Lipids Flashcards
1
Q
3 types of lipids
A
- cholesterol
- triglycerides
- lipoproteins
2
Q
what is cholesterol
define/describe
A
essential element of all animal cell membranes and the backbone of steroid hormones and bile acids
3
Q
what are triglycerides
A
txfr energy from food into cells
4
Q
what are lipoproteins
A
- transport lipids
- classified by density
- apoprotiein is dense
- triglyceride is less dense
5
Q
7 types of lipoproteins
A
- chylomicrons
- low-density lipoprotein
- high-density lipoprotein
- very-low-density lipoprotein
- Apolipoprotein B (apoB)
- Lipoprotein
- non-HDL cholesterol
6
Q
describe chylomicrons
A
least dense
found in blood after fatty meals
7
Q
describe LDL
A
carry most of our cholesterol
8
Q
describe VLDL
A
least dense, large
consists mostly of triglycerides that are txfr to cells
9
Q
describe HDL
A
most dense & smallest
participate in reverse cholesterol transport
10
Q
describe apoB
A
- protein that carries LDL and helps it bind to the cell wall
- contributes to atherogenesis
11
Q
describe lipoprotein a (lp(a))
A
- genetically determined subfraction of LDL
- causal factor in atherosclerosis
- one-time measurement rec in pts w/ family hx of ASCVD
- risk enhancing factor favoring early statin tx
12
Q
describe non-HDL cholesterol
A
- surrogate marker of apoB
- measured directly, less sensitive to fasting status
- better predictor of CV risk than LDL
- non-HDL Cholesterol = TC - HDL
13
Q
which lipid value is most sensitive to fasting?
A
triglycerides
14
Q
which lipoprotein carries the most cholesterol
A
LDL
15
Q
which lipoprotein is an independent risk for ASCVD
A
Lp(a)
16
Q
which lipoprotein represents all apoB containing particles?
A
non-HDL calculation
17
Q
what are the components of a lipid panel?
4
A
- total cholesterol
- LDL
- HDL
- triglycerides
18
Q
which components of a lipid panel are measured directly? which are calculated?
A
- direct: TC, HDL, triglycerides
- calc: LDL
19
Q
equation for TC
A
HDL + VLDL + LDL
20
Q
equation for non-HDL cholesterol
A
TC - HDL
21
Q
equation for VLDL
& when to use
A
TG / 5
only if TG is < 400
22
Q
equation for LDL
A
TC - HDL - (TG / 5)
23
Q
what are benchmarks for LDL levels?
5
A
- less than 100: optimal
- 100-129: near optimal/above optimal
- 130-159: borderline high
- 160-189: high
- more than 190: very high
24
Q
what are benchmarks for TC levels?
3
A
- less than 200: desirable
- 200-239: borderline high
- greater than 240: high
25
what are benchmarks for HDL cholesterol?
| 2
* less than 40: low
* greater than 60: high
26
benchmarks of triglycerides?
| 4
* less than 150: normal
* 150-199: borderline high
* 200-499: high
* more than 500: very high
27
what is the goal of lipid treatment? when does this goal change?
* to reduce LDL
* when triglycerides are greater than 500
28
what is the risk of treating when triglycerides are greater than 500?
pancreatitis
29
# Atherosclerosis
associated with?
* high LDL
* low HDL
30
# Atherosclerosis
pathophys
plaque w/ large amounts of cholesterol build up in arterial walls
31
# Atherosclerosis
mostly asx until?
rupture or vessel occlusion (MI or CVA)
32
# Familial Hypercholesterolemia
associated with which genetic components?
| 3
1. defective LDL receptors
2. genetic mutations of apo B
3. gain of function mutation of PCSK9
33
# Familial Hypercholesterolemia
which lipid is usually elevated?
