼ ﻳ‬Target organ damage ‫ﺮ ﻟﻮ ﻛﺎن ﻋﻨﺪه‬‫ اﻟﺴ‬‫ﻣﺮﺿ‬
microalbuminurea

risk factor ‫ او اﻛﺘﺮ‬3 ‫ﺮ ﻟﻮ ﻋﻨﺪه‬‫ﻣﺮﻳﺾ اﻟﺴ‬

Dyslipidemia ‫ﻮن ﻣﺪﺧﻦ او ﻣﺮﻳﺾ ﺿﻐﻂ او‬‫ﻣﺜﻼ ﻳ‬

T1DM ‫ ﺳﻨﻪ‬20 ‫ واﻟﻪ‬Type 1 ‫ﺮ‬‫ﻣﺮﻳﺾ اﻟﺴ‬

Risk factor ‫ ﻣﻊ‬FH ‫ او‬ASCVD ‫ ﻟﻮ ﻛﺎن ﻋﻨﺪه‬FH ‫ ال‬‫ﻣﺮﺿ‬

Familial Hypercholesterolemia ( FH) With ASCVD Or with Another Major Risk Factor
30 ‫ اﻗﻞ ﻣﻦ‬eGFR ‫ وال‬Sever CKD ‫ﻟﻮ ﻣﺮﻳﺾ‬

%10 ‫ وﻛﺎن اﻛﺘﺮ او ﻳﺴﺎوي‬10year ASCVD ‫او ﻣﺮﻳﺾ اﻧﺤﺴﺒﻠﻪ ال‬

55mg/dl (1.4mmol/L) ‫ ﻷﻗﻞ‬LDL ‫ اﻧﻪ ﻧﻮﺻﻠﻠﻬﻢ ال‬target ‫ وال‬Very high Risk ‫ﻛﻞ ﻫﺪول ﺑﻨﻌﺘﺒﺮﻫﻢ‬
 ⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

High Risk pt ; ‫ال‬2⃣

Pt with one of the Following
Total Cholesterol >8mmol/L ( 310mg/dl)
LDL >4.9 mmol/L (190 mg/dl)
Blood pressure >=180/110
FH Without major risk factor
DM Without target organ damage
DM duration >=10 year
DM with major Risk Factor
Moderate CKD ( eGFR 30-59)
10year ASCVD SCORE : 5-10%

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
3⃣pt with moderate Risk

Young pt <35 Years old with Type 1 DM

Type 2DM at age <50 year with DM duration <10 year without other Risk factor
ASCVD 10Year score ;1-5%

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

4⃣Low Risk pt
Score less than 1%
❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_95 #Dyslipidemia_9#

(Management Guidelines of Dyslipidemia according to ESC ( part 3

‫ ﺣﺎﻻت ال‬‫ ﻓ‬Dyslipidemia ‫ﻣﺮﻳﺾ ال‬

Low- Moderate Risk
Life style modification ‫ ﺑﺎل‬‫ﺘﻔ‬‫ﻏﺎﻟﺒﺎ ﻫﻴ‬
Drug therapy ‫وﻧﺎدرا ﻣﺎ ﻳﺤﺘﺎﺟﻮ‬

High- Very high risk ‫اﻣﺎ ﺣﺎﻻت ال‬

Drug + life style Modification ‫ﻓﻬﻴﻤﺸﻮ ﻋﻠ‬
: ‫ ﻋﻠﻴﻬﺎ اﻟﻤﺮﻳﺾ ﻧﻔﺲ اﻟﺠﺎﻳﺪﻻﻳﻦ اﻻﻣﺮﻳ‬‫ ﻫﻴﻤﺸ‬‫اﻻدوﻳﻪ اﻟﻠ‬
Start with High intensity Statin or High Tolerated Dose of statin
Goal ‫ﻟﺤﺪ ﻣﺎ ﻳﻮﺻﻞ ﻟﻞ‬
Ezetimibe ‫ ﻫﻴﻨﻀﺎﻓﻠﻪ‬Goal ‫ﻟﻮ ﻣﺎ وﺻﻞ ﻟﻞ‬
PCK9 Inhibitor ‫ﻟﻮ ﻣﺎ وﺻﻞ ﻫﻴﻨﻀﺎﻓﻠﻪ‬

