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CMT-uno > Lipid Disorders > Flashcards

Lipid Disorders Flashcards

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1
Q

Types of Lipids

Cholesterol

A

Essential element of all animal cell membranes and the backbone of steroid hormones and bile acids

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2
Q

types of lipids

Triglycerides

A

Transfers energy from food into cells

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3
Q

types of lipids

lipoproteins

A

-Transport lipids
-Classified by density
-Apoprotein is dense
-Triglyceride is less dense

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4
Q

types of lipoproteins

Apolipoprotein B (apoB)

A

-Protein that carries LDL and helps it bind to the cell wall
-Contributes to atherogenesis (plaque forming)

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5
Q

lipoproetins

Lipoprotein (a)

A

Genetically determined subfraction of LDL (if elevated, increased risk for CAD)
Causal factor in atherosclerosis
One-time measurement recommended in patients with strong family history of ASCVD
Risk enhancing factor favoring early statin treatment

indepedent from rest of lipid panel for risk determination

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6
Q

lipoproteins

Chylomicrons

A

Least Dense

Found in blood after fat-containing meal

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7
Q

lipoprotein

Low-density lipoprotein (LDL)

A

carry most of the cholesterol

L for lousy. we want this Low.

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8
Q

lipoprotein

High-density lipoprotein (HDL)

A

Most dense and smallest
Participate in reverse cholesterol transport

H is for High and Happy, we want this number high.

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9
Q

lipoprotein

Very-Low-Density Lipoprotein (VLDL)

A

Least dense, large
Consists mostly of triglycerides that is transferred to cells

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10
Q

Which lipid value is most sensitive to fasting?

A

Trig

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11
Q

Which lipoprotein carries the most cholesterol?

A

LDL

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12
Q

Which lipoprotein is an independent risk for ASCVD?

A

Lp(a) is independent risk factor for CAD

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13
Q
A
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14
Q

how does exercise help cholesterol?

A

increasing muscles mass increases HDL

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15
Q

How can you reduce LDL?

A

Eat more fiber. Have to poop it out!

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16
Q

What is always the goal of lipid tx?

A

reduce LDL

unless TRIG is >500 due to increased risk of pancreatitis

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17
Q

Atherosclerosis

A

Plaque with large amounts of cholesterols build up in arterial walls
Associated with high LDL and low HDL
Mostly asymptomatic until plaque rupture or vessel occlusion (MI, CVA)

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18
Q

Familial Hypercholesterolemia

A

defective LDL receptors, genetic mutations of apolipoprotein B, or gain in function of proprotein convertase subtilisin/kexin type 9 (PCSK9)

Typically, patients have elevated total cholesterol and normal triglycerides
Heterozygous (1 in 250 people)
Homozygotes (1 in 1,000,000 people)

probably won’t be tested on this

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19
Q

Familial Chylomicronemia AKA

A

Lipoprotein Lipase Deficiency (LPLD)
Fredrickson Type 1 Hyperlipoproteinemia
Familial Hypertriglyceridemia

probably wont be tested on this

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20
Q

Familial Chylomicronemia

caused by, characterized by, risk for?

A

Caused by an abnormality of lipoprotein lipase (LPL) that is responsible for the ability of tissues to take up triglycerides (TG) from chylomicrons
Characterized by marked hypertriglyceridemia

Important for patient to abstain from ETOH, bc at VERY HIGH RISK FOR PANCREATITIS

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21
Q

Dysbetalipoproteinemia

A

Elevated levels of remnant lipoproteins
Rare familial disease
Associated with premature ASCVD

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22
Q

Familial combined hyperlipidemia

A

Polygenic combination of lipid abnormalities
Most common genes: LDLR, APOB, PCSK9 (don’t need to memorize these)

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23
Q

When should you suspect genetic disorders?

