Dyslipidemia & CVD 2 Flashcards
(164 cards)
1
Q
Lifestyle modification approach for tx of dyslipidemia
A
- diet
- weight management : healthy and sustainable
- physical activity
2
Q
Benefits of weight loss of 2-7kg in terms of blood lipid profile?
A
- decrease LDL-C by 0.1 mmol/L
- decrease HDL-C by 0.03 mmol/L during loss and then increase by 0.04 mmol/L during maintenance
- decrease TG by O.07 mmol/L
3
Q
Benefits of physical activity (1200-2200kcal/week) in terms of blood lipids?
A
- decrease TG by 4-37%
- increase HDL-C by 2-8%
- decrease LDL-C by 0.7%
=> accentuated with weight loss
4
Q
Effect of resistance exercise
A
Little effect
5
Q
Which PA has the greatest benefits (kcal spent)
A
Volume/intensity of exercise
6
Q
Which PA has little effect on lipid profile
A
Resistance exercise
7
Q
Limitations of predictive equations
A
- different SFA have different effects
- predicts total cholesterol only
- assumes MUFA and carbohydrates are neutral
- effects on total cholesterol may not be linear
8
Q
Studies in 60s, 70s show:
A
Increased cholesterol in diet increases serum cholesterol levels
(don’t distinct LDL versus HDL)
9
Q
The 7 Countries Study =
- by who
- result
A
- Ancel Keys
- result:
- east Finland has the highest coronary deaths (on regressive line)
- Ushibuka has the lowest coronary death (on regressive line)
- Crete (mediterranean diet) = outlier not on regressive line,
10
Q
What +ve relationship was found by Keys?
A
+ve relationship between serum cholesterol and mortality due to heart disease
11
Q
What is dietary cholesterol and what is its impact on blood cholesterol levels
A
- found only in animal foods
- less effect on raising blood cholesterol than saturated fats but may be significant in some individuals
- very heterogenous responses to cholesterol
12
Q
How is the response to dietary cholesterol heterogenous ?
A
There are compensators (2/3) and non-compensators (1/3)
13
Q
T/F
Dietary cholesterol has a higher effect on raising blood cholesterol than saturated fats
A
False
But could be significant in non-compensators
14
Q
Average amount of cholesterol consumed
A
200-300mg/day
15
Q
What happens when non-compensators ingest cholesterol?
A
Increases synthesis and activity of LDL receptors
16
Q
Independent mechanisms of dietary cholesterol
A
- decreased synthesis and activity of hepatic LDLr
- increased cholesterol in chylo and chill remnants –> more atherogenic and increased cholesterol delivery to liver
- increased cholesterol in VLDL and VLDL remnants –> more atherogenic
- interferes with ability of HDL to clear cholesterol
17
Q
T/F
Cholesterol content is directly proportional to fat content
A
False
ex: high cholesterol in kidney, pancreas, liver but low fat
ex2: high fat in beef, lamb, pork, veal but low cholesterol
18
Q
Highest source of cholesterol
A
Brains > pancreas > kidney > liver
19
Q
Highest cholesterol content in fish & shellfish is in _
A
shrimp
20
Q
Total kcal from fat goal = _
A
25-35% of calories
Also helps to reduce T calories and saturated fat intakes
21
Q
Current intake in North America
A
34-37% of T kcal
22
Q
Which type of diet may decrease HDL-C which is not beneficial?
A
Very low-fat diet
23
Q
Is quantity or type of fat important?
A
Type of fat (or quality)
24
Q
How do saturated fatty acids reduce activity of LDL receptors?
A
- decrease transcription of LDL receptor gene
- alter PL composition of cell membranes to decrease binding
- alter LDL itself and delays binding to receptors
25
What was the first recommendation by NCEP and USDA for SFA?
