Hyperlipidemia Flashcards
Leading cause of death in US
CVD
How adherent to statins must you be before you get benefits?
80%
6 months after initiation of statin therapy, adherence rates are 40-65%
What’s the history of statin trials?
Two types of trials:
primary prevention – patients without evidence of CVD
secondary prevention – patients with CVD
Both types demonstrate reductions in mortality and number of cardiovascular events
How do you establish very high risk according to ATPIII guidelines?
Very high risk= established CVD + Major risk factors (especially DM) Severe and poorly controlled risk factors (especially continued smoking) Multiple RFs of the metabolic syndrome Acute coronary syndromes
Definition and Goal/initiation LDL level for high risk
CHD or CHD risk equivalent
LDL goal is 100 (or 70 for very high risk)
If LDL ≥ 100: Initiate TLC and pharmaceutical treatment
Definition and initiation LDL level for moderately high risk
2+ risk factors (10 year risk 10-20%)
130 - lifestyle interventions
If LDL ≥ 160: Initiate pharmaceutical treatment
Definition and initiation LDL level for moderate risk
2+ risk factors (<10% 10 year risk)
130
Definitions and Goal/initiation LDL level for lower risk
0-1 risk factors
If LDL ≥ 160: Initiate TLC (therapeutic lifestyle changes)
If LDL ≥ 190: Initiate pharmaceutical treatment
What are lipids? (differentiate between kinds)
Chylomicrons transport fats from intestinal mucosa to liver
In the liver, the chylomicrons release triglycerides and some cholesterol and become low-density lipoproteins (LDL)
LDL then carries fat and cholesterol to the body’s cells
High density lipoproteins (HDL) carry fat and cholesterol back to the liver for excretion
When oxidized LDL cholesterol gets high, atheroma formation in the walls of arteries occurs, which causes atherosclerosis
HDL cholesterol is able to go and remove cholesterol from the atheroma
Atherogenic cholesterol = LDL, VLDL, IDL
Causes of HLD
Diet Hypothyroidism Nephrotic syndrome Anorexia nervosa Obstructive liver disease Obesity Diabetes mellitus Pregnancy Acute hepatitis Systemic lupus erythematousus AIDS (protease inhibitors)
Dietary sources of cholesterol (differentiate between what kinds of fat, sources, and what kind of cholesterol levels they raise)
monosatured
- olives, olive oil, canola, peanut, cashews, almonds, most nuts; avocados
- lowers LDL, raises HDL
polyunsaturated
- corn, soybean, safflower and cottonseed oil, fish
- lowers LDL, raises HDL
saturated
- whole milk, butter, cheese, and ice cream; red meat; chocolate; coconuts, coconut milk, coconut oil, egg yolks, chicken skin
- raises both LDL and HDL
transfats
- margarines; vegetable shortening; partially hydrogenated vegetable oil; deep-fried chips; many fast foods; most commercial baked goods
- raises LDL
Types of hereditary HLD
Familial Hypercholesterolemia (most common)
Codominant genetic disorder, occurs in heterozygous form
Occurs in 1 in 500 individuals
Mutation in LDL receptor, resulting in elevated levels of LDL at birth and throughout life
High risk for atherosclerosis, tendon xanthomas (75% of patients), tuberous xanthomas and xanthelasmas of eyes.
Familial Combined Hyperlipidemia (increased chol/trigs)
Autosomal dominant
Increased secretions of VLDLs
Dysbetalipoproteinemia
Affects 1 in 10,000
Results in apo E2, a binding-defective form of apoE (which usually plays important role in catabolism of chylomicron and VLDL)
Increased risk for atherosclerosis, peripheral vascular disease
Tuberous xanthomas, striae palmaris
types of tests for lipid levels
Nonfasting lipid panel
measures HDL and total cholesterol
Fasting lipid panel
Measures HDL, total cholesterol and triglycerides
LDL cholesterol is calculated:
LDL cholesterol = total cholesterol – (HDL + triglycerides/5)
ATPIII guidelines of when to check lipids
Beginning at age 20: obtain a fasting (9 to 12 hour) serum lipid profile consisting of total cholesterol, LDL, HDL and triglycerides
Repeat testing every 5 years for acceptable values
USPSTF guidelines for checking lipids
Women aged 45 years and older, and men ages 35 years and older undergo screening with a total and HDL cholesterol every 5 years.
If total cholesterol > 200 or HDL <40, then a fasting panel should be obtained
Cholesterol screening should begin at 20 years in patients with a history of multiple cardiovascular risk factors, diabetes, or family history of either elevated cholester0l levels or premature cardiovascular disease.
Direct evidence regarding benefits and harms of dyslipidemia screening or treatment in younger adults remains unavailable (2016)
ATPIII goals for lipid levels
LDL < 100 →Optimal 100-129 → Near optimal 130-159 → Borderline 160-189→ High ≥ 190 → Very High Total Cholesterol < 200 → Desirable 200-239 → Borderline ≥240 → High HDL < 40 → Low ≥ 60 → High Serum Triglycerides < 150 → normal 150-199 → Borderline 200-499 → High ≥ 500 → Very High
8 JNC risk factors for determining LDL goals
Cigarette smoking
Hypertension (BP ≥140/90 or on anti-hypertensives)
Low HDL cholesterol (< 40 mg/dL)
Family History of premature coronary heart disease (CHD) (CHD in first-degree male relative <55 or CHD in first-degree female relative < 65)
Age (men ≥ 45, women ≥ 55)
High risk/CHD/CHD Risk Equivalent
CHD and CHD Risk Equivalents: Peripheral Vascular/Arterial Disease Cerebral Vascular Accident Diabetes Mellitus MI Stroke Imaging evidence of atherosclerosis AAA Symptomatic CAD
Framingham Heart Study
General Cardiovascular Risk Profile for Use in Primary CareFramingham risk score effective, but only predicts CHD risk (not stroke etc.)
CV diseases share common risk factors
Set out to develop a way to predict risk for all CVD events It builds on prior models by:
Adding HDL
Being based on study with more events
Estimating absolute CV risk
Allows prediction of all CV events
Stroke, CAD, PVD, CHF
who should you do a Framingham Risk Assessment on?
For patients with multiple (2+) risk factors Perform 10-year risk assessment For patients with 0–1 risk factor 10 year risk assessment not required Most patients have 10-year risk <10%
Should you use statin in pts recovering from stroke?
In patients with recent stroke or TIA, treatment with 80 mg atorvastatin significantly reduced recurrent strokes and CV events when compared with placebo
There was a small increase in the incidence of hemorrhagic strokeHigh dose statins (started within 1-6 months) are proven effective
Starting statins in first 12 hours may be effective too—studies ongoing
Avoid stopping statins in pts with acute stroke
Benefit seen for all levels of cholesterol (elevated or not elevated)
How are the new guidelines different from ATPIII?
No longer have therapeutic targets
New risk calculator
Use medications proven to reduce risk, i.e. STATINS
Avoid medications or supplements that may lower cholesterol number, but have no data to decrease CV risk
Focuses on treatment to reduce ASCVD events
Not a comprehensive approach to lipid management
How do new guidelines define ASCVD?
CHD, stroke, PAD
What is the goal of new guidelines?
identify those most likely to benefit from cholesterol-lowering statin therapy
