L8 - Hyperlipidemia

Question 1

What are the different types of lipoproteins? Are they “good” or bad”?

Answer 1

HDL = good

LDL = Bad

Triglyceride rich proteins (VLDL, IDL & Chylomicrons) = probably bad

Question 2

What lipoproteins are measured individually in a lipid panel?

Answer 2

HDL
LDL
Triglycerides (VLDL, IDL & Chylomicrons)
Total Cholesterol (HDL + LDL + triglycerides/5)

Question 3

What lipoproteins are not measured individually in a lipid panel?

Answer 3

VLDL, IDL & Chylomicrons are listed collectively as triglycerides

Question 4

What is the relationship between total cholesterol & heart disease risk on a population basis?

Answer 4

Directly proportional in men & women of all ages

However on individual basis total cholesterol is misleading

Question 5

Lowering cholesterol helps lower cardiac risk in who?

Answer 5

Almost everyone

He joked about putting statins in the water

Question 6

What non-cardiac presentations can results from hypercholesterolemia?

Answer 6

Xanthomata = high levels of cholesterol leads to the deposition of cholesterol in nodular plaques on the skin, retina or tendons

Secondary consideration to cardiac issues

Generally related with really high cholesterol seen in familial conditions, but can also have benign forms with normal lipid panel

Question 7

What is the relationship between total cholesterol & heart disease risk when looking at an individual?

Answer 7

Poor association

Can have high HDL lead to an inaccurate high total cholesterol reading when low LDL is present

Can have a low HDL level lead to an inaccurate normal total cholesterol when high LDL is present

Question 8

Patient presents with high triglycerides, low HDL & high LDL. What do you focus on first?

Answer 8

LDL

Then can focus on either triglycerides or HDL (no diffinitive research suggesting which one should be treated second) after LDL is in desired range

Exception = if triglycerides are over 500, need to get those under 500 before LDL can be accurately measured

Question 9

What is the relationship between LDL & heart disease risk when looking at an individual?

Answer 9

Strong directly proportional

More accurate than total cholesterol

Question 10

What are the different ranges of LDL?

Answer 10

Optimal <70 can be beneficial

Question 11

What is treatment goal for somebody with prior Coronary Heart Disease?

Answer 11

<100

Same as CHD equivalent

Question 12

What is the treatment goal for somebody with 2 or more risk factors for CHD & no previous history of CHD?

Answer 12

<130

Question 13

What is the treatment goal for somebody with 1 or less risk factors for CHD and no previous history of CHD?

Answer 13

<160

Question 14

How do statins work?

Answer 14

HMG CoA reductase inhibitor –> blocks step of cholesterol synthesis in the liver

Question 15

How do bile sequestrants work?

Answer 15

Interrupt entero-hepatic circulation –> excrete more bile –> need to make more bile –> use up cholesterol making new bile

Question 16

What drug should not be used when trying to get triglycerides lowered?

Answer 16

Bile sequestrants, cuz may actually increase triglycerides

Question 17

If trying to lower LDL, what drug do you use?

Answer 17

Use statin, but if patient can’t tolerate statin use bile acid sequestrant (less effective & more side effects)

Question 18

Side effects related to statins? What to do if see these in a patient?

Answer 18

Myopathy

Increased LFTs (Liver function test = bilirubin, INR, PT, albumin)

If severe side effects –> switch to bile acid sequestrant

Question 19

Side effects related to bile acid sequestrants?

Answer 19

GI problems = bloating, gas, diarrhea …

+ can raise triglycerides

Common. Part of reason why statins are first line

Question 20

Types of bile acid sequestrants mentioned in lecture?

Answer 20

Cholestipol

Cholestyramine

Both start with Chol

Question 21

What drug is best for raising HDL?

Answer 21

Niacin

Question 22

What is another name for Niacin?

Answer 22

Nicotinic Acid

Question 23

Actions of Niacin? Side effects?

Answer 23

Mainly raises HDL & lower triglycerides

Flushing (more severe form of blushing seen not just on the face). Common = why don’t use this drug if just targeting triglycerides

Question 24

Action of Fibric Acid derivatives?

Answer 24

Mainly lowers triglycerides, but also helps HDL & LDL a bit

Question 25

What Fibric Acid derivatives were mentioned?

Answer 25

Gemfibrozil Fenofibrate Both have fib in the middle

Question 26

Side effects of Fibric Acid derivatives?

Answer 26

Myopathy Y shouldn't be used in conjunction with statin

Question 27

Why should a fibric acid derivative not be used at the same time as a statin?

Answer 27

Both drugs can cause side effect of myopathy --> potentiated effect --> rhabdomyolysis

Question 28

What is the effect of therapuetic lifestyle changes (TLC) on LDL?

Answer 28

20-30%, good so should be part of every treatment regimen but not great so usually not enough on its own

Question 29

What is the relationship of statin dose on LDL level? Why is this important?

Answer 29

Dose dependent response = as increase does lower LDL If not at goal can up dose and get better results

Question 30

What is the difference between different statins and when are they used?