Goal was less than 10% of T kcal from SFA
26
Major sources of SFA (US)
- highly processed foods
- processed meats
- baked goods (cakes, cookies, donuts)
- pizza
- cheese
- ice cream
27
Primary contributor to total SFA intake in Canada
"All other foods" category which is not part of the CFG
28
New recommendations by Heart and Stroke Canada, CFG in terms of saturated fats are _
no limit on saturated fats but focus on a healthy balanced diet
29
Substitution of SFA to improve lipid profile and reduce CVD risk
- replacing SFA with MUFAs and PUFAs
30
T/F
| Replacing SFA with carbohydrates is beneficial in CVD risk
F
| depends on source of carb
31
How dietary SFA affects lipid profile
increases LDL-C
| increases HDL-C (depends on source)
32
Medium chain SFA
Caprylic (8)
| Caproic (10)
33
Intermediate chain SFA
Lauric (12)
34
Long chain SFA
Myristic (14)
Palmitic (16)
Stearic (18)
35
Which SFA are directly absorbed into portal vein and don't go through CM
Medium chain SFA (<10)
36
SFA that increase LDL-C
- Lauric
- Myristic
- Palmitic (in presence of high cholesterol)
37
Stearic effect
neutral effect
38
Effects of medium chain SFA (<10) on serum cholesterol
No effect
39
Effect of SFAs on VLDL
None
40
Effects of SFAs from dairy products
decrease CVD risk (compared to SFA from meat)
41
Effects of SFAs from cheese
less increase LDL compared to butter
42
Highest SFA in :
- coconut oil
- butter
- palm oil
- coconut oil = high lauric
- Butter = high palmitic
- palm oil = very high palmitic
43
Coconut Oil vs butter
- Co has higher %SFA than butter
- Co has high lauric acid
- B has high palmitic acid
- Co better than butter but worse than other vegetable oils
44
Trans FA impact on lipid profile
- increase LDL-C
- reduce LDL size
- reduce HDL-C
- increase inflammatory markers (+endothelial damage)
45
Consumption of trans FA
3% T kcal (decreasing)
46
Sources of trans FA
- heard margarine
- partially hydrogenated oils
- dairy (small amounts, better effect)
47
Trans fat consumption should be _
avoided
48
Trans fat occurs as a result of _
partial hydrogenation
49
Unsaturated fatty acids in the diet
- Omega 9 (oleic acid)
- Omega 6 (linoleic acid)
- Omega 3 (linolenic acid, EPA, DHA)
50
Omega-6 effect on lipid profile
- increases LDL clearance
| - may decrease HDL formation and/or Apo-A1
51
Risk of high PUFAs
inflammation, increased oxidative damage to LDL
52
Omega-6 sources
corn, sunflower, safflower, soybean oils, walnuts, sunflower seeds
53
Goal of omega 6 in diet
5-10% of calories
54
Main Mono-unsaturated FA
Oleic acid
55
Source of MUFAs
olive, canola oil, peanuts, meat, poultry
56
Effects of MUFAs on lipid profile
- does not lower HDL-C
57
Goal of MUFA in diet
<20% of T kcal (assuming a lower saturated fat diet)
58
Advantages of MUFAs
- don't decrease HDL like PUFA and carbs
- less susceptible to oxidation than PUFA
- don't increase TG as carbs often do
- don't increase cancer risk of high PUFA could
59
MUFAs are characteristic of __ diet
Mediterranean
60
Dietary sources of linoleic acid
safflower oil
soybean oil
corn oil
sunflower oil
61
Dietary sources of oleic acid
```
olive oil
canola oil (rapeseed)
peanut oil
avocados
nuts
```
62
Types of Omega-3 PUFAs
- EPA: eicosapentanoic acid
- DHA: docosahexanoic acid
- ALA: alpha linolenic acid
63
DHA & EPA sources
fish
64
ALA sources
canola, linseed, soybean oil
65
Omega-3 effects on lipid profile
- decrease TG in hyperlipidemic and hyperTG patients
| - don't lower LDL-C
66
T/F
| CCS recommendations promote use of omega-3 PUFA supplements to reduce CVD events
False
| they emphasise on good sources such as fish, omega 3 fortified eggs
67
Omega 3s __ risk of mortality in those with CVD
reduce
68
Omega 3s interfere with :
platelet aggregation and prevent coronary thrombosis
delay proliferation of fibroblasts
69
Omega 3s reduce/ increase plaque formation and growth
Reduce (because they reduce adhesion of molecules)
70
T/F
| Omega 3s reduce the number of VLDL particles being secreted by the liver
False
| Omega 3s decrease the TG content of the VLDL particles
71
Goal of fiber in diet?