A

if you see LDL over 200

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24
Q

Conditions that Affect Lipids (aka. Secondary causes of dyslipidemia)

A

Metabolic syndrome
Type 2 diabetes
Uncontrolled hyperglycemia
Obesity
Hypothyroidism
Liver disease
Renal disease
Corticosteroid use
Progestin use
Anabolic steroid use
Alcohol use/abuse

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25
You are treating a patient for high cholesterol. Current LDL is non-calculable, triglycerides > 450, HDL 40. TSH is elevated at 10 ( nl range < 4.0), HgA1C 9.8. Why is her cholesterol not at goal in spite of compliance with cholesterol medications?
Must correct DM and TSH
26
Specific Clinical Presentation of high cholesterol
Most patients do not have specific signs or symptoms Primarily detected with laboratory studies
27
Eruptive Xanthomas/Xanthelasma
28
Tendinous Xanthomas | common in famial disorders
29
Lipemia Retinalis
30
Corneal Arcus (arcus lipoides) Differs from arcus senilis Gap between limbus and the lipid deposit distinguishes the two
31
Corneal Arcus (arcus lipoides)
32
# Screening fasting requirements
Fasting not required for screening; use Non-HDL-C for guidance Guidelines vary by organization
33
Screening Children
Selective screening for children age >2 with family history or lipid disorder or premature ASCVD Between ages 9-11 Again, between ages 17-21
34
Lipid screening for Adults | when do you stop screening? (no previous lipid issues)
One time- Adults at age 20 if not previously done as a child Every 5 years for those at low risk after age 35 in men 45 in women More often for those at moderate to high risk Screening not recommended for those over age 75
35
Risk Levels
36
Risk-enhancing Factors | primary prevention
37
Cardiac Calcium Score
Helpful for deciding if they should be put on statins for having calcified vessels. only catches calcification not lipids in blood which cause events. Most useful in those with intermediate risk stratification (7.5-< 20%) The higher the score, the higher risk of heart disease May repeat every 3 to 7 years based on patient risk | “The single best test for **additional** risk stratification”
38
A patient with which of the following characteristics will a cardiac calcium score be most useful in a shared decision-making model? a. Aged 75 b. Intermediate ten-year risk of heart disease c. Low-density lipoprotein (LDL) 194 d. Type 2 diabetes e. Smoker
B-Cac score may be helpful with intermediate ten –year risk
39
The Pooled Cohort Equation is used to estimate the ten-year risk of heart disease or stroke for an individual. The risk is reported to be 10%. What risk category is the result? a. Borderline b. High c. Intermediate d. Low
C-intermediate
40
# CVD Primary Prevention
Refers to therapy in persons with NO known cardiovascular disease Studies indicate rates of cardiovascular events, heart disease mortality, and all-cause mortality are decreased in the right population
41
# CVD Secondary Prevention
Refers to therapy in persons with known cardiovascular disease Studies support that cholesterol lowering leads to decreased mortality and recurrent cardiovascular events
42
primary prevention for women who anticipate childbearing
Primary prevention with statins are not recommended for women who anticipate childbearing
43
# Primary prevention Risk factors and LDL goals
44
who gets statin treatment for primary prevention?
Anyone with LDL-C ≥190 mg/dL --> high intensity statin Age 40-75 with diabetes -->moderate intensity statin. Consider high intensity statin if risk enhancing factors or 10-year risk >20% Age 40-75 without diabetes with LDL 70-189 mg/dL and intermediate or high risk --> moderate intensity statin. & high intensity statin if additional risk enhancers | slide 38
45
# CVD Secondary Prevention is for
Among patients with established ASCVD, mortality benefits of cholesterol lowering are clear Regression of atherosclerotic plaque Slow or reverse carotid artery atherosclerosis Established ASCVD Acute coronary syndromes MI stable/unstable angina Coronary/arterial revascularization Stroke/TIA Peripheral artery disease of presumed atherosclerotic origin Persons over the age of 75 should continue statin therapy with decisions based on functional status, life expectancy, comorbidities, and patient preference