* total cholesterol
34
# Familial Hypercholesterolemia
describe clinical manifestation of heterozygous pts
* up to 3x normal levels of LDL
* LV disease begins in 30s or 40s
35
# Familial Hypercholesterolemia
describe clinical manifestation of homozygous pts
* extremely high LDL (up to 8x normal)
* atherosclerosis in childhood
* may require plasmapheresis to remove cholesterol
36
# Familial Chylomicronemia
AKA
| 3 things
1. Lipoprotein Lipase Deficiency (LPLD)
2. Fredrickson Type 1 Hyperlipoproteinemia
3. Familial Hypertriglyceridemia
37
# Familial Chylomicronemia
caused by?
abnormality of LPL that is responsible for ability of itssues to take up triglycerides (TG) from chylomicrons
38
# Familial Chylomicronemia
characterized by?
hypertriglyceridemia
39
# Familial Chylomicronemia
complications
| 2
* recurrent pancreatitis
* hepatosplenomegaly
40
# Familial Chylomicronemia
important to abstain from?
EtOH
41
# Dysbetalipoproteinemia
elevated levels of?
reminant lipoproteins
42
# Dysbetalipoproteinemia
associated with?
premature ASCVD
43
# Familial Combined Hyperlipidemia
most commonly affected genes?
| 3
* LDLR
* APOB
* PCSK9
44
Conditions that affect lipids
| AKA- secondary causes of dyslipidemia- 11
1. metabolic syndrome
2. type 2 diabetes
3. uncontrolled hyperglycemia
4. obesity
5. hypothyroidism
6. liver disease
7. renal disease
8. corticosteroid use
9. progestin use
10. anabolic steroid use
11. alcohol use/abuse
45
conditions that increase TC
| 10
1. obesity
2. uncontrolled DM
3. hypothyroidism/Cushing
4. nephrotic syndrome
5. CKD
6. obstructive liver disease
7. corticosteroid use
8. OCPs
9. Diuretics
10. Beta Blockers
46
conditions that decrease TC
| 3
1. hyperthyroidism
2. cirrhosis
3. malignancy
47
factor that increases LDL
| 1
1. alcohol use
48
conditions that decrease HDL
| 4
1. obesity
2. sedentary lifestyle
3. metabolic syndromes
4. beta blockers
49
conditions that increase triglycerides
| 6
1. DM
2. alcohol use
3. nephrotic syndrome
4. CKD
5. OCP
6. diuretics
50
you are treating a pt for high cholesterol. Current LDL is non-calculable, other values are:
* TG > 450
* HDL: 40
* TSH: 10 (normal < 4)
* HgA1C: 9.8
why is her cholesterol not at goal in spite of compliance with cholesterol medications?
must correct DM and TSH
51
Clinical Presentation
| 4- but really labs are best dx tool
1. eruptive xanthomas/xanthelasma
2. tendinous xanthomas
3. lipemia retinalis
4. corneal arcus
52
Screening Guidelines Children
* selective screening for children age > 2 y/o with family hx, lipid disorder, or premature ASCVD
* first screen between ages 9-11 and again between 17-21
53
Screening Guidelines Adults
* first at age 20 if not done as a child
* every 5 years for those at low risk after age 35 (men) or 45 (women)
* more often screenings based on relative risk
54
Screening Guidelines for Older Adults
* screening not recommended for those over age 75
55
Describe Pooled Cohort Equations
* estimates 10 year risk of MI, CVA, CV death
* does over-estimate risk of middle/higher SES pts
* separate calculator for white/black pts
56
Pooled Cohort Equation risk levels defined
10 year risk is....
