UNDERSTANDING CHOLESTEROL

1 The structure of a typical Lipoprotein

Lipoproteins are particles of combined fat and protein that carry cholesterol throughout the body
Attachment site

Classication of a Lipoprotein
HDL3 HDL2 High Density Lipoproteins
Final Stage (Good Cholesterol) picks up cholesterol oating free in the bloodstream

LDL Low Density Lipoprotein

Final stage (Bad Cholesterol) releases cholesterol in the blood stream

IDL Intermediate Density Lipoprotein

VLDL Very Low Density Lipoprotein

Intermediate stages to the transport of fat

Cholesterol Outer shell Phospholipid

Chylomicron rst stage; dietary cholesterol and triglyceride particles are absorbed by the intestine

Fatty inner core

4 Cholesterol storage in the liver

Note: too much cholesterol reduces the number of lipoprotein receptors on the surface of the liver cell

Red blood cell

2 Cholesterol transport in the blood:

Lipoproteins act as (fat shuttles) transporting cholesterol through the blood stream

Liver cell (sectioned)

Capillary
VLDL

VLDL travels through the bloodstream, attaching to the lining of capillaries.There, its fatty core of cholesterolis drawn out.

3 How cholesterol is made

(A) Exogenous Pathway (B) Endogenous pathway

Atherosclerosis
Consequence of high cholesterol
Normal artery

IDL

HDL LDL

The smallest particle (IDL) that remains in the blood sheds tiny disk-like particles of HDL (Good cholesterol).
LDL

Outer layer
LDL

Food particles

Lining

When the level of cholesterol in the blood stream is normal, arterial walls remain smooth and slippery

LDL (Bad cholesterol) remains in the blood and travels back to the liver to be removed

Liver
Bile acid Intestine Chylomicron Breakdown of triglyceride Blood stream Chylomicron remanant Free fatty acids Endogenous pathway (Cholesterol produced by the body)
VLDL IDL HDL

Muscle layer

Clogged artery
When cholesterol level is high, excess cholesterol concentrates in the walls of arteries, thereby reducing blood ow

Breakdown of triglyceride

LDL Cholesterol Foam cells Plaque

Free fatty acids Exogenous Pathway (Cholesterol consumed in food)

WHAT DOES YOUR CHOLESTEROL LEVEL MEAN?

HDL Good Cholesterol
HDL
Picks up cholesterol and takes it to liver for removal

LDL BAD Cholesterol

Cholesterol deposited on the artery wall

LDL

What should your total Cholesterol level be?

<200 mg/dl Desirable 200-239mg/dl Borderline high >240 mg/dl High

What should your HDL-C level be?

HDL HDL HDL

What should your LDL-C level be?

LDL LDL

40-59 mg/dl The Better

<40 mg/dl Higher risk

60 mg/dl Lower risk

100 -129 mg/dl <100 mg/dl Near or above optimal Optimal for heart diseases or diabetes

HIGH BLOOD CHOLESTEROL LEVEL INCREASES THE RISK OF ATHEROSCLEROSIS

Having high cholesterol levels increases the risk that you will have a heart attack or astroke
Normal Blood Vessel Blood Vessel With atherescilerosis

Fortunately, lowering your cholesterol levels can signicantly lower the chance that this will happen

A normal artery

Cholesterol begins to build up inside the artery wall, forming a Plaque

Either the plaque breaks open and chunks oat off to block blood vessels

blocks this blood vessel

... or the plaque gets bigger and gradually

WHAT HAPPEN DURING HEART ATTACK?

DURING HEART ATTACK,
If the blockage in the coronary artery isnt treated quickly, the

heart muscle will begin to die and be replaced by scar tissue.

Figure B is a cross-section of the coronary artery with plaque buildup and a blood clot.

A
Blocked blood ow Plaque buildup in artery

Healthy heart muscle blood clot blocks artery

Coronary artery

Heart Muscle Dead heart Muscle

Figure A is an overview of a heart and coronary artery showing damage (dead heart muscle) caused by a heart attack.

