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Flashcards in Dislipidemia Deck (71):
1

Dyslipidemias include?

High LDL

Low HDL 

High TG

2

Chylomicrons?

  • Transport fatty acids and cholesterol from the intestine to the liver
  • TG rich
  • Clears from the blood stream within 12 hours 

3

Lipoprotein Analysis should be done when patient has?

Fasted for 9-12 hours 

4

Along with age and family history risk factors for CHD include?

Hypertension or on HTN meds

Low HDL 

male- <40mg/d

FM- <50 mg/dl

5

C-reactive protein or CRP is what type of marker?

What are the ACC/AHA guidelines?

Inflammatory marker

hsCRP

< 1 mg/l= low risk

1-3= moderate

>3 is high risk 

6

Normal levels of Lp (a) are?

How can it be treated?

< 30 or 75 nmol/L 

Niacin, Estrogens, PCSK9-I

7

Vit D insuffieciency is linked to?

CHD and total mortality 

8

Combined cholesterolemia is?

High TG and Cholesterol

9

Mixed Dyslipidemia is?

High TG and low HDL

10

What are the two types of Familial Hypercholesterolemia?

Heterozygous 

Homozygous

11

What are the secondary causes of Hypercholesterolemia?

  1. DM
  2. Obese
  3. Alcohol
  4. Hypothyroidism 
  5. HIV
  6. Liver impairment
  7. CKD
  8. Pregnancy
  9. Menopause
  10. Autoimmune dissorders

12

LDL-C 

Desirable?

 

very high

 

<100

 

>190

13

TG levels?

Normal? 

 

very high?

<150

 

>= 500

14

Non HDL Cholesterol

Desirable?

 

Very high

<130

 

>= 220

15

Drug induced Dyslipidemia?

Thiazides

BBs

Estrogens

Atypical 

Steroids

Cyclosporine

Protease inhibitors 

Retinoids

  • ^LDL and TGs
  • Decrease HDL, ^ TGs
  • ^HDL and TGs, decrease LDL
  • decrease HDL  ^TGs
  • ^LDL and TGs
  • ^LDL and TGs
  • ^LDL and TGs, Decrease HDL
  • ^LDL and TGs, decrease HDL

16

The 2013 ACC/AHA Guideline Key Points?

  1. Encourage adherence of a heart healthy lifestyle
  2. Statins are recommended for adults in groups demonstrated to benefit
  3. Engage in Clinic patient discussion before initiating statin therapy 
  4. Initiate the appropriate intensity of statin therapy to reduce ASCVD risk
  5. Used Pooled cohort equation for estimating 10-ASCVD risk
  6. Evidence is inadequate to support specific LDL ot non HDL goals
  7. Nonstatin drug therapy may be considered in selected individuals  

17

NHLBI

Recommendations based on RCT evidence

Less expert opinion than in prior guidelines 

18

The changes from ATP-III

  • Dont focus on specific LDL or non HDL goals 
    • Obtain a lipid panel to monitor adherence 
  • Use medications proven to reduce ASCVD risk 
    • Moderate to high intensity statin 
  • Four Statin-Benefit groups
  • Risk decisions in primary prevention
    • Optimal lifestyle 
    • Clinic patietn discussion-shared decision making

19

What is the first statin benefit group?

Clinical ASCVD

  • MI, Angina, Revascularization
  • Stroke
  • Peripheral Vascular Disease

20

2nd Statin benefit group?

LDL-C >= 190 and >= 21 years 

21

3rd statin benefit group?

DM: Age 40-75 years, LDL-C 70-189 mg/dL

22

4th statin benefit group

Primary Prevention 

  • Risk calculator >= 7.5% 10 year 
    • No DM 
    • Age 40-75 
    • LDL-C 70-189 mg/dL

23

Summary of statin initiation recommendation to Reduce ASCVD risk

Is the patient older than 21 and have ASCVD?

If so is the patient older than 75?

 

if older than 21 and less than 75 initiate high-intensity statin therapy 

Patient is greater than 75 or not a canidate for High-intensity initiate moderate intensity 

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24

Summary of statin initiation recommendation to Reduce ASCVD risk

Does the patient not have ASCVD? 

 

Then if patient has a LDL >=190 initiate high intensity therpay

If it is not that high but the patient has DM with an LDL 70-189 age 40-75 Initiate moderate statin 

But if the patient calculated risk is >=7.5% then initiate high intensity therapy 

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25

Summary of statin initiation recommendation to Reduce ASCVD risk  

If the patient does not fit initial criteria move to primary prevention 

 

If patient if patient has LDL 70-189 and not receiving statin therpay 

Calculate their 10 year risk factor 

If >= 7.5% Moderate to High intenesity

5-less than 7.5 Moderate intensity

But during this time Clinicial-patient discussion must be made to decide if statin is the best choice for the patient. If no Encourage healthy lifestyle and manage other risk factors 

IF yes to statin do the same and initiate appropriate statin intensity. 

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26

High intensity statin therapy include what two drugs and what doses?

Atorvastatin 40 up to 80 mg 

Rosuvastatin 20 up to 40 mg 

27

Moderate intensity statin therapy drugs

 

Atorvastatin 10

Rosuvastatin 5 

Simvastatin 

Pravastatin 

lovastatin 

Fluvastatin 

28

Low intensity statin therapy?

Pravastatin 20 mg lower than moderate

Lovastatin 20mg loser than Moderate

29

ASCVD risk estimator 

>= 7.5%?

Moderate high intensity statin

30

Patients not in the benefit group what helps make clinical decisions?