‫ ﻣﻦ اﻟﺒﺪاﻳﺔ‬statin ‫ﻟﻮ اﻟﻤﺮﻳﺾ ﻋﻨﺪه ﻣﺎ ﻳﻤﻨﻊ اﺳﺘﺨﺪام ال‬

Ezetimibe ‫ﻓﻬﻴﺒﺪأ ﻋﻠ‬

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_96 #Dyslipidemia_10#

Statin Associated Muscle Symptom #SAMS

Source :Up*ToDate

Statin .. ‫ﻦ ﺗﺼﻴﺮ ﻣﻊ ال‬‫ ﻣﻤ‬‫ اﻟﻠ‬Muscle Symptom ‫ﺎل ﻟﻞ‬‫ ﻋﻨﺎ ﺧﻤﺲ أﺷ‬‫ﻓ‬

: 1⃣ Myalgia

‫ ﻃﺒﻴﻌ‬Creatine Kinase‫ﻮن ﻣﺴﺘﻮى ال‬‫ وﺑﻴ‬،‫ أو ﺗﻌﺐ ﻣﻊ أو ﺑﻌﺪ اﻟﺘﻤﺮﻳﻦ‬،‫ اﻟﻌﻀﻼت‬‫ﻣﺠﺮد ﺷﻌﻮر ﺑﻌﺪم اﻟﺮاﺣﻪ أو آﻻم ﻓ‬

Myalgia symptoms can be described as similar to what would be experienced with a viral syndrome
such as influenza.

2⃣ Myopathy – Muscle weakness (not due to pain), with or without an elevation in CK level.

3⃣ Myositis – Muscle inflammation.

4⃣ Myonecrosis
Statin ‫ او ارﺗﻔﻊ ﻋﻦ ﻗﻴﻤﺘﻪ ﻣﺎ ﻗﺒﻞ ﺑﺪأ ال‬Upper limit ‫ ﻋﻦ ال‬CK ‫ وارﺗﻔﻊ ﻣﺴﺘﻮى ال‬muscle ‫ ﻟﻞ‬Necrosis ‫ﻮن ﺻﺎر‬‫ﺑﻴ‬
.. ‫ اﻗﺴﺎم‬3 ‫وﺑﻨﻘﺴﻤﻪ ل‬

Mild – 3-10 fold elevation in CK•

•Moderate 10-50 fold elevation in CK

•Severe 50 fold or greater elevation in CK

5⃣Clinical rhabdomyolysis – Defined by the Task Force as myonecrosis with myoglobinuria or acute
.([renal failure (an increase in serum creatinine of at least 0.5 mg/dL [44 micromol/L

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

.. SAMS ‫ ﺑﺘﺰود ﻓﺮﺻﺔ ال‬‫ اﻟﻠ‬Risk factor ‫ﺷﻮ ال‬

Statin ‫ﺣﺴﺐ ﻧﻮع ال‬

SAMS ‫ ال‬‫ ﻓ‬Risk ‫إﻟﻬﻢ أﻗﻞ‬، Statin ‫ ﺗﻼت ادوﻳﻪ ﻣﻦ ﻋﺎﺋﻠﻪ ال‬‫ﻓ‬

fluvastatin, pravastatin, and pitavastatin

CYP3A4 ‫ ﺑﺎل‬metabolism ‫ﻻﻧﻪ ﻫﺪول اﻻدوﻳﺔ ﻣﺎ ﺑﻴﺼﻴﺮﻟﻬﻢ‬

SAMS ‫ وﻣﺎ ﺑﻴﺴﺒﺒﻮ‬‫ ﻣﺴﺘﻮاﻫﻢ ﺑﺎﻟﺪم ﻣﺎ ﺑﻴﻌﻠ‬‫ﺑﺎﻟﺘﺎﻟ‬، ‫ﻓﻤﺎ إﻟﻬﻢ ﺗﺪاﺧﻼت دواﺋﻴﺔ ﻣﻊ اﻻدوﻳﻪ اﻟﺘﺎﻧﻴﻪ‬