46
Who is at very high risk of CVD?
ACS within the past 12 months MI other than event listed above History of ischemic stroke Symptomatic PAD (ABI <0.85, amputation, previous revascularization) | Hx of plaque related event
47
Risk factors that are High risk of CVD?
Age ≥65 Heterozygous familial hypercholesterolemia **Diabetes mellitus** Hypertension CKD (GFR 15-59 mL/min/7.73m2) **Current smoker** LDL-C ≥100mg/dL despite maximally tolerated statin and ezetimibe History of congestive heart failure
48
What is the goal LDL for someone with secondary prevention?
less than 70 LDL
49
# Secondary Prevention
memorize this
50
# primary prevention
memorize this
51
who gets statin for secondary prevention?
Everyone! High or moderate intensity statin LDL-C goal < 70 mg/dL
52
Weight loss affect on Lipids
lowers LDL, increases HDL For those who are overweight or obese
53
Tobacco cessation
increases HDL
54
Modest alcohol use Will increase? And when is it contraindicated?
increases HDL, contraindicated for very high TG (red wine) someone with High TRIG will not benefit
55
Benefits of Mediterranean Diet
Total fat 35-40% fat but saturated fat replaced with monounsaturated fat Plant based, lean animal protein (preferably fish) Lowers LDL without lowering HDL Reduces endothelial dysfunction, insulin resistance, and vascular inflammatory markers
56
Specific nutrition guidance for treatment of elevated triglycerides
Low carbohydrate No simple sugars No alcohol
57
A 45-year-old woman with no risk factors for coronary heart disease is found to have a cholesterol level of 165mg/dL. What nutrition advice is most helpful? a. Abstain from all alcohol b. Begin a fish oil supplement c. Cut carbohydrate intake to less than 30% of total calories d. Decrease saturated fat to less than 15% of total calories e. Increase soluble fiber to 20 grams daily
E. Increase soluble fiber to 20 grams daily
58
Which of the following “natural” interventions has not been proven to reduce cholesterol? a.Almonds b.Walnuts c.Increase fiber dCo-Q-10 e.Plant stanols f.Red-yeast rice extract
d. Co-Q-10 does not help reduce cholesterol, might help with Side affects from chole meds
59
Pt is in primary prevention, what is their LDL goal? what about secondary? secondary over 75y?
100 if primary 70 if secondary with high intensity statin 70 with POSSIBLE moderate statin
60
What is first line medication class for lipid management?
Statin
61
If pt starts on statin, when do we check bloodwork again?
3 months
62
what if lipid still elevated after check up on statins?
if moderate statin, move them to high intesity statin or consider adding another agent (second line) such as PSK9 inhibitor or Ezetimibe
63
In what scenario is TRIG reduction more important that LDL reduction?
when TRIG is >500 due to risk of pancreatitis
64
Fish Oil Medications
icosapent ethyl (Vascepa), omega-3-acid ethyl esters (Lovaza)
65
Fish oil benefits
for reducing TRIG by up to 30% Reduces apoB Reduces hsCRP Reduces CV death, MI, CVA, unstable angina and coronary revasularization
66
Niacin (Niaspan) benefits and contraindications
Reduces LDL 15-25% *Increases HDL 25-35% Caution with cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors
67
SE of Niacin (Niaspan)
Flushing Pruritus Hyperglycemia Gout exacerbation Peptic ulcer disease
68
# Fibrates gemfibrozil (Lopid), fenofibrate (Tricor, Triglide, Lipofen)
*Reduce TRIG 40%* Reduce LDL 10-15% Increase HDL 15-20% Reduces CHD and CV events
69
Statins benefits
Reduces LDL by up to 50% (high intensity statin) Increases HDL Decreases TG Decreases hsCRP Dosed once daily
70
Statin MOA
Work by inhibiting the rate-limiting enzyme in the formation of cholesterol in the liver and increases hepatic LDL receptors
71
Statin Contra
Caution with niacin, fibrates, EES, antifungals, nefazodone, or cyclosporin Liver failure
72
Statin SE
Myalgias- bilateral mostly legs and shoulders CK elevations Myositis Rhabdomyolysis Elevated transaminases Diabetes development
73
# Statin Rule of 6 or 7
you get bigest reduction at initial dose, w/ each titration you get 6-7% off as you increase dose ## Footnote 40% at 10mg, then 46% at 20mg
74
Which of the following statin medications and doses is high-intensity intervention? a. Atorvastatin 40mg b. Lovastatin 20mg c. Pravastatin 40mg d. Simvastatin 40mg e. Rosuvastatin 10mg
