Dyslipidemia, anticoagulants Flashcards Preview

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Flashcards in Dyslipidemia, anticoagulants Deck (73):
0

What does cholesterol produce?

Cell Membranes, bile acids, steroid hormones
(Lipoproteins = triglycerides + cholesterol)

1

What might you find on a physical exam of someone with hyperlipidemia?

Xanthelasma: fatty deposits on hands, arm, face
Circumferential arcus: white ring around eyelid/iris (fat)
PVD: shiny extremities, discoloration of skin, hairlessness
Thickened achilles
HTN

2

If fasting, which lab results do you look at to determine if someone has hyperlipidemia, if they don't fast which lab results do you look at?

Fasting: Total cholesterol, LDL, HDL, TAGs
Not fasting: total and HDL
If total is more than 200 mg/dl or HDL less than 40, test again with fasting

3

What total cholesterol levels are desirable vs. borderline vs. high?

Desirable: less than 200 mg/dl
Borderline: 200-239
High: over 240

4

What levels of HDL are considered high vs. low?

High: over 60
Low: under 40

5

What levels of LDL are considered optimal, near optimal, borderline high, high, and very high?

Optimal: less than 100
Near optimal 100-129
Borderline high: 130-159
High: 160-189
Very high: over 190

6

What is primary hyperlipidemia?

Genetic heterozygous condition resulting in elevated total cholesterol (over 200) or triglycerides (over 500)
These patients are prone to pancreatitis

7

What is secondary hyperlipidemia?

Hyperlipidemia caused by diseases or drugs
Diabetes, hypothyroid, obstructive liver disease, chronic renal failure, alcohol, HIV/AIDS, obesity
Drugs: progestins, corticosteroids, anabolic steroids

8

Who is screened for hyperlipidemia? How often? What tests are done?

Adults over 20
Every 4-6 years
Fasting lipoprotein profile: total cholesterol, LDL, HDL, triglycerides
ALT, DK, HbA1c
Estimated 10 year ASCVD risk

9

What do the newest guidelines from the ACC/AHA focus on regarding hyperlipidemia?

Lower cholesterol by improving overall health as number one focus, if that doesn't work then add medication

10

What factors elevate and lower HDL?

Elevate: alcohol, saturated fats, weight loss
Lower: low fat diet, sugar, excess calories, polyunsaturated fats

11

What factors elevate and lower LDL?

Elevate: saturated fat, trans fatty acids, dietary cholesterol
Lower: MUFAs, complex carbs, and soy

12

What factors elevate and lower cholesterol?

Elevate: saturated fats, trans-fatty acids
Lower: substituting MUFAs and complex carbs for saturated fats, soy

13

What factors elevate and lower triglycerides?

Elevate: alcohol, sugar, high carb diet, excess calories
Lower: weight loss, fish oils

14

What are the 4 categories established indicating statin therapy for secondary prevention of ASCVD?

1. Clinical ASCVD
2. LDL over 190
3. Diabetes
4. Over 7.5% estimated 10-year ASCVD risk

15

How do HMG-CoA Reductase Inhibitors work? (AKA statins)

Inhibit the rate-limiting enzyme in the formation of cholesterol
Interrupts the process that the body is storing fats
Effect is to decrease LDLs, decrease TGs, and increase HDLs

16

For someone with clinical ASCVD, at what age should they receive high vs. moderate-intensity statins?

75 or older = high intensity statins
Under 75 = moderate intensity statins

17

What are bile acid sequestrants? Name a few

Work by binding bile acids in the intestine, resuting in the liver using hepatic cholesterol to producce more bile acids
Effect is to decrease LDLs and increase HDLs
Cholestyramine (Questran), Colestipol, Colesevelam
Note: these make the patient have oily poops

18

How does nicotinic acid (niaspan, niacin) work?

Reduces the production of VLDLs
Effect is to reduce LDLs, TGs, and increase HDLs
Note: it causes flushing, sweating

19

How do fibric acid derivatives work? Name a few

Fibrates reduce the synthesis and increase the breakdown of VLDLs
Effect is to reduce LDLs, decrease TGs, and increase HDLs
Gemibrozil (lopid), fenofibrate, clofibrate

20

How does eztimibe (zetia) work?

