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KG - Clin Med > Hyperlipidemia > Flashcards

Hyperlipidemia Flashcards

1
Q

two other names for hyperlipidemia?

A

dyslipidemia

hypertriglyceremia

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2
Q

two main lipids in blood?

A
  • cholesterol = forms backbone of steroid hormones and bile acids
  • triglycerides = important in transferring energy from food into cells

*both carried in lipoproteins

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3
Q

lipid content (low to high)?

A

HDL, LDL, VLDL, chylomicrons

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4
Q

density (low to high)?

A

chylomicrons, VLDL, LDL, HDL

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5
Q

characteristics of chylomicrons?

A
  • derived from dietary fat
  • travel via portal vein into liver/thoracic duct into circulation
  • normally completely metabolized, transferring energy form food into muscle and fat cells
  • will float to top when non-fasting serum stands (looks creamy)
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6
Q

characteristics VLDLs?

A
  • made in liver from stores of fat and carbs
  • consists mainly of triglycerides
  • metabolized to LDL
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7
Q

characteristics of LDLs?

A
  • most of cholesterol on LDL
  • deliver cholesterol to cells in organs where it’s used for cell membrane biosynthesis and bile acid synthesis in liver
  • 70% LDL taken up by liver and cholesterol is excreted into bile
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8
Q

“increased LDL in arterial endothelium promotes _________”

A

“increased LDL in arterial endothelium promotes ATHEROSCLEROSIS”

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9
Q

when does LDL increase?

A

LDL increases in ppl who:

  • consume large amts of saturated fatty acids and/or cholesterol
  • have defects in LDL receptor (Familial Hypercholesterolemia)
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10
Q

how to lower LDL levels?

A
  • decrease cholesterol synthesis (w/ HMG-CoA reductase inhibitors/Statins)
  • increase cholesterol excretion
  • decrease cholesterol absorption (plant sterol esters, ezetimbe)
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11
Q

characteristics of HDL?

A
  • made in liver & intestine
  • consist of apoproteins + cholesterol
  • participate in reverse cholesterol transport
  • lowering HDL = increased risk of heart disease
  • increased HDL is cardioprotective
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12
Q

“risk of MI increased by ____ % for every ____ mg/dL below median values”

A

“risk of MI increased by 25% for every 5 mg/dL below median values”

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13
Q

things that increase HDL?

A
  • exercise
  • estrogen
  • alcohol (1-2 drinks/day)
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14
Q

things that decrease HDL?

A
  • obesity
  • hypertrigylceridemia
  • smoking
  • lack of exercise
  • anabolic steroids
  • genetic factors
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15
Q

three major systems that maintain cholesterol balance?

A
  • extrahepatic organs
  • liver
  • intestines
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16
Q

what is the most common cholesterol screening?

A
  • fasting lipid panel = not affected much by eating, but triglycerides are greatly affected and are usu done on same specimens
  • LDL, HDL, triglycerides
  • acutely ill pts can have falsely low levels
  • do not screen pregnant ladies - extra weight = extra high levels
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17
Q

what is the recommended screening schedule per NCEP/ATP?

A

all adults >20 yrs old at least once every 5 years

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18
Q

what is the recommended screening schedule per USPSTF?

A

males >35 and < 35 if risk factors for CHD & females if risk for CHD (otherwise every 5 years for females)

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19
Q

what is the recommended screening schedule per AAFP?

A

males >35 yo

females > 45 yo

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20
Q

what is the recommended screening schedule per ACP?

A
  • asymptomatic males 35-65 yo
  • asymptomatic females 45-65 yo
  • not recommended for younger unless risk factors

no established interval for screening

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21
Q

total cholesterol formula?

A

total cholesterol = HDL + LDL + VLDL

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22
Q

values for total cholesterol?

A

desirable = 200
borderline high = 200-239
high = >240

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23
Q

values for triglycerides?

A

optimal = 500

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24
Q

values for LDL?

A

optimal = 190

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25
Q

values for HDL?

A

low = 60 – cardioprotective factor

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26
Q

what is the goal LDL for pts w/ CAD or DM?

A

<70

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27
Q

low cholesterol is not always a good sign… what disorders are associated w/ low cholesterol?