In the case of fluvastatin, the lower risk may be related to the much lower systemic exposure of the
extended-release formulation
The risk of muscle injury is substantially increased when taking statins extensively metabolized by
.CYP3A4 such as lovastatin, simvastatin, and atorvastatin

SAMS ‫ ﻟﻞ‬Risk ‫ ﺑﻴﺰود ال‬Preexisting neuromuscular disorders ‫ﻟﻮ ﻛﺎن اﻟﻤﺮﻳﺾ ﻋﻨﺪه‬

SAMS ‫ ﻟﻞ‬Risk ‫ﺒﺪ ﺑﺘﺰود ال‬‫ واﻟ‬‫ﻠ‬‫ وﻣﺸﺎﻛﻞ اﻟ‬D ‫ وﻧﻘﺺ ﻓﻴﺘﺎﻣﻴﻦ‬Hypothyroidism ‫ﺣﺎﻻت ال‬

‫ﻋﻮاﻣﻞ ﺟﻴﻨﻴﺔ‬

Genetic factors appear to increase the risk of statin myopathy

SAMS Risk ‫ﻓﺒﻴﺰﻳﺪ ال‬، ‫ ﺑﺎﻟﺪم‬statin ‫ وﺑﺘﺰود ﻣﺴﺘﻮى ال‬statin ‫ ع أدوﻳﻪ ﺑﺘﺘﺪاﺧﻞ ﻣﻊ ال‬‫ﻟﻮ اﻟﻤﺮﻳﺾ ﻣﺎﺷ‬

Concurrent drug therapy — The increase in susceptibility to myopathy is substantially greater in

patients receiving concurrent therapy with a number of drugs,
particularly those that inhibit CYP3A4
fibrates
glucocorticoids
cyclosporine
daptomycin
zidovudine
colchicine

SAMS ‫ ﻟﻤﻨﻊ ال‬Recommended ‫ واﻟﺠﺮﻋﻪ ال‬Statin ‫ ﺑﺘﺘﺪاﺧﻞ ﻣﻊ ال‬‫ اﻟﻠ‬Drug ‫اﻟﺼﻮره ﻣﺮﻓﻖ ﻓﻴﻬﺎ اﺷﻬﺮ ال‬

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_97 #Dyslipidemia_11#

Statin Associated Muscle Symptom #SAMS

Source :Up*ToDate

‫ وﺷﻔﻨﺎ اﻟﺨﻤﺲ اﻧﻮاع اﻟﺒﻮﺳﺖ اﻟﺴﺎﺑﻖ‬SAMS ‫ وﺻﺎر ﻋﻨﺪه‬statin ‫ ﻋﻠ‬‫ﻟﻮ اﻟﻤﺮﻳﺾ ﻣﺎﺷ‬
‫ ﻓﻮرا‬statin ‫ ﻓﺒﻴﻮﻗﻒ ال‬Rhabdomyolysis ‫ﻟﻮ ﺻﺎر ﻋﻨﺪ اﻟﻤﺮﻳﺾ‬

Rhabdomyolysis — Patients with symptomatic or asymptomatic rhabdomyolysis from a statin should⛔

discontinue therapy immediately

Rhabdomyolysis ‫ ﻏﻴﺮ ال‬SAMS ‫ ﺣﺎﻻت ال‬‫ﺑﺎﻗ‬

✅ If a patient requires a statin and experiences muscle symptoms (other than rhabdomyolysis), we
:suggest the following approach

‫ وﻻ ﺳﺒﺐ ﺗﺎﻧ‬Statin ‫ ﺳﺒﺒﻬﺎ‬Muscle problem ‫) ﻣﺮﻓﻖ ﻣﻊ اﻟﺼﻮر( ﻣﻦ ﺧﻼﻟﻪ ﺑﻨﺤﺪد ﻫﻞ ال‬Index ‫ﻓ‬

