Dyslipidemia /HTN Flashcards
Dyslipidemia
Elevation of plasma chol , triglyceride or both or a low high density lipoprotein that contributes to the development of atherosclerosis
LDL
Bad cholesterol … want this to be low < 100 ( less than 70 w/ heart disease or DM)
HDL
Good cholesterol … want this to high
40-60
Goal total cholesterol
< 200 mg/dL
Goal triglycerides
< 150 mg/dL
Non-pharm treatment for Dys
Always first step prior to medication
Heart - healthy diet ( avacado, almonds and blueberry) , regular exercise, avoid tobacco or smoking , weight loss
Treatment for children and aldolesence
Initial : lifestyle changes
Statins 1 st line agent in 10 years and older
Treatment for preg/ lactation
Statin therapy CONtRAindicated
Zétia ( C)
Discouraged in lactation
Tx in older pt
Age not a factor, depends on how long you expect them to live
Limited lifespan = do NOT initiate therapy
Primary prevention
Reduces the risk of MI and HF decreases the need for coronary procedures and improves quality of life
( before an event)
Secondary prevention
Clinical atherosclerotic cardiac disease already present or prevention of a second attack
Corner stone therapy
Lifestyle modification through weight loss , aerobic exercise and eating diets low in saturated fats
CVD risk Schemes ( big difference between prior to 2013 and after 2013)
Fasting lipids assess adherence / therapeutic response ( non-statin therapy discouraged due to lack of evidence)
You want a percentage decreased not exacting aiming at a number
Treatment for secondary prevention pt with ASCVD
< 75 yrs old = high intensity statin
> 75 yrs old = moderate in intensity statin
Tx for primary prevention pt with LDL > 190
High intensity statin
Primary prevention pt wit dm ( age 40-75) LDL 70-189
Moderate intensity statin unless ASCVD risk > 7.5 %
Tx with primary prevention pt when you assess there ASCVD score
> 7.5 high intensity statin
> 5 <7.5 moderate intensity stain
Statins ( decrease LDL)
Crestor, Lipitor, zocor,
Fibrates
Decrease TG and increase HDL
Ticor
Bile acid sequestrants
Decrease LDL
Questran
Nicotinic Acid Derivates
Decreases TG
Niacin
Omega 3 fatty acids
Decrease TG , last line
Selective cholesterol absorption inhibitors
Decrease LDL, TG and increase HDL
Zetia
PCSK9 inhibitors
Decrease LDL ( last line due to injection)
Statins ( background)
Competitive inhibitors of HMG CoA reductase - the limiting step in cholesterol biosynthesis - thus removing LDL from the blood
Cholesterol synthesis occurs at nigh so take shorter half live statins at night ( take longer acting during day)
Adverse: muscle aches, myopathy, rhabdo, bloating
Monitor: CK, LFTS,
High intensity statin
Decrease LDL by > 50 %
Lipitor 40-80mg
Crestor 20-40
Moderate intensity statin
Daily dose lowers LDL by 30-50 %
Lipitor 10-20 mg
Low intensity statin
Daily dose lowers LDL by < 30 %
Simvastatin 10 mg
Non statin therapy
Addition of non statin chol lowering agent when max intentsity agent who has less than anticipated response
Can use Niacin, BAS, omega 3
Lowering dose criteria
LDL < 40 on 2 consective checks
Statin big adverse effect
Muscle events
Myalgia
Similar to influenza aches and pain, involves muscle discomfort, ( CK WNL)
Myopathy
Muscle weakness not due to pain ( w/ or w/o CK elevation)
Myositis
Muscle inflammation
Myonecrosis
Elevation in muscle enzyme compared with baseline
Clinical rhabdomyolysis
Myonecrosis w/ myoglobinuria or acute renal failure
Management of statin associated myopathy
Stop statin and have CK go back to normal
( fluvastatin and pravastatin - lowest risk of statin myopathy )
Check for drug interaction
Start on fluvastatin or pravastatin