A
  • AIDS
  • severe liver disease
  • hyperthyroidism
  • malnutrition
  • chronic anemia
  • cerebral hemorrhage
  • malignancy
  • certain drugs
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28
Q

“The adult treatment panel III revealed a graded relationship between total cholesterol and _____ risk”

A

“The adult treatment panel III revealed a graded relationship between total cholesterol and CORONARY risk”

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29
Q

“when managing high cholesterol, management is influenced by ____ (primary prevention) or ____ (secondary prevention) of preexisting CHD”

A

“when managing high cholesterol, management is influenced by ABSENCE (primary prevention) or PRESENCE (secondary prevention) of preexisting CHD”

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30
Q

characteristics of hypertriglyceridemia?

A
  • risk factor of high cholesterol (esp if w/ low HDL)
  • associated w/ obesity, diabetes, liver disease, alcohol use, uremia, estrogens, steroids, isotretoin (Accutane), some BP meds
  • normal values based on 12 hr fast
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31
Q

“very high TG > 1000 can cause ______”

A

“very high TG > 1000 can cause PANCREATITIS”

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32
Q

characteristics familial hypercholesterolemia

A
  • condition when cell surface receptors for LDL molecule absent or defective
  • can’t synthesize LDL
  • occurs 1/1,000,000 (homozygotes 8x normal value ~800, heterozygotes 2X normal value ~200)
  • develop CDH early
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33
Q

clinical presentation of hyperlipidemia?

A

usu no signs/symptoms

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34
Q

what are xanthelasmas?

A
  • cholesterol filled, soft, yellow plaques that usu appear on the medial aspects of eyelids bilaterally’
  • occur 75% older pts w/ hypercholesterolemia
  • benign
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35
Q

what are eruptive xanthomas?

A
  • red-yellow papules

- triglycerides > 1000

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36
Q

what are tuberous xanthomas?

A
  • yellow-orange nodules up to 2 cm in diameter, often over knees and elbows
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37
Q

what is lipemia retinalis?

A
  • cream-colored blood vessels in funds

- triglycerides > 2000

38
Q

why should someone care about heart disease?

A

b/c of coronary heart disease

39
Q

characteristics of coronary heart disease

A
  • narrowing of small blood vessels that supply blood/O2 to heart
  • leading cause of death for men AND women (13.5 million w/ hx of MI and/or angina)
40
Q

statistics of MI?

A
  • 1.5 million ppl have MI
  • 500,000 die of MI
  • 250,000 die within 1 hr
41
Q

“By age 60, every ____ man and ____ woman develops coronary heart disease”

A

“By age 60, every 5th man and 17th woman develops coronary heart disease”

42
Q

non-modifiable risk factors of CHD?

A
  • family hx of premature CAD (male first degree relatives < 55 or female first degree relatives < 65)
  • men > 45, women > 55
  • male
  • symptomatic coronary artery disease
  • peripheral artery disease
  • AAA
  • CKD (Cr > 1.5) or estimated GFR < 60 mL/min
43
Q
  • modifiable risk factors of CHD?

- physical inactivity

A
  • HTN (BP > 140/90 or on antihypertensive)
  • hyperlipidemia or HDL < 40
  • DM
  • tobacco use
  • obesity
  • physical inactivity

*** HDL > 60 is a negative risk factor

44
Q

what is the primary target for modifying hyperlipidemia? (to lower risk of CHD?)

A
  • LDL (exact mechanism unknown)

- exact mechanism by which HDL particles protect against their formation is unknown

45
Q

old theory of cause of MI?

A
  • progressive narrowing of coronary arteries leads to blockage then acute MI
  • only 15% MIs due to “tight blockages”
  • majority caused by lesions w/ <50% stenosis
46
Q

new theory of cause of MI?

A
  • “vulnerable plaques” within wall of coronary arteries – plaques filled w/ lipid core and macrophage foam cells & inflammatory cells
  • plaques rupture & cause thrombosis, resulting in MI
47
Q

describe mechanism of vulnerable plaques

A
  • plaques filled w/ lipid core and lipid laden macrophage foam cells & inflammatory cells
  • foam cells produce tissue factor - stimulates thrombus formation when in contact w/ blood
  • thin fibrous caps separate lipid core form blood in artery lumen
48
Q

treatment of CAD?