20-30g/day
| 50% soluble fiber
72
Soluble fiber effect on lipid profile
- decrease total-C
- decrease LDL-C
(depends on initial level of hyperchlesterolemia)
73
Soluble fiber sources
```
oats
legumes
pectins
psyllium
gums
```
74
Carbohydrate effect on lipid profile
- increased VLDL-TG production
| - decrease HDL-C
75
Disadvantage of high CHO diet (mostly simple CHO)
- decreased HDL and increased TG
- Hyper TG in some populations
- increase BG and hyperinsulinemia
76
Alcohol effect on lipid profile
- increased HDL-C
77
Is it okay to consume alcohol? How much?
OK if consumed in moderation
| 1-2 drinks/day
78
Which alcohol may inhibit cell-mediated oxidation of lipoproteins? Why?
Red wine
Due to resveratrol (polyphenol)
79
What is the French paradox?
That red wine polyphenols decrease risk of CHD (eventhough French have a high saturated fat diet)
80
Why should alcohol be avoided COMPLETELY if have familial hypertriglyceridemia?
Because alcohol inhibits acylCoA oxidation in the liver (--> TG formation)
81
Soy protein effects on lipid profile
- reduces Total-C
- reduces LDL-C
- reduces TG
- no effect on HDL-C
82
Food sources of soy protein
tofu
soy beverage
soy protein isolates
tempeh
83
US Health claim that __ g of soy protein, as part of a diet low in saturated fat and cholesterol may reduce the risk of heart disease
25g
84
Which compounds present in soy protein are beneficial
isoflavones
| phytoestrogens
85
3 antioxidants are
vitamin C
vitamin E
beta-carotene
86
Antioxidants effect on lipid profile
May inhibit LDL oxidation (decreases atherosclerosis risk-
87
Are antioxidant supplements recommended
No
88
Hyperhomocysteinemia increases/decreases incidence of CVD ? At which amount?
INCREASES
>14umol/L --> increased risk of heart disease
89
What is hyperhomocysteinemia caused by?
deficient folate and B6 causes high homocysteine
90
in which patients does hyperhomocysteinemia appear?
in up to 40% of patients with CVD
91
Does B12 deficiency elevated homocysteine?
No
92
Which deficiencies elevated homocysteine?
Folate
| B6
93
What are recommendations to avoid hyperhomocysteinemia
- increase food sources of folate
| - supplement (500yg/d ONLY if high levels or family history of CVD
94
Before supplementing folate which deficiency should you be careful about?
B12 deficiency could be masked
95
T/F
| Low levels of B12 are associated with increased risk of CHD
False
96
Food sources of folate
```
fortified cereals
vegetable
citrus fruits/juices
legumes
organ meats
```
97
What are phytosterols/stanols?
| What do they compete with?
- - Are equivalent to plant cholesterol
| - - Compete with cholesterol absorption : increase decal excretion
98
Diet enriched with 2-2.5g sterols/stanols reduced __ by 6-14% ?
LDL-C
99
Main source of stanols/sterols
Fortified margarine
100
Nuts are rich in which FA ?
rich in: mono- and polyunsaturated FA
| low in: SFA
101
Nuts are rich in what other nutrients ?
