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Flashcards in lipids Deck (40):
1

LDL >190

getting a statin

2

have DM, goal of LDL less than

70 (60 ideal)

get a statin

3

if have CAD

automatically get a statin

4

flowchart for

statin use

5

VLDL=

TAGS/5

6

LDL =

total cholesterol - HDL - TAGS/5

7

total cholesterol =

HDL + VLDL + LDL

8

LDL =

total cholesterol - HDL - TAGS/5 (if in mg/dL)

total cholesterol - HDL - TAGS/2.2 (if in mmol/L)

9

Familial hypercholesterolemia

Rare in the homozygous state (about one per million) is a condition in which the cell-surface receptors for the LDL molecule are absent or defective, resulting in unregulated synthesis of LDL

Homozygotes have extremely high levels present with atherosclerotic disease in childhood

*Heterozygotes* have LDL concentrations twice normal; persons with this condition may develop CHD in their 30s or 40s
-look normal, do lipid panel*

10

Familial hyperchylomicronemia

Have marked hypertriglyceridemia with recurrent pancreatitis and hepatosplenomegaly in childhood

11

factors affecting lipids
*see chart

obesity (inc. TAGs, dec. HDL)
sedentary (dec. HDL)
DM (inc. TAGs, inc. tot. cholesterol)
etOH (inc. TAGs, but inc. HDL)
hypothyroid (inc. total)
hyperthyroid (dec. total)
nephrotic syndrome (dec. total)
CKD (inc. total, inc. TAGs)
cirrhosis (dec. total)
obstructive liver disease (inc. total)
malignancy (dec. total)
cushing's disease (or cort. steroid use) (inc. total)
OCTs (inc. TAGs, inc. total)
diruetics (inc. total, inc. TAGs)
B-blockers (may be on for HTN) (inc. total, dec. HDL)

12

hyperlipidemia s/s

Most patients with high cholesterol levels have no specific symptoms or signs

Most are detected by the laboratory, either as part of the workup of a patient with cardiovascular disease or as part of a preventive screening strategy

13

Eruptive xanthomas

Red-yellow papules (especially on the buttocks)

Extremely high levels of chylomicrons or VLDL particles

*know pics

14

Tendinous xanthomas

On certain tendons (achilles, patella, back of the hand)

High LDL concentrations

*know pics

15

Lipemia retinalis

Cream-colored blood vessels (in the fundus)

Extremely high triglyceride levels

*know pics (slide 26)

16

hyperlipidemia epi

With known cardiovascular disease cholesterol lowering leads to a consistent reduction in total mortality and recurrent cardiovascular events in men and women and in middle-aged and older patients

Treatment algorithms have been designed to assist clinicians in selecting patients for cholesterol-lowering therapy based on their overall risk of developing cardiovascular disease

17

hyperlipidemia pathophysiology

The two main lipids in blood are cholesterol and triglyceride carried in lipoproteins

Lipoproteins are usually classified on the basis of density
High-density lipoproteins (HDL)
Low-density lipoproteins (LDL)
Very-low-density lipoproteins (VLDL)

18

hyperlipidemia screening


*All patients with cardiovascular disease and diabetes should have their lipids measured*

*Diabetes and LDL greater than or equal to 70 mg/dL should be treated with statins*

rest FYI

A complete lipid profile (total cholesterol, HDL cholesterol, and triglyceride levels) after an overnight fast should be obtained

According to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, however, such patients are treated with statins independent of their lipid levels

Similarly, patients aged 40–75 with diabetes should also have a complete lipid profile



19

For men without other risk factors, screening is recommended beginning at age ??

