Dyslipidemia highlights

Question 1

HDL:
1) What level is protective?
2) When are you at risk?

Answer 1

1) > 60 mg/dL
2) < 40 mg/dL

Question 2

LDL, list the following:
1) Borderline high
2) High
3) Very high

Answer 2

1) 130-159 mg/dL
2) 160-189 mg/dL
3) > 189 mg/dL

Question 3

TG (triglycerides):
1) What level is normal?
2) What is elevated?

Answer 3

1) < 150 mg/dL
2) > 150 mg/dL

Question 4

Lipid panel:
1) What does a standard lipid panel calculate?
2) What affects LDL levels?
3) What are measured and not affected by TG levels?

Answer 4

1) calculates LDL-C
2) TG levels
3) Direct LDL-C, HDL, & TC

Question 5

What are the major risk factors for ASCVD?

Answer 5

1) *Cigarette smoking
2) Elevated blood pressure**
3) LDL-C levels (TC and HDL-C) (TG is a risk enhancer and used as criteria for metabolic syndrome which is a risk enhancer)
4) *A1C (if indicated) (fasting glucose)
4) *AGE

• used to calculate ACC/AHA 10-year risk of ASCVD

Question 6

Use ACC ASCVD calculator to estimate 10-year risk:
What are the 3 main groups of risk factors?

Answer 6

1) Demographics: Age, Sex, Ethnicity
2) Tests/Labs: BP mm Hg, TC mg/dL, HDL-C mg/dL
3) Medical history: Tx for HTN, DM status, current smoker

Question 7

The major influencer in the calculated 10 year ASCVD risk is what?

Answer 7

Age

Question 8

Optimal lifestyle interventions: Combination of diet and ___________ counseling to achieve __________ = improve cardiovascular health

Answer 8

physical activity; weight loss

Question 9

Differentiate between high, moderate, and low intensity statins based on % LDL reduction

Answer 9

1) >/= 50%
2) 30-49%
3) <30%

Question 10

What are the doses of the 2 high intensity statins?

Answer 10

1) Atorvastatin (40mg) 80mg
2) Rosuvastatin: 20mg (40mg)

Question 11

What 3 groups need primary prevention for ASCVD?

Answer 11

1) LDL-C > 189 mg/dL
2) Patients with LDL-C 70-189 mg/dL with DM
3) Patients with LDL-C 70 – 189 mg/dL without DM

Question 12

Primary prevention for the general pop. age 40-75 w. no DM or clinical CVD (LDL-C 70-189 mg/dL) based on 10 yr ASCVD risk

1) Low risk (< 5%): lifestyle and risk reduction education, _________
2) Borderline risk (5-7.4%) + risk enhancing factors: lifestyle, statin may be considered in _______________.
3) Intermediate risk (7.5%-19.9%) – ____________ intensity statin
4) High risk (>20%): __________ intensity statin

Answer 12

1) no statin
2) select patients
3) moderate
4) high

Question 13

Define metabolic syndrome

Answer 13

3 or more of the following:
1) Men waist > 40 inches; Women waist > 35 inches
2) Fasting glucose > 100 mg/dL
3) BP > 130/85 mmHg
4) TG > 150 mg/dL
5) HDL < 40 mg/dL for men; < 50mg/dL for women

Question 14

Give the BLUF for metabolic syndrome

Answer 14

Findings 3 of 5 following factors:
1) Reduced HDL-C (male 40 mg/dL or less, female 50 mg/dL or less thresholds)
2) Elevated waist circumference (male 40”/female 35”thresholds)
3) TG
4) BP
5) & Fasting blood glucose

Risk enhancer

Question 15

Statin MOA: Competitively blocking ____________________, the active site of the first and rate-limiting enzyme in the mevalonate pathway

Answer 15

HMG-CoA reductase

Question 16

Statins: Inhibition of this site blocks the conversion of HMG-CoA to mevalonic acid within the _____________

Answer 16

hepatocyte

Question 17

Statins may have additional non–lipid-related effects, list 4

Answer 17

1) Stabilization of atherosclerotic plaques
2) Anti-inflammatory
3) Immunomodulatory
4) Antithrombotic effects

Question 18

List 2 adverse affects of statins

Answer 18

1) Myopathy (muscle issue)
2) Transaminase elevations

Question 19

Statins:
1) _______________ is the most likely to cause muscle symptoms; the FDA does not recommend dosing beyond ____mg daily.
2) What are the 2 least likely statins to do this?