```
plant protein
soluble fibers
folic acid
antioxidants
arginine (= Nitric oxide precursor)
```
102
High intake (30-60g/d) __ risk of CHD.
Reduces
103
Moderate intake of nuts reduces which lipid?
Reduces LDL-C and improves endothelial function
104
T/F
| Eating nuts has a notable effect on body weight
False
105
NCEP =
National cholesterol education program (created the dietary approach for dyslipidemia)
106
Dietary approach of dyslipidemia targets:
1st target = LDL-C
other targets = metabolic syndrome factors (TG, HDL, waist circ)
107
What model does the dietary approach of dyslipidemia follow?
TLD model = therapeutic lifestyle changes
108
Therapeutic lifestyle changes decrease/ increase:
- decrease saturated fats and dietary cholesterol
- increase physical activity
- weight management to reduce coronary risk
109
- Step 1 to decrease saturated fats and cholesterol
| - Step 2 and 3
Step 1: < 10%SFA and < 300mg cholesterol
| Step 2 and 3: <7% SFA and <200mg cholesterol
110
Which diets (2) can be used for prevention or treatment of dyslipidemia ?
- The Mediterranean diet
| - The Portfolio diet
111
The Mediterranean diet is high in
- oleic acid (olive oil)
- fruits, vegetables, legumes
- fish
112
The Mediterranean diet is low in
- red meat
113
The Mediterranean diet is moderate in
- dairy (cheese and yogurt)
| - wine consumption
114
Results of Mediterranean diet
- decrease in CV events
- decrease LDL-C, app-B, TG
- increase HDL-C
- additive effect to statins
- decrease inflammatory markers
115
Mediterranean diet has a decrease in mortality of _ %
25%
= very high
116
What is the Portfolio diet?
- vegetarian diet
- low in saturated fat
- high in phytosterols, soy proteins, soluble fibres, almonds
117
Results of Portfolio diet:
- decrease in 29% LDL-C
| - decrease CRP
118
What is the problem with the portfolio diet?
Has a low adherence (40-45%)
| Was done in a very controlled environment
119
A low-fat diet with satins decreases LDL-C by _%. Is it more or less than the portfolio diet.
31%
| More
120
CCS Guidelines 2016 in terms of dietary recommendations
- healthy eating and activity and Mediterranean dietary pattern to lower CVD risk
- omega-3 PUFA supplements should not be used to reduce CVD events
- avoid intake of trans fats
- decrease intake of saturated fats for CVD risk reduction (substitute SFA with PUFAs)
- moderate energy intake to maintain/achieve a healthy body weight
- adopt a healthy dietary patterns
121
Healthy dietary patterns recommended by CCS Guidelines
- Mediterranean
- Portfolio
- DASH
- high in nuts (30g+/d)
- high in legumes (4servings+/d)
- high in olive oil (60mL+/d)
- rich in fruits and veg (5servings+/d)
- high in total fiber 30g+/d) and whole grains (3servings+/d)
- low-glycemic load or low-glycemic index
- vegetarian
122
Dietary factors that increase HDL-C
- saturated fats
- dietary chol
- alcohol (less han 2drinks/d)
123
Dietary factors that decrease HDL-C
- simple sugars/high carb diet
- polyunsaturated fat, high
- obesity
124
Other factors that increase HDL-C
- long-term aerobic exercise program
- estrogens
- female sex
125
Other factors that decrease HDL-C
- androgens
- male sex
- anabolic steroids
- some antihypertensive drugs
- diabetes mellitus
- cigarette smoking
126
What do Statins inhibit
HMG-CoA reductase
127
Statins examples:
- atorvastatin (Lipidor)
- lovastatin (Mevacor)
- simvastatin (Zocor)
- rosuvastatin (Crestor)
- pravastatin (Pravachol)
128
Mechanism of statins
Block cholesterol synthesis
| Increases LDL receptor mediated removal
129
Predicted effect of statins
- decrease LDL-C
- decrease TG
- increase HDL-C
130
4 classes of drugs to treat hyperlipidemia
- HMGCoA reductase inhibitors (Statins)
- Cholesterol absorption inhibitors
- Bile acid sequestrants (BAS)
- PCSK9 inhibitors
131
Cholesterol absorption inhibitor drugs
ezetimibe (Eztrol)
132
Ezetimibe mechanism
Inhibit cholesterol GI (intestinal) absorption
133
Ezetimibe predicted efect
Decrease LDL-C
134
Which 2 drugs are commonly used together?