A. Atorvastatin 40mg
75
Which of the following statins would you select to reduce LDL by 35-50% a. atorvastatin (Lipitor) 40 mg  b. atorvastatin (Lipitor) 80 mg  c. rosuvastatin (Crestor) 10 mg  d. rosuvastatin (Crestor) 20 mg  e. simvastatin (Zocor) 10 mg  | (moderate intensity)
c. rosuvastatin (Crestor) 10 mg
76
What is perc goal of LDL lowering for patient with clinical ASCVD taking a high-intensity statin?  a. 10%   b. 20%  c. 25%  d. 30%  e. 50% 
e. 50% (high intensity)
77
# Bile Acid Sequestrants cholestyramine (Questran), colesevelam (Welchol), colestipol (Colestid)
Reduces LDL by 15-25% **Safe in pregnancy** OK with liver disease
78
# Cholesterol Absorption Inhibitors ezetimibe (Zetia)10mg daily
Reduces LDL 15-20% Reduces hsCRP Once daily dosing Well tolerated On boards, this is second step for with statins | (has reduced numbers but not shown to reduce events
79
# PCSK9 Inhibitors alirocumab (Praluent), evolocumab (Repatha) benefits
Decrease LDL 50-60% Decrease Lp(a) 20-30% Reduces CV events and death | shot
80
# Adenosine Triphosphate-Citrate Lyase (ACL) Inhibitors Bempedoic Acid (Nexletol) Bempedoic Acid + ezetimibide (Nexlizet) Benefits
Lowers LDL by 17-20% In combo with ezetimibe (up to 38%) Decreases hsCRP Decreases diabetes risk Once daily dosing
81
You are treating a patient with CAD and high cholesterol They present in clinic for follow-up with labs: LDL 110, HDL 45, Tg 120. VS: 140/88, HR 12. Current medications include rosuvastatin 20 mg po at hs. What is target LDL?
< 70
82
Which of the following is indicated to get patient to goal? continue rosuvastatin and add atorvastatin 20 mg ? add ezetimibe 10 mg po daily (cholesterol absorption inhibitor) start Praulent (PCSK9-I) start Nexitol (ACL inhibitor) start gemfibrozil ( bile acid sequestrant)
b- YES a- NO dont prescribe 2 statins
83
# Primary prevention age 40-75 with LDL 70-190 Low
Low < 5% - emphasize lifestyle to reduce risk
84
# primary prevention age 40-75 with LDL 70-190 Borderline
borderline 5-7.5% 10 year risk If risk enhancers present then DISCUSS moderate intensity STATIN
85
# Primary prevention age 40-75 with LDL 70-190 Intermediate
7.5-20% risk moderate intensity STATIN
86
# Primary prevention age 40-75 with LDL 70-190 High risk
> or = 20% high intensity STATIN
87
# primary prevention age 40-75 with DM and LDL 190 or higher
no risk assessment necessary high intesnity statin
88
# primary prevention 45-75 y with DM
moderate STATIN risk assessment to decide if High intensity statin
89
90
# primary LDL levels
91
# primary Chlesterol levels
92
# primary prevention HDL levels
93
Pooled Cohort Equations
Separate Equations for White and Black patients Estimates 10-year risk of MI, CVA, CV death Does over-estimate risk of middle to higher socioeconomic class patients Disclaimer reads that it is not intended for those with previous MI/CVA, LDL >190, or <40-years-old or >79-years-old
94
How to interpret cardiac calcium score
95
# SECONDARY prevention Age < 75 ASCVD NOT at very high risk | Goal and Tx
goal: LDL 70 or less High intensity statin if not tolerated moderate statin with ezetimibe
96
# Secondary prevention pt at very high risk ASCVD | goal and Tx (3 possible steps)
goal: 70 or less 1. high intensity statin 2. add ezetimibe if LDL not low enough 3. if still not low enough add pcsk9
97
Who is at VERY high risk?
ACS within the past 12 months MI other than event listed above History of ischemic stroke Symptomatic PAD (ABI < 0.85, amputation, previous revascularization)
98
who is at high risk?
Age ≥65 Heterozygous familial hypercholesterolemia Diabetes mellitus Hypertension CKD (GFR 15-59 mL/min/7.73m2) Current smoker LDL-C ≥ 100mg/dL despite maximally tolerated statin and ezetimibe History of congestive heart failure
99
Individuals with clinical ASCVD should be on? | what kind of prevention?
STATIN secondary
100
Individuals with primary elevation of LDL cholesterol >190 mg/dL should be on ..
primary prevention STATIN
101
Individuals aged 40-75 with diabetes and LDL ≥70mg/dL
primary prevention statin
102
Individuals aged 40-75 without clinical ASCVD or diabetes with LDL 70-189 and estimated 10-year CVD risk of 7.5% or higher
primary prevention statin

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