Dyslipidemia

Question 1

Triglycerides serve what function in the body?

Answer 1

Essential energy source

Question 2

Cholesterol is needed for what in the body?

Answer 2

Cell membrane structure, bile acid formation, steroid hormone synthesis

Question 3

Hyperlipidemia can be..

Answer 3

Hypercholesterolemia

Hypertriglyceridemia

Elevated LDL

Question 4

Physical exam findings in hyperlipidemia

Answer 4

Xanthelasma

Circumferential arcus

PVD

Thickened achilles

HTN

Question 5

If not fasting for lab testing, which values should you pay attention to?

Answer 5

Only Total and HDL. If TC are over 200mg/dl or HDL<40, retest

Question 6

Total cholesterol numbers

Answer 6

Good- 240 mg/dl

Question 7

HDL numbers

Answer 7

Low- 60 (very good)

Question 8

LDL numbers

Answer 8

Optimal- 190

Question 9

Are numbers supposed to be important anymore?

Answer 9

No, should be focusing on RISK

Question 10

What are the typical total cholesterol and TC in someone with primary hyperlipidemia?

Answer 10

Total >200, TC often >500

Question 11

Causes of secondary hyperlipidemia

Answer 11

DM
Hypothyroid
Obstructive liver disease
Chronic renal failure
Drugs such as progestins, corticosteroids, anabolic steroids

Question 12

When should lipid screening start? When to re-screen?

Answer 12

All adults 20 and older. Every 4-6 years if numbers/risk normal.

Question 13

A lipid screen should include which tests?

Answer 13

Total, LDL, HDL, TC, ALT, CK, HbA1c. Complete 10 year estimated ASCVD risk assessment.

Question 14

What intervention should everyone receive, regardless of risk or numbers?

Answer 14

Therapeutic lifestyle changes. Reduce saturated fats/cholesterol, increase activity, control weight.

Question 15

Diet effects on HDL

Answer 15

ETOH, saturated fats, and weight loss RAISE HDL

Low fat diet, sugar intake, excess calories, and excess polyunsaturated fats LOWER HDL

Question 16

Diet effects on LDL

Answer 16

Saturated fat, trans fatty acids, and cholesterol RAISE LDL

MUFAs, complex carbs, and soy LOWER LDL

Question 17

Diet effects on total cholesterol

Answer 17

Saturated fats and trans fatty acids RAISE total cholesterol

Substituting MUFAs and complex carbs for saturated fats, soy LOWER total cholesterol

Question 18

Diet effects on TC

Answer 18

ETOH, sugar, high carb diet, excess calories RAISE TC

Weight loss, omega 3 fatty acids LOWER TC

Question 19

Total fat recs

Answer 19

25-35%

Question 20

Total carb recs

Answer 20

50-60%

Question 21

Daily fiber recs

Answer 21

20-30 grams

Question 22

Total protein recs

Answer 22

15%

Question 23

Total daily cholesterol intake should be

Answer 23

less then 200mg

Question 24

ASCVD risk factors

Answer 24

Gender, age, race, total cholesterol, HDL, systolic BP, treatment for BP, diabetes, smoker

Question 25

What drug class is the focus of ASCVD prevention?

Answer 25

Statins

Question 26

Name the four main categories established for statin therapy for secondary prevention of ASCVD

Answer 26

Clinical ASCVD LDL >/= 190 Diabetes >/= 7.5% estimated 10-yr ASCVD risk

Question 27

You would expect to see an LDL reduction of _____ in moderate intensity statin therapy

Answer 27

30-50%

Question 28

You would expect to see an LDL reduction of _____ in high intensity statin therapy

Answer 28

50% or greater

Question 29

What is the LDL level at which there is generally a reduction in ASCVD risk with statin therapy

Answer 29

LDL >70

Question 30

Primary agents and doses for low intensity statin therapy

Answer 30

Pravastatin 10-20mg Lovastatin 20mg

Question 31

What reduction in LDL can be expected with low intensity statin therapy?

Answer 31

<30%

Question 32

What are the primary agents and doses for moderate intensity statin therapy?

Answer 32

Atorvastatin 40mg Rosuvastatin 10mg SImvastatin 20-40mg Pravastatin 40mg Lovastatin 40mg Fluvastatin 40mg BID

Question 33

Which agents and doses are used in high intensity statin therapy?

Answer 33

Atorvastatin 80mg Rosuvastatin 20mg

Question 34

How do statins work?

Answer 34

Inhibition of HMG-CoA reductase, which is the rate limiting enzyme is the formation of cholesterol

Question 35

What effect do statins have in general on lipid profile

Answer 35

Decrease LDL Decrease TG Increase HDL

Question 36

Statin therapy recs for clinical ASCVD

Answer 36

75 and under- high intensity statin therapy Over 75 or unable to tolerate high intensity therapy- moderate intensity therapy

Question 37

In primary hyperlipidemia, a reduction in LDL of 39mg/dl results in ASCVD risk reduction by

Answer 37

~20%

Question 38

Statin therapy for primary hyperlipidemia is for patients with an LDL of

Answer 38

190 or more

Question 39

What is a secondary concern for patients with primary hyperlipidemia?

Answer 39

High TG level, which may require therapy in addition to statins

Question 40

When considering statin therapy for ASCVD risk reduction in diabetes, does the type (I or II) matter?