A
  • cholesterol lowering drugs (statins) can stabilize vulnerable plaques and may treat underlying inflammation
  • must treat ALL aspects of CAD
  • goal LDL < 70 w/ known CAD
49
Q

what do statins do?

A
  • lower cholesterol

- decrease incidence of major vascular events, coronary mortality, and CVA

50
Q

treatment of hyperlipidemia?

A
  • diet
  • exercise
  • medication
51
Q

average American diet?

A
  • 35% of calories from fat (15% saturated)

- 400 mg/d of cholesterol

52
Q

cholesterol lowering diet?

A
  • 25-30% of calories from fat (< 200 mg/d of cholesterol

- LDL decreases 8-10% w/ switch from average American diet to cholesterol lowering diet

53
Q

Mediterranean diet?

A
  • high in fruits/veggies/whole grains/nuts/beans/seeds
  • olive oil = source of fat
  • low to moderate amts of fish/poultry/dairy
  • little red meat
  • low LDL, low risk CHD
54
Q

dietary approaches to stop HTN (DASH diet)

A
  • rich in fruits/veggies
  • moderate in low fat dairy products
  • low animal protein
  • contains plant sources of protein (legumes/nuts)
  • low BP/low LDL/
    may lower risk of CHD & strokes
55
Q

what is one of the few things that can increase HDL?

A

exercise

56
Q

what is the minimum you should exercise/week

A
  • 30 minutes of moderate-intense physical activity on most, if not all, days of the week
57
Q

first line treatment for LDL?

A

HMG Co-A reductase inhibitors - Statins

58
Q

characteristics of HMG Co-A Reductase Inhibitors (STATINS)

A
  • inhibits the enzyme that catalyzes the rate limiting step in cholesterol synthesis
  • only class of drugs to show improvements in mortality in & secondary prevention
  • first line for LDL treatment
  • lowers triglycerides (not as well as fibrates)
  • may increase HDL
  • usu take at night
59
Q

list of statins?

A
  • atorvastatin/lipitor
  • rosuvastatin/crestor (best but most $$$)
  • simvastatin/zocor
  • fluvastatin/lescol
  • lovastatin/mevacor
  • pravastatin/pravachol
59
Q

In which groups have statins been successful? (though they benefit everyone!)

A
  • patients w/ CHD (w/ or w/out hyperlipidemia)
  • men w/ hyperlipidemia but no known CHD
  • men w/ hypertension & multiple cardiac risk factors but w/out hyperlipidemia
  • men & women w/ average total and LDL-C levels and no known CHD
59
Q

list of statins?

A
  • lipitor
  • crestor (best but most $$$)
  • zocor
  • lescol
  • mevacor
  • pravachol
59
Q

list of statins?

A
  • lipitor
  • crestor (best but most $$$)
  • zocor
  • lescol
  • mevacor
  • pravachol
60
Q

In which groups have statins been successful? (though they benefit everyone!)

A
  • patients w/ CHD (w/ or w/out hyperlipidemia)
  • men w/ hyperlipidemia but no known CHD
  • men w/ hypertension & multiple cardiac risk factors but w/out hyperlipidemia
  • men & women w/ average total and LDL-C levels and no known CHD
61
Q

side effects statins?

A
  • myopathy

- elevated LFTs

62
Q

what meds to try if statins can’t be tolerated?

A
  • ezetimbe/zetia
  • bile acid sequestrates
  • fenofibrate/TriCor
  • niacin
63
Q

which statins tend to have lower risk of myopathy?

A
  • pravastatin/pravachol
  • fluvastatin/lescol
  • rosuvastatin/crestor
64
Q

what do you do to ensure that your patient has no elevated LFTs when taking statins?

A
  • obtain baseline LFTs
  • if elevated, usu occurs in first 3 months
  • ALT 3x the upper limit on 2 occasions –> d/c dose or decrease dose
  • (dose dependent)
65
Q

restrictions for simvastatin at any dose?

A

contraindicated for pts taking…

  • gemfibrozil
  • certain antifungals
  • certain antibiotics (erythro/clarithro/telithromycin)
  • HIV protease inhibitors
  • nefazodone
  • cyclosporine
  • danazol
66
Q

restrictions for 80 mg simvastatin? (high dose simvastatin changes)

A
  • avoid 80 mg dose bc high risk myopathy

- 80 mg dose ok if pt on it for 1 yr w/out myopathy

67
Q

restrictions for intermediate/low dose simvastatin?