35 years

For women and for men aged 20 to 35 without increased risk, the USPSTF makes no recommendation for or against routine screening for lipid disorders
-decreased efficacy of screening entire population

Although there is no established interval for screening, screening can be repeated every 5 years for those with average or low risk and more often for those whose levels are close to therapeutic thresholds.
*controversial

20

A2013 ACC/AHA guidelines recommend screening of all adults aged ?? or older for high blood cholesterol

21 years

United States Preventive Services Task Force (USPSTF) suggests beginning at age 20 years only if there are other cardiovascular risk factors such as tobacco use, diabetes, hypertension, obesity, or a family history of premature cardiovascular disease

21

hyperlip. Risk stratification**

Without cardiovascular (coronary) disease should have their 10-year risk of CHD calculated

LDL cholesterol greater than 190 mg/dL are recommended for treatment independent of their 10-year risk of cardiovascular disease, all other patients are recommended for treatment based on their overall cardiovascular risk

Women-low HDL may be most important risk factor

Elderly >75 cholesterol may not be a risk factor

The best method for estimating 10-year risk is controversial

2013 ACC/AHA guidelines
(link)

Framingham 10-year calculator (Table 28–1) includes CHD but not stroke risk (not tested on?)

22

if pts >25, your 10 year risk for coronary heart disease is ??

30%

23

Initial cholesterol measurement

Total cholesterol alone

Total cholesterol and HDL cholesterol

LDL cholesterol**

24

Numerous other risk factors have been studied in an attempt to better predict future CHD events

**High-sensitivity C-reactive protein (hs-CRP) (ppl who are already sick have higher levels of CRP, confounding)

Electron beam computed tomography (EBCT)
Homocysteine
Fibrinogen
Lipoprotein (a)
LDL subfractions
(certain fractions of LDL are worst than others)
Ankle-brachial index

25

**Treatment decisions**

Clinical cardiovascular disease or diabetes

Patient age

LDL cholesterol greater than 190 mg/dL

Estimated 10-year risk of developing cardiovascular disease

26

hyperlip. tx: diet

Low fat, low cholesterol (original thought)
Mediterranean diet
Soluble fiber, garlic, vitamin C, pecans, plant sterols

27

Other risk factor reduction

Smoking cessation**

HTN control

ASA use

Raise HDL

28

who should get ASA (high risk)

after HA/CVA, hypercoaguable risk factors
DM
LDL> 190

controversial for others: negative effects

29

how to Raise HDL

aerobic exercise
healthy fats
moderate etOH use

30

when to tx

CAD/CVD : high intensity statin or moderate if >75

LDL >190 : high intensity statin

age 40-75, +DM, LDL >70 mg/dL : moderate statin or high if 10 yr CVD risk >= 7.5%

age 40-75, no CAD/CVD/DM, LDL 70-189 mg/dL, est. 10 yr CVD risk 7.5% or higher : moderate to high statin

31

low-intensity statins

lowers LDL on average by less than 30%

32

moderate-intensity statins

lower LDL by about 30% to less than 50%

33

high-intensity statins

lowers LDL by about greater than 50%

*atorvastatin
*rosuvastatin

34

atorvastatin

lowers LDL, raises HDL and lowers TAGs

35

statin SEs

myopathies
liver toxicity

36

new drug

PCSK9 inhibitors (won't be tested on)
slide 39 -know statins

37

how to tx high TAGs

Dietary:
Avoid alcohol, simple sugars, refined starches, saturated and trans fatty acids, and restricting total calories

Control of secondary causes of high TAG levels

Drug therapy (niacin, a fibric acid derivative, omega-3-acid ethyl esters, or an HMG-CoA reductase inhibitor (statin MOA)) is indicated. Combinations of these medications may also be used

38

?? are made in the gut and travel via the portal vein into the liver and via the thoracic duct into the circulation
Normally completely metabolized, transferring energy from food into muscle and fat cells.

Chylomicrons

39

The plaques in the arterial walls of patients with atherosclerosis contain large amounts of ??

cholesterol

The higher the level of low-density lipoproteins (LDL) cholesterol, the greater the risk of atherosclerotic heart disease

The higher the high-density lipoproteins (HDL) cholesterol, the lower the risk of coronary heart disease (CHD)

High total cholesterol levels are also associated with an increased risk of CHD

40

know slide 9

flow chart algorithm

if have CAD, getting tx
if not, check LDL
>190 get statin
if have DM get statin