Question

Sample A is from a 35 year old male who visited his GP complaining of chest pain during exercise. An ECG taken at rest was normal but ischaemic changes developed on exercise. A family history revealed that his father died of a heart attack at the age of 45 years. The laboratory test results for his fasting blood sample were as follows:

Analyte                       Patient values                        Reference range for fasting

     blood sample

Sodium                                    139                              135-145 mmol/L

Potassium                                4.1                               3.0-5.0 mmol/L

Total protein                           69                                65-80 g/L

Albumin                                  35                                35-47 g/L

Calcium                                  9.3                               9.0-10.5 mg/dl

Lactate dehydrogenase           250                              90-190 IU/L

Creatine kinase                       129                              30-60 IU/L

Asparatate transaminase         70                                < 40 IU/L

Gamma glutamyl transferase 30                                < 50 IU/L

Total Bilirubin                        13                                0.4-15 μmol/L

Glucose                                   12                                3.5-5.5 mmol/L

Fructosamine                          351                              205-285 μmol/L

Cholesterol                             

            Total                            7.2                               <5.2mmol/L

            HDL                            1.4                               >1.5 mmol/L

            LDL                            ?                                  <3.5 mmol/L

Triglycerides                           2.95                             <1.7mmol/L

On the gradient gel electrophoresis, plasma sample for this patient showed the presence of small dense LDL particle.

1. Calculate and comment on the LDL cholesterol values. What does the presence of small dense LDL mean?
2. How many cardiovascular risk factors does this patient have?
3. Discuss the type of hyperlipidaemia this patient is likely to have.
4. What further tests and dietary/drug treatments would you recommend for this patient?

Answer 1

1. calculation of low density lipid

low density lipid = Total cholesterol- HDL cholesterol- Triglycerides

LDL=7.2-1.4-2.95

LDL= 2.85

small dense LDL-Cholesterol (m/mol/l) is 0.82 - 1.002 mmol/l here small particles of sdLDL suggest that there is more chance of development of coronary artery disease and congestive cardiac disease.

Elevated plasma low-density lipoprotein cholesterol (LDL-C) levels to be a significant risk factor for coronary heart disease (CHD).

When there is too much cholesterol in blood, it builds up in the walls of arteries, causing a process called atherosclerosis, a form of heart disease. The arteries become narrowed and blood flow to the heart muscle is slowed down or blocked. The blood carries oxygen to the heart, and if not enough blood and oxygen reach heart, pt may suffer chest pain. If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack.

There are two forms of cholesterol that many people are familiar with: Low-density lipoprotein (LDL or "bad" cholesterol) and high-density lipoprotein (HDL or "good" cholesterol.) These are the form in which cholesterol travels in the blood.LDL is the main source of artery-clogging plaque. HDL actually works to clear cholesterol from the blood.

2. patient have cardio vascular risk factors are:

patient have high lactate dehydragenase which indicate risk of cardiac disease.

CK-MB is also 129 IU/L so its indicate there is damage in myocardial wall

increased fructosamine and glucose level indicate that patient have diabetes also its major risk for cardiac disease

Age is also one of risk factor for cardiac disease, also patient having family history of myocardial infarction.

total cholesterol ,HDL, LDL and Triglyceride is higher so these shows there is major risk for atherosclerosis in my patient.

3.Types of hyperlipidemia in this kind of patients

Hyperlipidemiain general can be classified to:

Primary: it is also called familial due to a genetic defect, it may be monogenic: a single gene defect or polygenic: multiple gene defects. Primary hyperlipidemia can usually be resolved intoone of the abnormal lipoprotein patterns.

Secondary: it is acquired because it is caused by another disorder like diabetes, nephritic syndrome, chronic alcoholism, hypothyroidism and with use of drugs like corticosteroids, beta blocker and oral contraceptives. Secondary hyperlipidemia together with significant hypertriglyceridemia can cause pancreatitis.

Symptoms of hyperlipidemia

Generally hyperlipidemia does not have any obvious symptoms but they are usually discovered during routine examination or until it reaches the danger stage of a stroke or heart attack.Patients with high blood cholesterol level or patients with the familial forms of the disorder can develop xanthomas which are deposits of cholesterol may form under the skin, especially under the eyes. At the same time, patients with elevated levels of triglycerides may develop numerous pimple-like lesions at different sites in their body.

4. test required for cardiac disease

• Electrocardiogram (ECG).periodically  ECG records these electrical signals and can help detect irregularities in your heart's rhythm and structure.
• Holter monitoring. A Holter monitor is a portable device to record a continuous ECG, usually for 24 to 72 hours. Holter monitoring is used to detect heart rhythm irregularities.
• Echocardiogram. This noninvasive exam, which includes an ultrasound of chest, shows detailed images of heart's structure and function.

• Cardiac catheterization: In this test, a short tube (sheath) is inserted into a vein or artery in leg (groin) or arm. Aided by X-ray images on a monitor.

  The pressures in your heart chambers can be measured, and dye can be injected. The dye can be seen on an X-ray, which helps to see the blood flow through heart, blood vessels and valves to check for abnormalities.

treatment , advice, diet suggest for this patient:

take low fatty diet in normal routine'

measure blood glucose level periodically and take less carbohydrates in diet

take high protien diet and green leafy vegetables

take anticoagulant medication as per advice also for controlling hypertension take antighypertensive drungs as per schedules

take antidiabetic medication in routine. if suggested insulin injection that take in proper unit according to RBS measurement.

start light exercise if having pain than stop it immediately.

take care of self from any injury or wounds.