Works by inhibiting cholesterol and phytosterol absorption from the brush border of the intestines
No effect on fat soluble vitamins (A,D,E,K)
No effect on CYP450
Used in combination with a statin
Not used as often because of coronary side effects

21

What can happen with patients taking statins and fibric acids together?

Increased risk of myopathy
Contraindicated with severe hepatic disease

22

What can happen with patients taking statin and niacin?

Increased risk of hepatic dysfunction

23

Name some drug interactions with lovastatin and simvastatin

Intraconazole (sporanox)
Ketoconazole (nizoral)
Erythromycin
Clarithromycin (biaxin)
Gemfibrozin
Grapefuit juice

24

Who is at greater risk of myopathy?

Age over 80
Small body frame and frail
Impaired renal/hepatic system
Alcohol abuse

25

What drugs combined with statins increase risk of myopathy?

Niacin
Gemfibrozil
Cyclosporin
HIV protease inhibitors
Verapamil
Amiodarone

26

What drugs should pregnant and nursing women avoid related to hyperlipidemia? What is the only safe drug they can take?

Statins
Ezetimibe
Niacin
Fibric acid derivatives
Bile acid-binding resins are the only safe drugs during pregnancy (oily poop drugs!)

27

How quickly does primary hemostasis start working?

Occurs immediately (seconds-minutes) in response to a vessel injury that results in a "platelet plug"

28

How does primary hemostasis work?

Exposed subendothelial collagen attracts circulating platelets, which then adhere to each other. These platelets adhere, degranulate, and aggregate
Promoted by a group of pro-coagulants (von willebrand factor, clotting factor VIII, ADP), causes localized vasoconstriction

29

How do platelets activate, degranulate and aggregate in primary hemostasis?

Adhered platelets activate and change shape forming pseudopods (like an "arm" that grabs platelet to form a platelet plug) and release thromboxane A2
Platelets degranulate, releasing a variety of biochemicals.
Aggregation begins, using fibrinogen and vWF and a connecting agent

30

What agents are released during degranulation?

Serotonin, histamine (vasoconstrict)
Thromboxane (vasoconstrict, degranulate platelets)
ADP (makes plasma membrane sticky, degranulates platelets)
Clotting factors Va, VIIIa, IXa
Platelet factor 4 (heparin neutralizing factor, enhances clot formation)

31

What is secondary hemostasis?

Takes minutes to hours and results in fibrin clot formation
The fibrin clot is a meshwork of protein that acts as a net to collect other cells and stabilize the platelet plug. Then the net retracts and fibrin strands shorten to trap the platelets.
Each clotting factor is converted to its active form until fibrin ends the coagulation cascasde

32

Once the coagulation process is activated, what natural anticoagulants regulate this process?

Prostacyclin
Antithrombin III
Heparin
Protein C
Protein S

33

What mediates lysis in the fibrinolytic system?

Plasmin, activated by coagulation and inflammation substances
Plasmin splits fibrin and fibrinogen into fibrin degradation products

34

Name some oral and IV antiplatelet medications

Oral: aspirin, ticlopidine, clopidogrel (plavix), prasugrel, ticagrelor
IV: abciximab, eptifibatide, tirofiban

35

What is aspirin? What is the normal dosage?

COX inhibitor, prevents production of thromboxane A
The action is irreversible, lifespan of a platelet is 10 days
Dosage 81-325 mg every day

36

Aspirin precautions?

Children (reye's)
Pregnancy
CV (blunts effect of ACEI, b-blockers, diuretics due to prostaglandin inhibition)
Asthmatics (increased leukotrienes which increase bronchoconstriction
Increased bleeding with other anticoagulants (treat with platelet transfusion)

37

What class ticlopidine (ticlid) and clopidogrel (plavix)? How do they work and why are they used?

Thienopyridine that blocks ADP receptor on platelet and inhibits fibrinogen from binding
Used for prevention of ischemic events (for patients with aspirin intolerance)
Plavix is also used in combination with aspirin

38

Why is hardly anyone on ticlipidine (ticlid) anymore?

Risk for...
Neutropenia
TTP
GI upset
Teratogenesis

39

Clopidogrel (plavix) precautions?