Answer 19

1) Simvastatin; 40mg
2) Fluvastatin and Pitavastatin

Question 20

How do you dose Fluvastatin? (a moderate statin)

Answer 20

Fluvastatin 40mg BID

Question 21

True or false: Currently, the benefits of statin therapy do not outweigh any presumed risk of cataract development.

Answer 21

False; they do

Question 22

Which statins do the following interact with? Is it recommended to use them anyways?:
1) Cyclosporine/ tacrolimus
2) Gemfibrozil
3) Warfarin

Answer 22

1) Lova, Pita, Simva; (do not use). (also interacts w. others)
2) All (do not use)
3) Fluva, Lova, Rosuva, Simva (use anyways)

Question 23

If still above LDL-C goal on max tolerated statin and ezetimibe, then it would be reasonable to consider a PCSK9i following shared decision on net benefit, safety, & ________

Answer 23

cost

Question 24

Ezetimibe (Zetia): inhibits the absorption of cholesterol from the______________

Answer 24

small intestine

Question 25

Ezetimibe (Zetia): 10 mg daily, anytime, typically as an _________________ if LDL-C not at goal or consider if statin intolerant

Answer 25

add on to max tolerated statin

Question 26

PCSK9i 1) A monoclonal antibody that binds to and inactivates PSCK9 particles in ___________________. 2) What is Proprotein convertase subtilisin/kexin type 9 ?

Answer 26

1) extracellular fluid. 2) an enzyme encoded by the PCSK9 **gene** in humans on **chromosome 1**

Question 27

PCSK9i: 1) Bind to PSCK9 particles resulting in more ________ recycling, thus increasing density of LDL receptors on the surface of ____________ to remove more LDL-particles from the extracellular fluid. 2) This effectively increases LDL receptors on ______________ and clearance of LDL-C from blood. 3) What is it used for?

Answer 27

1) LDLR; hepatocytes 2) surface of cells 3) Add on therapy to statins +/- ezetimibe

Question 28

What come in the form of SQ injections every 2-4 weeks, no dose titration?

Answer 28

Pcsk9 inhibitors

Question 29

1) What is the clinical application of Bempedoic Acid (Nexletol)? 2) What are the downsides of it?

Answer 29

1) Add on Tx to max tolerated statin 2) Questionable if improves long term cardiovascular outcomes -Has not been adequately studied in combination with other add on therapy

Question 30

Fibrates: Fibric acid Derivatives 1) Synergistic risk of myopathy with statins causing ______________ and acute _______________. 2) What is not recommended?

Answer 30

1) rhabdomyolysis and acute renal failure 2) Combination therapy

Question 31

Bile acid sequestrants: 1) are resins that disrupt the _______________ circulation of ________ acids by combining with bile constituents and preventing their reabsorption from the gut. 2) In general, they are classified as ____________ agents, although they may be used for purposes other than lowering cholesterol such as chronic diarrhea

Answer 31

1) enterohepatic; bile 2) hypolipidemic

Question 32

Give 3 examples of bile acid sequestrants

Answer 32

1) Cholestyramine (generic and various propriety names) 2) Colestipol (Colestid) 3) Colesevelam (Welchol)

Question 33

Statins are the work horse for both _________ and ___________ prevention of ASCVD

Answer 33

primary; secondary

Question 34

TG > 500 associated with what 2 things?

Answer 34

increased risk of pancreatitis, risk enhancer for ASCVD

Question 35

Hypertriglyceridemia 1) ACC/AHA list hypertriglyceridemia as a ____________________ for ASCVD. 2) It is also a component of what?

Answer 35

1) risk-enhancing factor 2) Metabolic syndrome

Question 36

1) There is association between hypertriglyceridemia and ASCVD. Have studies demonstrated a reduction in cardiovascular events or deaths with the treatment of isolated hypertriglyceridemia? 2) Hypertriglyceridemia is also a risk factor for acute ________________ (esp. > 500)

Answer 36

1) No 2) pancreatitis

Question 37

What are the doses of astorvastatin, rostuvastatin, and simvastatin when they're used as moderate statins? (not sure if need to know)

Answer 37

1) Astorvastatin: 10mg 2) Rostuvastatin:10mg 3) Simvastatin: 20-40mg

Question 38

What are the doses of the 2 low intensity statins? (not sure if need to know)

Answer 38

1) Pravastatin: 10-20mg 2) Lovastatin: 20mg