Administer the SAMS clinical index (SAMS-CI) to determine the likelihood that muscle symptoms are
.due to statin use

4-2 ‫ ﻣﻦ‬SAMS-CI ‫ﻟﻮ ﻃﻠﻌﺖ ﻗﻴﻤﺔ ال‬

low SAMS-CI ‫ﺑﻨﻌﺘﺒﺮه‬
‫ ﻟﻠﻤﺮﻳﺾ‬Statin ‫ﺑﻨﻮﻗﻒ ال‬
depression ‫ او‬Anexity ‫ﻦ اﻟﺴﺒﺐ أدوﻳﺔ ﺗﺎﻧﻴﻪ او‬‫ ﻣﻤ‬muscle disease ‫ اﺳﺒﺎب ﺗﺎﻧﻴﻪ ﻟﻞ‬‫ﺑﻨﺪور ﻋﻠ‬
Symptom ‫ إﻻ ﻟﺘﺮوح ال‬Statin ‫وﻣﺎ ﺑﻨﺮﺟﻊ ال‬

After symptom resolution;

If patient was not on a high-intensity statin, restart the same statin at a lower dose.

•If patient was on a high-intensity statin, switch to an alternative high-intensity statin

(atorvastatin, rosuvastatin) and address concerns about side effects. If the patient experiences
adverse muscle symptoms on the alternative high-intensity statin, we recommend switching
to fluvastatin, pravastatin, or pitavastatin.

•If the patient was already on a low daily dose of a statin, consider alternate-day dosing

(11-5) ‫ ﻋﺎﻟ‬SAMS -CI Score ‫ﻟﻮ ﻛﺎن ال‬

Discontinue the statin.•

•Assess for drug interactions, including those related to addition of a new medication or a change in
administration of a long-term medication that may account for symptoms.
 •Assess for comorbidities which may account for or exacerbate symptoms (vitamin D deficiency,
hypothyroidism, acute or chronic renal failure, or obstructive liver disease). Correct hypothyroidism
or low vitamin D level if present.

After symptom resolution:

•If patient was not on a high-intensity statin, restart the same statin at same or lower dose. If patient
was already on the lowest dose, consider alternate-day dosing, although this may result in lower
efficacy.

•If patient was on a high-intensity statin, switch to an alternative high-intensity statin

(atorvastatin, rosuvastatin) and address concerns about side effects. If the patient experiences
adverse muscle symptoms on the alternative high-intensity statin, we recommend switching
to fluvastatin, pravastatin, or pitavastatin

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪
SAMS-CI Score ‫ اﺳﺒﻮع ﺑﻨﺮﺟﻊ ﻧﻌﻴﺪ ال‬12-4 ‫ﺑﻌﺪ‬

•If the SAMS-CI score is still high, switch to a statin with different pharmacokinetic properties
and/or consider non-statin low-density lipoprotein (LDL) cholesterol-lowering therapy.

-If switching statin therapy to an agent with a different pharmacokinetic profile is unsuccessful ,
initiate alternate-day (or less frequent) dosing with careful monitoring.

•If SAMS-CI score is low, consider and evaluate for non-statin-associated conditions or therapies
that may be causing symptoms.

•If symptoms persist, discontinue all statin therapy and consider non-statin cholesterol-lowering
therapy

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
 Cardiology_98 #Dyslipidemia_12#

Statin Associated Muscle Symptom #SAMS

Source :ESC
CK ? ‫ ﺑﻨﻘﻴﺲ ﻟﻠﻤﺮﻳﺾ ال‬‫ﻣﺘ‬

?How often should creatine kinase (CK) be measured in patients taking lipid-lowering drugs