* less than 5%: low
* 5-7.5%: borderline
* 7.5-20%: intermediate
* more than 20%: high
57
Risk enhancing factors- basically who will benefit the most from therapy?
| 12
1. family hx of premature disease
2. metabolic syndrome
3. chronic inflammatory conditions
4. high risk race/ethnicity
5. elevated hsCRP
6. elevated apo B
7. primary hypercholesterolemia
8. CKD
9. hx of pre-eclampsia or premature menopause
10. presistently high TG
11. elevated apo(a)
12. low ankle brachial index
58
# Cardiac Calcium Score
is the......
| best....
single best test for additional risk stratification
59
# Cardiac Calcium Score
what type of imaging?
noncontrast cardiac gated CT
60
# Cardiac Calcium Score
repeat how often?
every 3 to 7 yrs based on risk
61
# Cardiac Calcium Score
how to interpret a cardiac calcium score
| 5 categories
* 0: no evidence of CAD
* 1-10: minimal evidence of CAD
* 11-100: mild evidence of CAD
* 101-400: moderate evidence of CAD
* 400 + : severe evidence of CAD
62
A pt with which of the following characteristics will a cardiac calcium score be most useful in a shared decision-making model?
* aged 75
* intermediate 10-year risk of heart disease
* LDL of 194
* type 2 DM
* smoker
intermediate 10 year risk of heart disease
63
The Pooled Cohort Equation is used to estimated the 10-year risk of heart disease or stroke for an individual. The risk is reported to be 10%. What risk category is the result?
* borderline
* high
* intermediate
* low
intermediate
64
# CV Disease Prevention
what is primary prevention
* refers to therapy in persons with no known cardiovascular disease
65
# CV Disease Prevention
what is secondary prevention
* therapy in persons with known CV disease
66
# CV Disease Prevention
At what age do you stop primary prevention?
75
67
# CV Disease Prevention
What shouldn't you use as primary prevention in pregnant women?
statins
68
# CV Disease Prevention
When do you consider lifestyle factors and drug therapies in someone with 0-1 risk factors?
* Lifestyle changes: LDL > 160
* Drug therapies: LDL > 190
69
# CV Disease Prevention
When do you consider lifestyle factors and drug therapies in someone with 2+ risk factors?
* Lifestyle: LDL > 130
Drug therapies
* 10-year risk 10-20%: LDL > 130
* 10-year-risk < 10%: LDL > 160
70
# CV Disease Prevention
When do you consider lifestyle factors and drug therapies in someone with CHD?
* Lifestyle: LDL > 100
* Drug Therapies: LDL > 130
71
# CV Disease Prevention
Who gets high intensity statins for primary prevention?
* LDL > 190
* Age 40-75 with diabetes AND risk enhancing factors or 10-year risk >20%
* Age 40-75 without diabetes with LDL 70-189 and intermediate or high risk with additional risk factors
72
# CV Disease Prevention
Who gets moderate intensity statins for primary prevention?
* Age 40-75 with diabetes
* Age 40-75 without diabetes with LDL 70-189 and intermediate or high risk
73
# CV Disease Prevention
Descisions to continue statin therapies in pts older than 75 y/o should be based on:
| 4 things
1. functional status
2. life expectancy
3. comorbidities
4. pt preference
74
# CV Disease Prevention
who is very high risk?
| 4 things
1. ACS within past 12 mo
2. MI other than event listed above
3. hx of ischemic stroke
4. symptomatic PAD
75
# CV Disease Prevention
what is considered high risk>
| 8 things
1. > 65 y/o
2. heterozygous familial hypocholesterolemia
3. DM
4. hypertension
5. CKD
6. current smoker
7. CHF
8. LDL >100 with statin and ezetimibe
76
# CV Disease Prevention
who gets a statin in secondary prevention?
EVERYONE
77
# Lipid Treatment
What lifestyle changes should be made? what lipid does component act on?
| 5 general measures
1. exercise (increases HDL)
2. wt loss (decreases LDL, increases HDL)
3. tobacco cessation (increases HDL)
4. modest alcohol use (increases HDL)
5. Aspirin (not rec for all)
78
# Lipid Treatment
after how long should you recheck lipids after lifestyle changes?
4-6 wks
79
# Lipid Treatment
Desired dietary intake for lifestyle changes?