Ezetimibe + statin
135
Bile acid sequestrant drugs
- cholestyramine (Questran)
| - colestipol (Colestid)
136
Bile acid sequestrants mechanism
- promote sterol excretion
- increases LDL receptors
- bind bile acids in the GI tract and prevent their reabsorption
137
Bile acid sequestrants predicted effect
- decrease LDL
138
PCSK9 inhibitor drugs
- evolocumab (Repatha)
| - alirocumab (Praluen)
139
PCSK9 inhibitors predicted effects
- decreased LDL
140
PCSK9 inhibitors mechanisms
prevent catabolism of LDL receptors
| block PCSK9 action --> more LDL recycling
141
2 classes of drug treatment of hypertriglyceridemia
- fibrates
| - nicotinic acid
142
Fibrates mechanism
decreases VLDL synthesis
| enhances LPL action
143
Fibrates drugs
Gemfibrozil (Lopid)
| Fenofibrate (Lipidil)
144
Fibrates predicted effect
decrease TG
decrease LDL-C
increase HDL-C
145
Nicotinic acid mechanism
decreases VLDL synthesis
| increases LPL activity
146
Nicotinic acid drug
Nicotinic acid slow release (Quest, Niaspan)
147
Nicotinic acid predicted effect
decrease TG
increase HDL-C
decrease LDL
148
Adverse effects of statins
myalgia, myopathy, increase liver enzymes, low risk of diabetes
149
Which statin interacts with grapefruit juice
Simvastatin
150
Side effects of ezetimibe?
diarrhea, rash, fatigue, muscle weakness, pain
151
Contra-indications to prescribing ezetimibe
liver disease or failure
152
When is it recommended to prescribe ezetimibe
As a second-line tx in patients with clinical CVD and targets not reached by maximal statin dose
153
Side effects of bile acid sequestrants (cholestyramine)
- constipation, pain, hemorrhoids
| - may decrease absorption of fat and liposoluble vitamins, Ca, Fe, Zn, Mg
154
Contra-indications to prescribing BAS
existing haemorrhoids, peptic ulcer, hiatus, hernia, multiple drug use, extensive travel, hypertriglyceridemia
155
Side effects of PCSK9 inhibitors
diarrhea, muscle or joint pain, bruising around injection site
156
PSCK9 =
enzyme that binds to LDL receptors and promotes their degradation (instead of LDL recycling on the cell surface)
157
Why is PCSK9 rarely prescribed?
expensive (7000$/y)
injectable drug
recently approved
158
PCSK9i recommended for who?
primary (familial) hypercholesterolemia with high LDL-C despite maximal statin dose
159
Side effects of fibrates (gemfibrozil)
GI reactions (taste changes, abdominal pain), muscle toxicity
160
Contra-indications to prescribe gembribrozil?
hepatic or renal dysfunction, gallbladder disease, combination tx with simvastatin
161
Fibrates prescribed for which patients?
in highly elevated TG (familial hyperTG)
162
Nicotinic acid side effects
Only 50-60% tolerance, GI stress, skin flushing and itching, hepatotoxicity, arrhythmias
163
Contraindications to prescribe nicotinic acid
active peptic ulcer, hepatic disease, gout, hyperuricemia
164
Nicotinic acid prescribed for which patients?
used for primary hypercholesterolemia and/or hyperTG, and hypoalphalipoproteinemia