A
  • no more than 20 mg for its taking amlodipine & ranolazine

- no more than 10 mg for its on amiodarone, verapamil, diltiazem

68
Q

restrictions for simvastatin at any dose?

A

contraindicated for pts taking…

  • gemfibrozil
  • certain antifungals
  • certain antibiotics (erythro/clarithro/telithromycin)
  • HIV protease inhibitors
  • nefazodone
  • cyclosporine
  • danazol
69
Q

characteristics of fibrates?

A
  • used to stimulate lipoprotein lipase, lower VLDL secretion, stimulate fatty acid oxidation
  • lower triglycerides
  • increase HDL slightly, lower LDL slightly
  • increased risk of myopathy when combined w/ statin
  • ideal first line agents for diabetics w/ hypertriglyceridemia
70
Q

list of fibrates?

A
  • gemfibrozil/lopid
  • fenofibrate/tricor
  • fenofibric acid/trilipix (can use w/ statin)
  • clofribrate/atromic-S
71
Q

characteristics of niacin? (nicotinic acid)

A
  • lower production of VLDL
  • mobilize free fatty acids from adipocytes
  • lower total cholesterol & LDL by 10-25%
  • lower triglycerides
  • **not as potent as statins or fibrates
72
Q

characteristics of bile acid sequestrants?

A
  • forms non absorbable complex w/ bile acids in intestine, releasing CL- ions in process
  • inhibits enterohepatic reuptake of intestinal bile salts
  • increases fecal loss of bile salt-bound LDL cholesterol
  • lowers LDL by 10-30% (not as potent as statins, more side effects)
  • minimally increases HDL
  • may increase triglycerides by 10%
  • may be used for monotherapy in pts who can’t tolerate statins
73
Q

dosing of niacin?

A
  • Niaspan, Slo-Niacin, BID dosing

- ASA prior, night-time dosing

74
Q

which dosings of niacin can decrease flushing?

A
  • slo-niacin

- BID dosing (divides dose, so lowers flushing)

75
Q

side effects bile acid seqestrants

A
  • constipation
  • flatulence
  • dyspepsia
76
Q

in which pts should bile acid sequestrants be avoided?

A

pts w/ hypertriglyceridemia

77
Q

list of bile acid sequestrants

A
  • cholestyramine/questran

- colestipol/colestid

78
Q

side effects bile acid seqestrants

A
  • constipation
  • flatulence
  • dyspepsia
79
Q

characteristics of cholesterol absorption inhibitor?

A
  • inhibits absorption of cholesterol at brush border of small intestine
  • decreased delivery of cholesterol to liver
  • decreased hepatic cholesterol stores
  • increased clearance of cholesterol from blood
  • lower LDL
80
Q

list of brands & dosing omega 3 fatty acids

A
  • Omacor& Lovaza: 4 g/day will lower triglycerides by 20-50%

- AHA recs 1 g/day for CHD & 2-4 g/day for hypertriglyceridemia

81
Q

what is the drug name of a cholesterol absorption inhibitor + simvastatin?

A

ezetimbe + simvastatin = vytorin

82
Q

characteristics omega 3 fatty acids (fish oil)

A
  • from salmon, flax seed, soybean oil, canola oil, nuts
  • lowers triglycerides
  • ?? increases LDL
  • OTC
83
Q

list of brands & dosing omega 3 fatty acids

A
  • Omacor& Lovaza: 4 g/day will lower triglycerides by 20-50%

- AHA recs 1 g/day for CHD & 2-4 g/day for hypertriglyceridemia

84
Q

what is benefit of red yeast rice on cholesterol?

A
  • lowers total cholesterol
  • lowers LDL
  • has monacolins that have HMG CoA reductase inhibitor activity
85
Q

what is benefit of plant sterols (Benecol) on cholesterol?

A
  • mildly lowers total cholesterol

- inhibition of cholesterol absorption

86
Q

what is benefit of soluble fiber on cholesterol?

A
  • ATP III & AHA recommend as an optional dietary strategy to lower cholesterol
87
Q

what are some issues of medication therapy?

A
  • cost
  • safety
  • side effects
  • inadequate instruction
  • lack of F/U
  • pt not convinced of benefit
  • pt denial

KG - Clin Med (2 decks)

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