RISK FACTORS OF HEART ATTACK

Diet

lack of Exercies

Obesity

Age

Smoking

Diabetes

Hypertention

Stress

WARNING SIGNS OF HEART ATTACK

A study of heart attack survivors between the ages of 25-65 shows that one in four put their lives at risk by failing to recognize the symptoms Jaw:

Pain radiates up to jaw and into back

Left arm:

Pain radiates down arm, weakens muscles

Central chest:

Tight ache to intense agony, lasting 30 minutes or more Jaw: Pain radiates up to jew and into back

Abdomen:

Constrictive pain, angina pectoris - often mistaken for indigestion

What Is Hypertension?
Blood Vessels Elastisity Blood Viscosity Heart pump

Determined by 3 factors What Does your Blood Pressure Mean? Normal Warning Danger

Recommendations for follow up

Systolic 130 130-139 140-159 160-179 180 Initial Blood pressure Diastolic 85 85-89 90-99 100-109 110 Recommendations Check Check again in 2 years' time Check again in 1 years' time Conrm within 2 months' time Check/hospitalize within 1 months' time Check/hospitalize immediately or within 1 weeks' time, according to the clinical condition

Smoking

Who are at risk?

High salt intake

Stress

Diabetes

Obesity

What happen if you are not treated ?

Venule

Blocked coronary arteries

Damaged heart tissue

Damage to the eye

Healthy vessels Small hemorrhages Narrowing of arteries Exudates (accumulations of proteins that have leaked out

Tissue

Capillaries Arteriole Normal artery Damaged artery wall Calcium deposits Blood clot Blocked artery Fat deposits

Normal heart Enlarged heart Bleeding insufciency

Area of burst arterioles

Blockage insufciency
Area of blocked arterioles Dead brain tissue

Damage to Blood Vessels

Damage to the heart:

Heart disease leading to heart attack Congestive heart failure

Narrowing of renal artery

Circle of wills Aneurysm Blood from a bursl aneurysm Blocked artery

Blood clot

Circle of wills Diseased kidney

Damage to the Brain:

Damage to the kidneys:

Stroke Cerebrovascular insufciency

Blood vessels damage Kidney disease leading to failure

has no sexual agshporion can be used safely with other blockers

is structurally different from conventional blocking drugs

better efficacy compared to any other hypertencive

Meta analysis of efcacy of antihypretensive agent

Proportion of patients with normalised blood pressure
Nebivolol VS
Lisinopril ACE-1 ARB Atenolol Metoprolol BB Nifedipine Nifedipine CCB Combined
0.1 0.2 0.5

odds Ratio
1

10

Mor effective in normalising blood pressors and Reducing central activ pressure

Favours Control

Favours Nebivolol

Can used safely in Diabitic hypertensive Better metabolic Profile

Better metabolic Profile Less or new onser diabetes

with dual mechanism of action, provides reduction of LDL level by 65%

The Dual Inhibition Concept offers broader Lipid control and increases the likelihood of patients reaching their LDL-C goals
Inhibition of cholesterol absorption
Synthesis

Inhibition of cholesterol synthesis

Absorption

Dual inhibition

LDLc

80% -50%
Absorption

21% -38%
Synthesis

-22%
Synthesis

-25%
Absorption

15-20%

25-45%

45-65%

HELPING MORE CHD OR CHD RISK EQUIVELANT TO REACH LDL GOAL OF LESS THEN 70MG/DL

100 Patients (%) attaining LDL-C < 70 mg/dl 80 60

Atovastatin (Ator) Ezetimibe/simvastatin (Eze/Sim) 64.1 64.1

81.8

40 20 0

23.8

26.3

31.2

VYTAL

Ator 10 mg/d vs Eze/Sim 20 mg/d

Ator 20 mg/d vs Eze/Sim 20 mg/d

Ator 40 mg/d vs Eze/Sim 40 mg/d

REDUCES C-REACTIVE PROTEIN

20 Median Change (%) 10 0 -10 -20 -30 -40 -50 3.2 Placebo

Ezetimibe Pooled Pooled Ezetimibe 10mg Simvastatin +Simvastatin

-6.3 -14.3

HOW IS CORONARY ANGIOPLASTY DONE?

Coronary Balloon Angioplasty Angioplasty With Stent Placement

An illustration showing the possible insertion sites for a catheterization procedure