Answer 30

Differing effectiveness Crestor = most effective, but more expensive and individuality means some can't handle it

Question 31

What is secondary CHD prevention?

Answer 31

Lower cholesterol in somebody who has already had CHD so they don't get another episode <100 goal

Question 32

If the patient is on a statin but still very far from goal, what should you do?

Answer 32

Raise dose, but in a stepwise fashion Don't jump up multiple dosages at once cuz more likely to get side effects

Question 33

Follow up schedule for somebody that has an LDL >30 more than desired treatment goal at dianosis?

Answer 33

Start TLC & drug --> follow up in 6 weeks Continue seeing every 6 weeks and up dose until get to treatment goal

Question 34

What is the difference in HDL between sexes?

Answer 34

Pre-menopasual women have higher HDL cuz estrogen increases HDL (may have high total cholesterol but that isn't bad)

Question 35

What are CHD risk factors?

Answer 35

Smoking HDL 45 men, >55 women) 1st degree relative with CHD (60, "eliminates" a risk factor

Question 36

If LDL is less than 30 away from treatment goal on diagnosis, what should you do?

Answer 36

Start with just TLC Follow up in 6 weeks. Give another 6 weeks if still not at goal If still not at goal by third visit use drug If no motivation for TLC just jump to meds

Question 37

What are CHD equivalents?

Answer 37

Any CHD (stent, MI, angina ...) Carotid Stenosis Peripheral Artery disease Aortic aneurysm Renal artery stenosis Diabetes *Familial hyperlipidemia is sort of an equivalent

Question 38

How to proceed in a patient with CHD equivalent?

Answer 38

Suggested TLC + drug For diabetes, must use drug + TLC (evidence shows it is helpful even if LDL is lower than treatment goal. Same for patients with previous CHD)

Question 39

What is primary CHD prevention?

Answer 39

Trying to prevent first CHD in somebody with CHD equivalent <100

Question 40

If see somebody who is really young or has really healthy lifestyle with high LDL, what should you suspect?

Answer 40

Familial/genetic Didn't fast before test --> inaccurate

Question 41

If see somebody with an LDL >160 what should you suspect?

Answer 41

Familial/genetic Didn't fast before test --> inaccurate

Question 42

How is treating a genetic or familial cause different?

Answer 42

More aggressive Drug & TLC from the start

Question 43

What is the treatment goal for somebody with familial/genetic hyperlipidemia?

Answer 43

Treat as CHD equivalent --> <100

Question 44

Secondary causes of Hyperlipidemia?

Answer 44

``` Diabetes Obesity Smoking Renal Failure Liver Disease Hypothyroidism Meds (progestins, estrogen, HIV drugs, steroids & corticosteroids) ```

Question 45

High LDL with no apparent secondary cause. What should you consider?

Answer 45

Think familial

Question 46

Patient has LDL >190. What do you do?

Answer 46

If familial, drug + TLC If non-familial (just crazy bad lifestyle), just TLC

Question 47

How is LDL measured?

Answer 47

Too expensive to measure directly Measure other stuff & calculate with equation If triglycerides over 500 equation doesn't work. Can send out for direct measurement but takes too long & is expensive

Question 48

What does LDL undetermined mean?

Answer 48

Triglycerides are over 500 so can't calculate LDL

Question 49

When would you focus on triglycerides before LDLs?

Answer 49

If triglycerides are > 500, need to treat it until < than 500 so can accurately measure LDL Once <500 can treat LDL

Question 50

Why is having a triglyceride >500 bad?

Answer 50

Pancreatitis is a concern Can't measure LDL accurately

Question 51

How does triglyceride level correlate with CHD risk factor?

Answer 51

Directly proportional, but no proof that it is cause and effect. Could just be that people with high triglycerides tend to have other risk factors

Question 52

What is treatment goal for somebody with CHD equivalent?

Answer 52

< 100 Same as prior CHD

Question 53

What the action of bile sequesterants?

Answer 53

Main action is to lower LDL, but also help raise HDL. It is the only drug that actually may rise Triglycerides.

Question 54

Which hyperlipedemia drug has a significant effect on 2 different classes of lipoproteins?

Answer 54

Niacin raises HDL & lowers triglyceride

Question 55

43 yo female smoker with HTN and HDL of 43. Father had MI at 62. Treatment goal?

Answer 55

2 risk factors --> <130 Dad is not risk factor (he is too old)

Question 56

40 yo female non-smoker with well controlled HTN on medication. Father had MI at 62. HDL is 67. Treatment goal?

Answer 56

1 for HTN, but - 1 for high HDL --> 0 RF Goal <160 Dad is not risk factor (he is too old)

Question 57

Treatment goal for diabetic 45 yo woman with HDL of 65 & no HTN. Non-smoker with no family history of CHD?

Answer 57

Diabetic = equivalent --> ignore other risk factors <130

Question 58

What type of hyperlipidemia can lead to pancreatitis?

Answer 58

Triglycerides > 500