Statin ‫ﻗﺒﻞ ﻣﺎ ﻳﺒﺪأ اﻟﻌﻼج ﺑﺎل‬

recheck ‫ وﺑﻨﺮﺟﻊ ﻧﻌﻤﻠﻪ‬statin ‫ﻣﺎ ﺑﻨﺒﺪأ ﻟﻠﻤﺮﻳﺾ‬، ‫ ﻣﺮات‬4 ‫ ب‬upper limit ‫ ﻣﻦ ال‬‫ اﻋﻠ‬CK ‫ ﺣﺎﻟﺔ ﻛﺎن ال‬‫ﻓ‬

‫ وﺑﻨﺘﺎﺑﻌﻪ‬CK ‫ ﺑﻬﻠﺤﺎﻟﺔ ﺑﻨﻘﻴﺴﻠﻪ ال‬myalgia ‫ وﺻﺎر ﻋﻨﺪه‬statin ‫ ع‬‫ﻟﻮ اﻟﻤﺮﻳﺾ ﻣﺎﺷ‬

.Routine monitoring of CK is not necessary

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

... ‫ وﻻ ﻳﻮﻗﻔﻪ‬statin ‫ﻤﻞ‬‫ ﻫﻨﺤﺪد ﻫﻞ ﻳ‬CK ‫ ﻗﻴﻤﺔ ال‬‫ﺑﻨﺎء ﻋﻠ‬

( If CK >4 Time ULN ( Upper Limit of Normal

‫ اﺣﺘﻤﺎﻻت‬3 ‫ ﻋﻨﺎ‬‫ﻓ‬

ULN ‫ ﻋﻦ ال‬10time ‫ ارﺗﻔﻊ ل‬CK ‫ﻮن ال‬‫ ﻳ‬1⃣

‫ ﻛﻞ اﺳﺒﻮﻋﻴﻦ‬CK ‫ وﺑﻨﺘﺎﺑﻊ ال‬Renal Function ‫ وﺑﻨﺸﻴﻚ ع ال‬Statin ‫ﺑﻬﻠﺤﺎﻟﺔ ﺑﻨﻮﻗﻒ ال‬

6-2‫ ﻛﻞ‬CK ‫ وﻧﺘﺎﺑﻊ ال‬statin ‫ ال‬‫ﻫﻴﺴﺘﻤﺮ اﻟﻤﺮﻳﺾ ﻋﻠ‬, Symptom ‫ وﻣﺎ ﻓ‬10 ‫ واﻗﻞ ﻣﻦ‬4 ‫ ﻣﻦ‬‫ اﻋﻠ‬CK ‫ ﻟﻮ ﻛﺎﻧﺖ ﻗﻴﻤﺔ ال‬2⃣
‫اﺳﺎﺑﻴﻊ‬

‫ اﻋﺮاض‬‫ وﻓ‬10 ‫ واﻗﻞ ﻣﻦ‬4 ‫ ﻣﻦ‬‫ اﻋﻠ‬CK ‫ ﻟﻮ ﻛﺎﻧﺖ ﻗﻴﻤﺔ ال‬3⃣

Normal ‫ ﻟﺤﺪ ﻣﺎ ﻳﻮﺻﻞ ﻟﻞ‬CK ‫ وﺑﻨﺘﺎﺑﻊ ال‬statin ‫ﺑﻨﻮﻗﻒ ال‬

‫ ﺑﺠﺮﻋﺔ اﻗﻞ‬statin ‫وﺑﻌﺪ ﻣﺎ ﻳﻮﺻﻞ ﻟﻠﻨﻮرﻣﺎل ﺑﻨﺮﺟﻊ ال‬

CK ‫وﺑﻨﺘﺎﺑﻊ ال‬
CK ‫ ال‬‫ﻦ ﻳﻌﻠ‬‫وﺑﻨﺴﺘﺒﻌﺪ أي ﺳﺒﺐ ﻣﻤ‬

.Consider the possibility of transient CK elevation for other reasons such as exertion

‫ وﺑﻨﺴﺘﺨﺪم‬myopathy ‫ ﻓﺒﻨﻌﺘﺒﺮه‬‫ ﻋﺎاﻟ‬CK ‫ ﺣﺎﻟﺔ ﺿﻞ ال‬‫ﻓ‬

Alternative Therapy

If CK <4 time ULN

1⃣ If no muscle symptoms, continue statin (patient should be alerted to report symptoms; check CK).

