hypercholesterolemia

Question 1

cholesterol

Answer 1

steroid released by the liver and intestines

Question 2

cholesterol function

Answer 2

regulates cell membrane fluidity and helps produce vitamin D, steroids and bile

Question 3

triglyceride pathway

Answer 3

triglycerides get transported by VLDL from the liver or chylomicrons from the intestines to adipose tissue for energy and storage

Question 4

cholesterol pathway

Answer 4

cholesterol gets transported by LDL for plasma membranes and steroid synthesis or HDL for excess to be converted into bile

Question 5

atherosclerosis

Answer 5

lipid deposition and plaque reaches critical point where disruption occurs and overlying thrombus forms which obstructs blood flow

Question 6

hypercholesterolemia causes (8)

Answer 6

diabetes, hyperthyroidism, pregnancy, menopause, CKD, liver disease, gout, FH

Question 7

normal total cholesterol

Answer 7

<5 mmol/L or <200 mg/dl

Question 8

normal HDL

Answer 8

> 1 mmol/l or 40-60 mg/dl

Question 9

normal LDL

Answer 9

<3 mmol/l or <100 mg/dl

Question 10

normal non-HDL

Answer 10

<4 mmol/l

Question 11

normal triglycerides

Answer 11

<2.3 mmol/l

Question 12

familial hypercholesterolemia

Answer 12

autosomal dominant disorder involving high LDL-C

Question 13

heterozygous familial hypercholesterolemia

Answer 13

inherited mutation from one parent

Question 14

homozygous familial hypercholestrolemia

Answer 14

inherited mutation from both parents

Question 15

hypercholesterolemia diagnosis

Answer 15

total cholesterol >7.5 mmol, check personal or family history of premature CHD, check SBC or DLCN criteria and refer to DNA testing

Question 16

hypercholesterolemia monitoring

Answer 16

full lipid profile, liver function tests, renal function, HbA1C, TFTs, creatine kinase

Question 17

full lipid profile

Answer 17

aim for >40% reduction in non-HDL-C

Question 18

liver function test

Answer 18

do not start statins if transaminases >3x upper limit, repeat at 3 months and 12 months

Question 19

renal function test

Answer 19

low statin dose if severe impairment

Question 20

haemoglobin A1C test

Answer 20

can diagnose diabetes

Question 21

thyroid function test

Answer 21

can diagnose hypothyroidism

Question 22

creatine kinase

Answer 22

low statin dose if raised <5x upper limit and persistent muscle pain prior to starting; stop statin if >5x upper limit or experiencing pain

Question 23

statins function

Answer 23

reduce cholesterol synthesis in the liver by inhibiting HMG-CoA reductase

Question 24

high-intensity regimen

Answer 24

statin dose that reduces LDL-C by >50%

Question 25

primary prevention drug

Answer 25

atorvastatin (20mg) daily

Question 26

primary prevention aim

Answer 26

reduce non-HDL-C by >40%

Question 27

secondary prevention drug

Answer 27

atorvastatin (80mg) daily, provided after a CV event

Question 28

secondary prevention aim

Answer 28

reduce LDL-C to <2mmol/l or non-HDL-C to <2.6 mmol/l

Question 29

atorvastatin contraindications

Answer 29

active liver disease, pregnancy, breastfeeding, antiviral drug interactions

Question 30

atorvastatin side effects

Answer 30

nausea, indigestion, headaches, nosebleeds, sore throat, cold-like symptoms, constipation, flatulence, diarrhoea

Question 31

ezetimibe

Answer 31

inhibits cholesterol absorption at brush border of intestine causing increased LDL receptor expression on hepatocyte cell surface and more cholesterol removal

Question 32

when to offer ezetimibe

Answer 32

primary hypercholestreolemia with side effects to statins

Question 33

ezetimibe contraindications (3)

Answer 33

increased risk of gallstones, myopathy and rhabdomyolysis, moderate to severe liver impairment

Question 34

ezetimibe side effects

Answer 34

hypertension, abdominal pain, diarrhoea, flatulence, increased ALT/AST, headaches, fatigue

Question 35

bempedoic acid

Answer 35

inhibits cholesterol synthesis (combined with ezetimibe)

Question 36

when to offer bempedoic acid

Answer 36

patients intolerant to statins or contraindicated and LDL-C levels unaffected by ezetimibe

Question 37

bempedoic acid contraindications

Answer 37

gout, liver conditions, pregnant or breastfeeding

Question 38

bempedoic acid side effects

Answer 38

anaemia, myopathy with statins, deranged LFTs, reduced eGFR, gout, extremity pain

Question 39

when to offer icosapent ethyl

Answer 39

triglycerides >1.7 mmol/l and LDL-C 1.04-2.6 mmol/l and established CVD and already on statin

Question 40

icosapent ethyl contraindications

Answer 40

allergic to fish, hepatic impairment, atrial fibrillation, bleeding risk

Question 41

icosapent ethyl side effects

Answer 41

atrial fibrillation, bleeding, peripheral oedema, gout, musculoskeletal pain, constipation

Question 42

inclisiran

Answer 42

increases LDL receptor recycling and expression on hepatocyte cell surface and more cholesterol removal

Question 43

when to offer inclisiran

Answer 43

LDL 2.6 mmol/l and established CVD and already on maximal tolerated oral lipid lowering therapy

Question 44

inclisiran warnings

Answer 44

high cost drug approval for hospital use and some GPs reluctant to prescribe

Question 45

PCSK9 inhibitors

Answer 45

bind PCSK9 to prevent LDL receptor degradation on hepatocyte cell surface and more cholesterol removal

Question 46

PCSK9 inhibitor examples

Answer 46

evolocumab, alirocumab

Question 47

PCSK9 inhibitor warnings

Answer 47

expensive