Answer 40

No, Type I or II treated the same for ASCVD risk

Question 41

Which level of therapy is acceptable for diabetics with an LDL greater than 190?

Answer 41

Moderate intensity therapy

Question 42

When is high intensity therapy needed in diabetes?

Answer 42

LDL greater than 190 and 10yr ASCVD risk > 7.5%

Question 43

When should a 10yr ASCVD risk assessment be completed?

Answer 43

In patients without ASCVD or DM with an LDL<190

Question 44

Why are statins so great?

Answer 44

They demonstrate substantial ASCVD risk reduction across all LDL levels, especially for those with high ASCVD risk

Question 45

What are some areas that need additional investigation in the new ASCVD risk reduction guidelines?

Answer 45

- Other biomarkers to guide treatment - Best non-invasive imaging for risk assessment - Lifetime vs 10yr risk and optimal age to begin statins - Other subgroups such as HF, ESRD on HD, HIV, solid organ transplant, etc.

Question 46

What are the secondary treatment goals of the guidelines?

Answer 46

Treat TG >200 if LDL goal has been achieved Treat low HDL (<40)

Question 47

Cholestyramin (Questran), Colestipol, and Colesevelam are all _____ and work by

Answer 47

Bile acid sequestrants Bind bile acids in the intestines --> liver uses more hepatic cholesterol to produce bile --> decreased LDL and increase in HDL

Question 48

What effect does nicotinic acid have on blood lipoproteins?

Answer 48

Causes a reduction in the synthesis of VLDLs which results in decreased LDLs and TGs and an increase in HDLs

Question 49

Gemfibrozil (Lopid), Fenofibrate, and Clofibrate are all ________. How do these agents work?

Answer 49

Fibric acid derivatives They reduce synthesis and increase the breakdown of VLDLs which results in decreased LDLs and TGs and an increase in HDLs

Question 50

How does Ezetimibe (Zetia) work?

Answer 50

Inhibits absorption of cholesterol and phytosterol at the brush border. Has little effect on vitamin A,D,E, and K (fat soluble vitamins) or the CYP450 system. Used in conjunction with a statin

Question 51

Statin plus Ezetimibe results in an LDL reduction of ______ Statin plus bile acid sequestrant results in an LDL reduction of ______

Answer 51

~25% ~8-16%

Question 52

Nasty risk associated with statin use

Answer 52

Myopathies

Question 53

Statin plus fibric acid derivative is used for _______, increases the risk of ________ and is contraindicated in _________.

Answer 53

decreasing TGs myopathies severe hepatic disease

Question 54

Statin+Niacin=

Answer 54

:-( Also, increased risk of hepatic dysfunction

Question 55

Significant drug interactions with Lovastatin and Simvastatin

Answer 55

``` Itraconazole (Sporanox) Ketoconazole (Nizoral) Erythromycin Clarithromycin (Biaxin) Gemfibrozil Grapefruit juice ```

Question 56

Individuals at increased risk for statin induced myopathies

Answer 56

``` >80 Small body frame Frailty Impaired renal/hepatic function ETOH ```

Question 57

Drug combos with statins that increase myopathy risk

Answer 57

``` Niacin Gemfibrozil Cyclosporin HIV protease inhibitors Verapamil Amiodarone ```

Question 58

Currently the only lipoprotein lowering agent safe for use during pregnancy

Answer 58

Bile acid sequestrants

Question 59

In the future we'll be using

Answer 59

Cholesteryl ester transfer protein inhibitors (CETP) Exchanges lipoprotein particles in a reverse cholesterol transport process (Sounds pretty serious...) Significant DROP in LDL along with a bump in HDL Anacetrapib and Dalcetrapib are possible candidates (Fun fact- Anacetrapib can stick around in the body for 4 years after cessation of therapy, kind of freaks some researchers out, but YOLO, right?)

Question 60

Another potential future therapy for altering lipoprotein profile is Eprotirome. Whats it do?

Answer 60

Thyroid hormone acts to mediate lipid lowering activity. Eprotirome is an analog of thyroid hormone. Up to an additional 30% reduction in lipoproteins when added to statin therapy (Apparently the company developing this drug pulled the plug a year ago due to really bad "unwanted effects after long term exposure"...why are we learning this crap?)

Question 61

Microsomal triglyceride transfer protein inhibitors, another possible future treatment, does what

Answer 61

Reduces the secretion of VLDL in the liver Provides up to 50% reduction in plasma LDL levels

Question 62

Mipomersen, future therapy candidate, does what

Answer 62

May reduce plasma levels of lipoprotein A Being tested in severe hypercholesterolemia and statin intolerant pts

Question 63

Take home message- The focus should be on assessing a patient’s risk for Atherosclerotic Cardiovascular Disease and whether they fall into one of the four statin therapy groups, which are.....

Answer 63

Clinical ASCVD LDL > 189 Individuals 40-75 with Diabetes and LDL 70-189 without ASCVD Individuals 40-75 with Diabetes and LDL 70-189 and a 10-year ASCVD risk of 7.5% or higher

Question 64

What determines the intensity of statin therapy?

Answer 64

Presence of Clinical ASCVD Risk of Developing ASCVD Presence of Diabetes with/without hyperlipidemia Presence of isolated hyperlipidemia (genetic component)