2⃣ If muscle symptoms, monitor symptoms and CK regularly.

If symptoms persist, stop statin and re-evaluate symptoms after 6 weeks; re-evaluate indication for
statin treatment.

• Consider re-challenge with the same or another statin.

• Consider low-dose statin, alternate day or once/twice weekly dosing regimen or combination
.therapy

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#
#Cardiology_99 #Dyslipidemia_13
Canadian & NICE Protocol management in Statin Induce Muscle pain
 Cardiology_100 #Dyslipidemia_14#
Dyslipidemia ‫ ال‬‫اﺧﺮ ﺑﻮﺳﺖ ﻓ‬

Active liver disease ‫ ﻋﻨﺪه‬‫اﻟﻤﺮﻳﺾ اﻟ‬

‫او‬
(unexplained persistent elevations of serum transaminases ( ALT
Statin .. ‫ﻣﻤﻨﻮع ﻳﺎﺧﺪو‬
Statin is Contraindicated in active liver disease or in patients with unexplained persistent elevations
.of serum transaminases

‫ ؟‬ALT ‫ ﺑﻨﻘﻴﺲ ال‬‫ﻣﺘ‬

ALT ‫ ﺑﻨﻘﻴﺴﻠﻪ ال‬Statin ‫ ال‬‫ﻗﺒﻞ ﻣﺎ ﻳﺒﺪأ اﻟﻤﺮﻳﺾ ﻋﻠ‬

‫ اﺳﺒﻮع ﻣﻦ ﺑﺪاﻳﺔ اﻟﻌﻼج‬12-8 ‫ ﺧﻼل‬ALT ‫ ﺑﻨﺮﺟﻊ ﻧﻘﻴﺲ ال‬statin ‫وﺑﻌﺪ ﻣﺎ ﻳﺒﺪأ‬

... ‫ اﺳﺒﻮع ﻣﻦ زﻳﺎدة اﻟﺠﺮﻋﺔ‬12-8 ‫ ﺑﻌﺪ‬ALT ‫ ورﻓﻌﻨﺎﻟﻪ اﻟﺠﺮﻋﻪ ﺑﺮدو ﺑﻨﻘﻴﺴﻠﻪ ال‬Low dose statin ‫ ع‬‫وﻟﻮ اﻟﻤﺮﻳﺾ ﻛﺎن ﻣﺎﺷ‬

Routine control of ALT thereafter is not recommended during statin treatment, unless symptoms
suggesting liver disease evolve.

.During treatment with fibrates, control of ALT is still recommended

⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪⚪

3time ULN ‫ اﻗﻞ ﻣﻦ‬ALT ‫ﻟﻮ ﻛﺎﻧﺖ ﻗﻴﻤﺔ ال‬

‫ اﺳﺎﺑﻴﻊ‬6-4 ‫ ﺧﻼل‬ALT ‫ وﺑﻨﺮﺟﻊ ﻧﻘﻴﺴﻠﻪ ال‬statin ‫ ال‬‫ﻤﻞ اﻟﻤﺮﻳﺾ ﻋﻠ‬‫ﺑﻴ‬

upper limit ‫ ﻣﻦ ال‬3time ‫ اﻋﻠ‬ALT ‫ﻟﻮ ﻛﺎﻧﺖ ﻗﻴﻤﺔ ال‬

‫ او ﺑﻨﻘﻠﻞ اﻟﺠﺮﻋﺔ‬Statin ‫ﺑﻨﻮوﻗﻒ ال‬

‫ اﺳﺎﺑﻴﻊ‬6-4 ‫ ﺧﻼل‬ALT ‫وﺑﻨﺘﺎﺑﻊ ال‬

Cautious reintroduction of therapy may be considered after ALT has returned

.• If ALT remains elevated check for the other reasons

❤ ‫_أﻓﻴﺪك‬‫ﻟﻌﻠ‬#