11/2 Flashcards
cholesterol absorption inhibitor
ezetimibe
can further dec LDL by 12-20% when combined with statin
fibrates
gemfibrozil, fenofibrate, fenofibric acid
fibrates SE
GI, rash, myalgia, dizziness
fibrates increase levels of
statins, ezetimibe, SUs, warfarin
CETP inhibitors
CETP (cholesterol ester transfer protein) turns HDL to LDL
increase HDL
anacetrapib and evacetrapib increase HDL up to 130% and decrease LDL 35-40%
PCSK9 inhibitors MOA
inhibit the binding of PCSK9 to LDL receptors and upregulate the recycling of LDL receptors resulting in a drastic decrease in LDL-C
PCSK9 inhibitors indication
adjunct to diet and statin to reduce LDL in familial heterozygous hypercholesterolemia or atherosclertic CVD
PCSK9 inhibitors
alirocumab and evolocumab
expensive (cheaper than heart attack)
reduce LDL 60-70%
red yeast rice
contains lovastatin
mipomerson
inhibits ApoB100 synthesis
adjunct to lipid-lowering medications and diet to reduce LDL-C, apoB, TC amd non-HDL-C on patients with HoFH
BBW of hepatotoxicity
200 mg SQ once weekly
lomitapide
microsomal TG transfer protein inhibitor indicated as an adjunct to a low-fat diet and other lipid-lowering treatments in pts w HoFH
BBW of hepatatoxicity
5-60 mg PO QD
blocks production of VLDL and chylomicron
ATP III
CHD and CHD risk equivalents greater than 20% 10 year risk: goal LDL less than 100 mg/dL
2+ risk factors and less than 20% 10-year risk: goal LDL less than 130 mg/dL
0-1 risk factors: goal LDL less than 160 mg/dL
ATP III risk factors
- cigarette smoking
- HTN (BP>140/90 or antiHTN med)
- low HDL
- FH of CHD (dad younger than 55, mom younger than 65)
- age (men 45, women 55)
ATP III CV risk eqivalents
- eqivalent of having a heart attack
- CHD
- symptomatic carotid artery disease
- peripheral artery disease
- AAA (abdominal aortic aneurysm)
- DM
statin benefit groups
- clinical ASCVD
- LDL-C greater than 190 mg/dL
- diabetes and 40-75 yo
- ASCVD 10 year risk >7.5% and 40-75 yo
clinical ASCVD (ACC/AHA)
- acute coronary syndrome (ACS)
- hx of MI
- stable or unstable angina
- coronary or other arterial revascularization
- stroke/TIA
- peripheral artery disease (atherosclerotic origin)
statin intensity (ACA/AHA) in benefit groups
clinical ASCVD: high if younger than 75, moderate if older than 75
LDL greater than 190: always high
DM and age 40-75: high if ASCVD risk is greater than 7.5% and moderate if ASCVD risk is less than 7.5%
ASCVD risk greater than 7.5% and age 40-75: mod-high
who does NOT automatically get a statin (but may still get a statin)?
- age 21-39 without ASCVD and LDL less than 190
- age >75 without ASCVD and LDL less than 190
- ASCVD risk less than 5% and LDL 70-189
- hemodialysis or NYHA class III or IV HF
high-intensity statins
daily dose lowers LDL-C >50%
- atorvastatin 40-80 mg
- rosuvastatin 20-40 mg
mod intensity statins
daily dose lowers LDL 30-50%
- atorvastatin 10-20 mg
- pravastatin 40-80 mg
- rosuvastatin 5-10 mg
- simvastatin 20-40 mg
- lovastatin 40 mg
- fluvastatin 80 mg
- pitavastatin 2-4 mg
low intensity statin
daily dose lowers LDL by 30% -simvastatin 10 mg -pravastatin 10-20 mg -lovastatin 20 mg fluvastatin 20-40 mg -pitavastatin 1 mg
ASCVD risk factors (NLA)
age: male older than 45, female older than 55
FH of early CHD: dad younger than 55 or mom younger than 65
smoker
HTN: BP >140/90 or current use of BP med
low HDL-C: male less than 40 or female less than 50
NLA risk categories
- very high: clinical ASCVD or DM with 2 or more risk factors or end organ damage
- high: DM with 0-1 risk factors, CKD stage 3B or 4, LDL greater than 190, 3 or more major risk factors, 2 major risk factors and high 10 year risk score (ATP III framingham greater than 10% or pooled cohort greater than 15%)
- moderate: 2 major risk factors and 10yr risk 5-15%
- low: 0-1 major risk factors
NLA risk assessment
identify very high or high risk patients
count major ASCVD risk factors (0-1 and no other indicators = low; 3 or more = high)
if 2 major ASCVD risk factors, calculate ASCVD risk to decide between mod and high
NLA target
primary: non-HDL-C and LDL-C
secondary: ApoB
NLA target goals
low-high risk: non-HDL-C less than 130, LDL-C less than 100, ApoB less than 90
very high risk: non-HDL-C less than 100, LDL-C less than 70, ApoB less than 80
lifesytle modifications to reduce TG
5-10% weight loss
restrict alcohol, sugar and refined carbs
moderate or higher intensity physical activity (at least 150 min/week)
classification of TG levels
less than 150: normal
150-199: borderline high
200-499: high
greater than 500: very high
ACC/AHA management of TG
lifestyle management, rule out medications as cause of elevated TG, use TG-lowering medications to prevent pancreatitis in those with TG > 500
NLA management of TG
- high (200-499): replace dietary carbs with unsaturated fats and proteins to dec TG and non-HDL-C, non-HDL-C and LDL-C still primary goal; treat w statins, may add TG lowering agent if non-HDL-C not met on max statin dose
- very high (500-999): TG is primary target; use TG lowering agent or statin (if no hx of pancreatitis)
- very high (greater than 1000): TG is primary target to prevent pancreatitis; treat w fibrates (2-4 g/day), omega 3 FA or niacin
non-HDL-C ACC/AHA vs NLA
ACC/AHA - role undefined in treatment decision-making, no RCTs designed to assess titrated drug therapy to achieve specific non-HDL-C goals
NLA - better primary target than LDL-C, more predictive of ASCVD mobidity/mortality, practical advantages (universal, non-fasting, valid w high TGs)
LDL-C ACC/AHA vs NLA
ACC/AHA - no RCTs designed to assess titrated drug therapy to achieve specific LDL-C goals, used as factor to determine 4 statin benefit groups, de-emphasis on frequent monitoring, monitoring to evaluate adherence and response to statin therapy
NLA - co-primary target w non-HDL-C, relegated to less importance
ApoB ACC/AHA vs NLA
ACC/AHA - role undefined, not endorsed due to limited evidence
NLA- optional secondary target, more predictive of ASCVD morbidity/mortality than LDL-C but not consistently more predictive than non-HDL-C, may remain elevated in some patients who have reached non-HDL-C and LDL-C goals, measurement of levels not necessary until patients have reached non-HDL-C and LDL-C goals