Hypertension definition
Based upon the average of 2+ readings at each of the two or more office visits after initial screening
( normal 120/80)
Stage one HTN
130-139/ 80-89
Stage two HTN
140-149/90
Isolated systolic / diastolic HTN
> 130/ < 80
< 130/>80
HTN emergency
Diastolic >110
HTN risk factors
Age ( systolic BP)
Obesity, fam hx, race ( blacks), high sodium, alcohol consumption, dm and dyslipidemia
Blood pressure goals ( general, >60, <60, CKD/DM, >18 w/ dm or CKD)
General : <140/90
> 60 : 150/90
CKD/DM : <130/80
>18 with dm or CKD < 140/90
Drug treatment titration strategy
- Max first med before adding a second or ADD second med before reaching max dose of first med OR start with 2 medication classes or as a fixed dose combination
JNC 8 initial drug recommendations
Non blacks : TD, ACEI, ARB, CCB ( alone or combined )
Blacks : TD or CCB
CKD pt : ACEI or ARB
NO beta blocker treatment
Black population HTN treatment
Thiazide Diuretics and CCB’s are shown better efficacy as mono therapy
NO longer ACEI or ARBS - increases fluid overload
Thiazide Diuretics
HCTZ, Metolazone,
Monitoring parameters: K ( decreases) Ca ( increases) NA ( decreases ) increased (Scr), increased glucose
Weight and blood pressure
Given once daily ( don’t give at night)
Ace inhibitors
Lisinopril, captopril ( PRIL)
Monitoring : K increases Scr increases
- check 1-2 week after initation
- cough and angioedema, AKI
Angiotensin receptor blockers ( ARBS)
Losartan, Valsartan (ARTAN)
Monitoring: increased K and Scr, angioedema (less)
CCB
Dihydropyrodines (HTN)
- amlodipine (DIPINE)
Non-Dihydropyridines ( rate control )
- verapamil / diltiazem ( concern for heart black ) (don’t use in HF)
Monitoring: peripheral edema, reflex tachycardia, HA
2nd line agents for HTN
Potassium sparing diuretics Beta-blockers Alpha 1 blockers Central acting agents Direct vasodilators
Potassium sparing diuretics
Spironolactone
Monitoring : increased K ( caution in dual use with ACEI/ARB arrthymias
Gynecomastia in men
Beta blocker ( last line)
Metoprolol succinate ( QD) Metoprolol tartate (BID)
(LOL)
Uses : use with combined CHF or CVD, dresses HR > BP effects , caution for bronchospasm (COPD/ASTHMA)
Rebound HTN may happen with rapid d/c
Alpha 1 blockers
Terazosin ( ZOSIN)
Use with cormorbid BPH
Adverse: orthostatsis, reflex tachy, dizziness, peripheral edema
Centrally acting agents
Clonidine ( available in once a week patch called Catapres)
Adverse: rebound hypertension, sedation, dry mouth, impotence
Direct Vasodilators
Hydralazine
Monitoring : reflex tachy , helps with HF and Minoxidil helps with getting rid of excess fluid
Dose adjusting and monitoring
If BP not reached after 4 weeks of initation therapy —> increase dose of drug or add a second ( 1st line agent ) from a different class
If BP goal is not achieved with 2 agents —> dada 3rd recommended agent ( avoid ACEI/ARB combos)
If goal still not consider : patient adherence and dose optimization
Simplify regimens/reduce pill burden to avoid non adherence
Resistant HTN
BP above goal with > agents from differing classes at optimal dose
Consider white coat hypertension ( most common)
Drug causes : (NSAIDS, stimulants, oral contraceptives,
Consider spironolactone therapy as add on agent
Lifestyle modifications and SBP reduction range
Weight —> 5-20
DASH eating —> 8-14
Treatment for children
Ace #1 or ARBS
TD, CCB
Beta blockers no recommended
Treatment of HTN in preg
ACE and ARBD are CONtRAindicated die to renal abnormalities
Labetalol or Methyldopa
Treatment for geriatrics in HTN
Therapy requires gently initiation ( risk of falls)
Progress towards goals help preserve cognitive function