Metabolized by CYP2C19, genetic predisposition to poor metabolism along this pathway, may require increased dosing
CP450 inhibitor
Dose adjustment for renal/hepatic disease

40

What is prasugrel (effient)? How does it compare to clopidogrel?

New thienopyridine that has greater prevention of platelet aggregation than clopidogrel but more fatal events and higher risk of bleeding during CV surgery

41

What is ticagrelor (brilinta) and how does it compare to clopidogrel?

Allosteric antagonist, blocks ADP receptors from a different binding site
Reduces death rates after MI more than clopidogrel
BUT, there is a higher rate of non-procedure related bleeding and higher incidence of fatal intracranial hemorrhage compared to clopidogrel
Used in combo therapy with ASA, precaution: hepatic dysfunction

42

What are GPIIb/IIIKa inhibitors? What are they used for? Name a few

Block the GPIIb/IIIa receptor, preventing fibrinogen binding
Used for acute coronary syndrome and PCI
Abciximab (ReoPro), eptifibatate (integrillin), tirofiban (agrastat)

43

Why would you use Abciximab vs eptifibatide? How would you treat bleeding?

Abciximab for ACS with planned PCI, most prolonged effects
Eptifibatide for the same thing, dosage based on serum creatinine (decreased dosage for creatinine 2-4)
For bleeding, reverse with platelets if they are on abciximab, just discontinue the drug if they are on eptifibatide or tirofiban

44

When are antiplatelets stopped before surgery and restarted?

7-10 days before surgery, resume 24 hours after surgery
Clopidogrel should be stopped 5 days before surgery
Patients at high risk for cardiac events should not discontinue

45

How does heparin work? What are the uses?

It is a heterogenous mixture of polysaccharide chains
Activates Antithrombin III which increases inhibition of Thrombin IIa and Factor Xa by 1000-fold
Uses: DVT/PE tx, DVT prophylaxis, ACS, warfarin contraindicated

46

True/False: Heparin has an inability to inhibit clot-bound thrombin.

TRUE, this is a major drawback of heparin use

47

When heparin causes bleeding, what is the reversal?

Protamine 1 mg/ 100 units of heparin given OR 50mg bolus of protamine

48

Type 1 vs. Type 2 HIT

Type 1: non-immune mediated, benign, mild drop in platelets, usually within 4 days of heparin tx, NOT associated with thrombosis
Type 2: immune mediated, starts 5-14 days of heparin tx, reduction in platelets less than 150k or decrease by 50% of baseline

49

What is HITT?
10-25% of cases
25-30% mortality

Thrombocytopenia with thromboembolism
Venous (more common): DVT, PE, gangrene, dural sinus thrombosis
Arterial: cerebral infarction, limb ischemia, skin necrosis, MI, gut, renal, adrenal infarction

50

What lab tests help diagnose HIT?

ELISA assay (measures titer of IgG to heparin)
C-serotonin release assay (detects platelet activation, not readily available)

51

HIT treatment?

Don't delay treatment waiting for labs!!
Stop heparin and start argatroban (or another non-heparin anticoagulant)

52

How does a low molecular weight heparin (enoxaparin/lovenox) work? What is it used for?

Binds with Antithrombin III and inhibits factor Xa
Uses: DVT prophylaxis (40mg qd), ACS (1mg/kg q12h), VTE tx

53

LMWH precautions? (exoxaparin/lovenox)

Pregnant women (monitor anti-Xa levels)
Obese pt (needs weight based)
NOT recommended for renal insufficiency
Spine surgery pt or epidural

54

Fondaparinux (arixtra): class of drug, how does it work, what are the uses?

Synthetic factor Xa inhibitor
Binds with anti-thrombin III to potentiate Xa inhibition (no effect on IIa)
Uses: ACS, PE/DVT tx, DVT prophylaxis (7.5 mg)

55

What are argatroban and lepirudin used for? What is bivalirudin used for? What class are these drugs?

IV direct thrombin IIa inhibitors
Argatroban and lepirudin for HIT
Bivalirudin for PCI
Note lepirudin ad desirudin can only be used once due to anaphylaxis issues

56

IV direct thrombin IIa inhibitors interactions? Treatment of bleeding?