1. total fat 25-30% of cals
2. saturated fats < 7% of cals
3. dietary cholesterol < 200 mg/d
4. 20-30g of soluble fiber daily
5. 2g of plant stanols and sterols daily
6. antioxidants
80
# Lipid Treatment
which diet is most moften recommended for cholesterol reduction?
mediterranean
81
A 45 y/o woman with no risk factors for CHD is found to have cholesterol levels of 165 mg/dL. What nutrition advice should you give?
1. abstain from all alcohol
2. begin a fish oil supplement
3. cut carbohydrate intake to < 30% of cals
4. decrease saturated fat to < 15% of cals
5. increase fiber to 20g daily
increase fiber to 20g daily
82
Which of the following "natural" interventions has not been proven to reduce cholesterol?
1. almonds
2. walnuts
3. increased fiber
4. Co-Q 10
5. Plant stanols
6. Red-yeast rice extract
Plant stanols
83
# Lipid Treatment
first, second, third line for hyperlipidemia?
1. statins
2. ezetimibe
3. PCSK9 inhibitors
84
# Lipid Treatment
first, second, third line for hypertriglyceridemia?
1. fibrates
2. niacin
3. fish oil
85
# Lipid Treatment
names for fish oil tx
1. icosapent ethyl (vascepa)
2. omega-3-acid ethyl esters (lovaza)
86
# Lipid Treatment
Benefits of fish oil tx
* reduce TG up to 30%
87
# Lipid Treatment
dosage for fish oils
| CAD tx vs TG
1. 1g/d for CAD
2. 2-4g/d for TG reduction
88
# Lipid Treatment
Contraindications of fish oils
1. fish/shellfish allergy
2. increased bleeding risk
3. discontinue for surgery
89
# Lipid Treatment
benefit of niacin (niaspan)?
* reduces LDL 15-25%
* increases HDL 25-35%
90
# Lipid Treatment
what to take 1 hr before Niacin?
Aspirin or NSAID
91
# Lipid Treatment
Contraindications of Niacin?
* caution with cyclosporine, macrolides, anti-fungals, and other CYP metabolites
92
# Lipid Treatment
names for fibrates that might be prescribed?
1. gemifibrozil (Lopid)
2. fenofibrate (Tricor, Triglide, Lipofen)
93
# Lipid Treatment
benefits of fibrates
* reduce TG 40%
* reduce LDL 10-15%
* Increase HDL 15-20%
94
# Lipid Treatment
contraindications of fibrates?
1. impaired renal function
2. caution w/ cyclosporine, macrolides, anti-fungals, and CYP450 metabolites
95
# Lipid Treatment
MOA of statins
* inhibit the rate-limiting enzyme in the formation of cholesterol in the liver and increases hepatic LDL receptors
96
# Lipid Treatment
risks of statins
| 6
1. myalgias
2. CK elevations
3. myositis
4. rhabdomyolysis
5. elevated transaminases
6. DM development
97
# Lipid Treatment
contraindications of statins?
* Liver function
* niacin, fibrates, EES, anti-fungals, nefazodone, cyclosporin
98
# Lipid Treatment
by how much do low intensity statins reduce LDLs? which meds/doses are low intensity?
1. < 30%
2. Pravastatin, 10-20mg
3. Lovastatin, 20mg
99
# Lipid Treatment
by how much do moderate intensity statins reduce LDLs? which meds/doses are moderate intensity?
1. 30-50%
2. Pitavastatin, 2-4mg
3. Simvastatin, 20-40mg
4. Pravastatin, 40-80mg
5. Atovastatin, 10-20mg
6. Rosuvastatin, 5-10mg
100
# Lipid Treatment
by how much do high intensity statins reduce LDLs? which meds/doses are high intensity?
* reduce LDLs by ~50%
1. Atovastatin, 40-80mg
2. Rosuvastatin, 20-40mg
101
which of the following statin medications and doses is high intensity intervention?