  • Familial Hx
  • Elevated lifetime risk
  • LDL >= 160 
  • CRP >= 2.0 
    • CAC score >= 300

 

31

If patient is tolerant to therapy statin therapy when should you follow up?

4-12 wks 

32

To Lower LDL a patient should start eating?

Shouldnt eat?

Veggies, Fruits, whole grains, low fat dairy, poultry, fish, olive oil and nuts

Sweets, sugar sweetend beverages and red meats 

Restrict saturated and trans fats

33

What type of exercise should patients do>

aerobic activity 3-4 sessions weekly 

40 minutes per session 

34

Weight reduction and physical activity can have the biggest impact on?

Lowering TGs

35

Smoking cessation lowers your risk for what dramatically?

CHD

36

Estrogens can lower LDL but they also increase?

TG

37

Plant stanols a type of plant cholesterol can reduce?

LDL

38

Bile Acid Resins names

Colesevelam

Cholestyramine

Colestipol

39

Bile acid resins increase LDL receptor activity as a result these?

Reduce LDL but have also been known to increase HDL and TG

40

What are some adverse effects of Bile acid resins like, Colesevelam, Choletyramine, Colestipol 

These can also interact with?

Poor taste, GI dicomfort

DI with digoxin, levothyroxine, thiazides, warfarin, BBs, 

41

Nicotinic Acid or Niacin does what?

Move everything

Moves everything in the right direction

42

Adverse effects of Niacin?

Flushing is the main one and it can also increase uric acid and blood glucose 

can also cause hepatotoxicity but only with the sustained release forms increases AST and ALT 

43

Niacin interacts with what drugs?

Disease interactions?

Statins and fibrates 

DM, gout (uric acid0, PUD

44

With niacin dosing what should you do?

Start low and go slow

45

Fibrates?

What do they do?

Gemfibrozil

Clofibrate

Fenofibrate

Fenofibric Acid 

Lower hepatic TG production and VLDL synthesis 

 

46

Fibrate AE?

DI?

Gallstones, pancreatitis 

Increase LFT, myalgias

GI distress

These increase myopathy with statins (gemfibrozil) 

Increase prothrombin time in warfarin patients

47

Cholesterol absorption inhibitor?

Ezetimibe

48

Ezitimibe can be used?

As a therapy of its own or added to a statin

49

What is the action of Ezetimibe?

Selectively blocks intestinal absorption of dietary and biliary cholesterol 

NPC1-Like 1 

50

Ezetimibe reduces was type of cholesterol?

LDL and TG

also increases HDL

51

Ezetimibe has a DI with? 

AE

Cholestertyramine

More GI complaints compared to placebo

52

Statins inhibit?

HMG CoA reductase 

Increase LDL receptor activity 

this decreases LDL and TG and increases HDL

53

AE of Statins?

  • Myopathy
  • Rhabdomyolysis 
  • increases AST and ALT
  • Glucose impairment 
  • GI abdominal pain, cramping, farts
  • Sleep disturbances 

 

54

Statin DIs

 

  • These DIs increase myopathy
    • Itraconazole, ketoconazole, fluconazole
    • Amiodarone
    • Verapamil, Diltiazem
    • Erythromycin, clarithromycin
    • Grapefruit juice 
    • Cyclosporine
    • Gemfibrozil
    • Kind of niacin and Fenofibrate
  • Warfarin elevated prothrombin time 

55

Patients can be predisposed to Adverse effects what are some ways?

  • Multiple or serious comorbidities, impaired renal or hepatic function
  • Hx of previous statin intolerance or muscle disorders
  • Unexplained ALT elevations >= time ULN
  • Use of drugs affecting statin metabolism 
  • Age >75 
  • Asian ancestry 

 

56

It is important to check ____ function at baseline 

 

 

Hepatic function at baseline 

57

Decreasing the statin dose is reasonable if LDL levels fall below ___ two times

<40 

58

It may be harmful to initiate ____ at 80 mg or increase to ___ mg 

Simvostatin to 80 

59

Fish oil dosing?

Cardioprotective 1000-2000 mg EPA/DHA

Dylipidemia 2000-5000 mg 

 

60

Fish oil is MOA?

Antiplatelet 

Antiinflammatory 

TG lowering 

Antiarrhythmic

AntiHTN 

61

Precription fish oil products?

Lovaza 

Vascepa

Epanova 

 

62

Increase the dose of ____ gradually has been known to decrease?

Fish oil has been known to decrease SE

63

PCSK9 Inhibitors can drastically decrease?

LDL levels and can also decrease TG some

64

Mipomersen does what?

Decreases secretion of apo B containing lipoproteins from the liver 

adjunct therapy with lipid lowering meds 

65

Lomitapide?

MTP inhibitor that decreases lipoprotein production 

66

Management of reduced HDL levels <40 

 

  • First deal with LDL
  • Intensify non-pharm
    • Exercise
    • Diet/weight
    • SMoking
  • Acheive non-HDL goal
  • RCT data doesnt support treatment 
  • Niacin and fibrates can increase HDL 

67

You should treat LDL first unless TGs are >= ___?

500

68

High TGs are associated with?

Treatment?

Artherosclerosis 

  • Fat restrictions
  • focus on good carbs
  • etoh restriction
  • weight reduction
  • DM control 
  • Fibrates, niacin, fish oil, statins

69

Indications for LDL Apheresis?

  1. Hypercholesterolemic homozygotes with LDL > 500
  2. Heterozygotes with LDL > 300 
  3. Heterozygotes with LDL > 200 with documented CHD

70

The Improve-it study concluded that?

Addition of Ezitimibe with Simvostatin did in fact reduce LDL better than monotherapy of just statin

71