Interactions: increased bleeding with anticoagulants, thrombolytics, antiplatelets
Treatment of bleeding: stop infusion, can give Factor VII, FFP, and cryoprecipitate

57

How does warfarin work? What is it used for?

Interferes with production of Vitamin K-dependent clotting factors (II, VII, IX, X) and interferes with carboxylation of natural anticoagulants (Protein C and S)
Uses: prevention clot/embolis with DVT, Afib, and mechanical heart valves, long term tx of VTE

58

Warfarin dosing is based on ____ (lab value). Start with 5-10 mg/day. Overlap with heparin/LMWH for ___ days

INR
Therapeutic INR is 2-3
Overlap for 1-2 days

59

List warfarin adverse effects and interactions

Adverse effects: Bleeding, birth defects, cutaneous necrosis. Use caution in NSAIDs and antiplatelets
Interactions: Increases effect of amiodarone, cimetidine, acetaminophen, and phenylbutazone. Decreases effect of sucralfate, cholestyramine, spironolactone, barbituates, and Vit K foods

60

Reversal/treatment of bleeding with warfarin therapy?

Vitamin K
FFP
Note: FFP's INR is 1.5 so it can't help more than that

61

If warfarin is d/c for surgery, how long before surgery is it d/c and how long post-op until it is resumed?

5 days before surgery d/c
12-24 hours post-op resume
Bridging with heparin up until 4 hours of surgery is a possibility too

62

Dabigatran (pradaxa): drug class, uses?

Direct thrombin inhibitor IIa (new oral anticoagulants)
Uses: prevents stroke for Afib and treats DVT/PE

63

Dabigatran (pradaxa) advantages and disadvantages?

Adv: no routine monitoring, predictable pharmacokinetics, less diet/drug interactions, rapid peak (1 hr), short half-life (12 hrs)
Disadv: high cost, bid dosing, no antidote, no assay for monitoring effect, no long term data

64

Rivaroxaban (xarelto): class, use?

Class: direct factor Xa inhibitor
Use: stroke/embolism prevention in Afib, prevents DVT, treats PE/DVP

65

Rivaroxaban (xarelto): advantages/disadvantages?

Adv: no routine, monitoring predictable pharmacokinetics, less diet/drug interactions, rapid peak (2.5-4h), short half-life (7-11h)
Disadv: high cost, no antidote, no assay, no long term data

66

Apixaban (eliquis): class, use?

Class: direct factor Xa inhibitor
Use: stroke/embolism prevention in Afib, prevent DVT, tx DVT/PE

67

Apixaban (eliquis): advantages/disadvantages?

Adv: no routine monitoring, predicable pharmacokinetics, less diet/drug interactions, rapid peak (3h), short half-life (12h)
Disadv: high cost, bid dose, no assay, no long term data, reversed ONLY with prothrombin complex concentrate

68

How do fibrinolytics work? Name some.

Plasminogen activators convert plasminogen to plasmin
Plasmin causes fibrinolysis
Streptokinase, urokinase, tPA, recombinant tPA (alteplase, reteplase), tenecteplase (TNK-ase)

69

Fibrinolytic uses?

Acute STEMI
Acute ischemic stroke
Urokinase used for CVC de-clotting and PE

70

Fibrinolytic absolute contraindications?

Previous hemorrhagic stroke
Ischemic stroke within 3 mo
Intracranial neoplasm
Active internal bleeding
Aortic dissection (CXR r/o wide mediastinum)
Significant head/facial trauma within 3 mo

71

Fibrinolytic relative contraindications?

Uncontrolled HTN (180/110)
Severe chronic HTN
Current use of anticoagulants (INR over 2.5)
Bleeding disorder
Non-compressible vascular puncture

72

What statins are indicated for low, moderate, and high intensity statin therapy?

HIGH: Atorvastain 80mg, rosuvastatin 20mg
MODERATE: atorvastatin 40, rosuvastain 10, simvastatin 20-40, pravastatin 40, lovastatin 40, fluvastatin 40, pitavastatin 2-4
LOW: pravastatin 10-20, lovastatin 20, simvastatin 10, fluvastatin 20-40, pitavastatin 1