1. Atorvastatin, 40mg
2. Lovastatin, 20mg
3. Pravastatin, 40mg
4. Simvastatin, 40mg
5. Rosuvastatin, 10mg
Atorvastatin, 40mg
102
Select all statins that could be used to reduce LDL by 35-50%
1. atorvastatin, 40mg
2. atorvastatin, 80mg
3. rosuvastatin, 10mg
4. rosuvastatin, 20mg
5. simvastatin, 10mg
rosuvastatin 10 mg
103
# Lipid Treatments
what meds are bile acid sequestrants?
* cholestryamine (Questran)
* colesevelam (Welchol)
* colestipol (Colestid)
104
# Lipid Treatments
moa of bile acid sequestrants
binds bile acids in the intestine which increases bile acid synthesis and LDL receptor activity
105
# Lipid Treatments
benefits of bile acid sequestrants?
1. reduces LDL by 15-25%
2. safe in pregnancy
3. can use with liver disease
106
# Lipid Treatments
risks of bile acid sequestrants?
TG may increase
107
# Lipid Treatments
contraindications of bile acid sequestrants?
| NOT A MED
TG >500 mg/dL
108
# Lipid Treatments
what med is a cholesterol absorption inhibitor?
ezetimibe (zetia) 10 mg daily
109
# Lipid Treatments
MOA of ezetimibe
inhibits intestinal absorption of dietary and biliary cholesterol by inhibiting cholesterol transport.
can use as monotherapy or add to statin
110
# Lipid Treatments
benefits of ezetimibe
* reduced LDL 15-20%
* reduces hsCRP
* well tolerated, QD
111
# Lipid Treatments
contraindications of ezetimibe
liver failure
112
# Lipid Treatments
which meds are PCSK9 inhibitors
* alirocumab (Praluent)
* evolocumab (Repatha)
113
# Lipid Treatments
moa of PCSK9 inhibitors
human monoclonal antibodies that inhibit LDL receptor degradation
use as a monotherapy or with statins
114
# Lipid Treatments
benefits of PCSK9 inhibitors
* decrease LDL 50-60%
* decrease Lp(a) 20-30%
115
# Lipid Treatments
which meds are adenosine triphosphate-citrate lyase inhibitors? (ACL)
Bempedoic Acid (nexletol)
Bempedoic Acid + ezetimibide (Nexlizet)
116
# Lipid Treatments
moa of ACL inhibitors
* targets cholesterol synthesis in the liver (two steps upstream of statins)
* up regulation of LDL receptors in the liver
117
# Lipid Treatments
benefits of ACL inhibitors
* lowers LDL by 17-20%
* combo w/ ezetimibe: 38%
118
# Lipid Treatments
contraindications of ACL inhibitors
* not to be used with simvastatin 20mg or pravastatin 40mg
119
# Lipid Treatments
which med is angiopoietin-like 3 (ANGPTL3) inhibitor?
evinacumab
120
# Lipid Treatments
moa of ANGPTL3 Inhibitors
* monoclonal antibody
* activates lipoprotein lipase and endothelial lipase to increase lipid metabolism
121
# Lipid Treatments
benefits of ANGPTL3 inhibitors
1. reduces TG
2. reduces non-HDL cholesterol
3. LDL redution by 49%
122
# Lipid Treatments
which med is small interfering RNA?
inclisiran (leqvio)
123
# Lipid Treatments
moa of small interfering rna
silences RNA involved in the synthesis of PCSK9 that controls synthesis of LDL cell surface receptors
124
# Lipid Treatments
indications of inclisiran
1. maximally tolerated statin dose
2. clinical CV disease
3. pts with heterozygous familal hypercholesterolemia
125
# Lipid Treatments
use small interfering RNA meds in combo with? to do what?
* adjunct to statins
* to address LDL
126
# Lipid Treatments
how often to check lipids? how often after desired levels achieved?
* check 12 wks after therapy initiation
* after at goal: check anually
