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Clinical 2 (Sam) > 2 - Dyslipidemia > Flashcards

2 - Dyslipidemia Flashcards

1
Q

Why do we want to lower cholesterol?

A

to reduce risk of CV disease, angina, MI, cerebrovascular disease, ischemic stroke, peripheral artery disease

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2
Q

What are some modifiable risk factors for CVD?

A
  • reduce bad fat in diet (saturated fats)
  • exercise
  • stop smoking
  • HTN
  • dyslipidemia
  • diabetes
  • BMI > 27
  • waist circumference
  • excessive alcohol
  • poor nutrition
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3
Q

What are some non-modifiable risk factors for CVD?

A
  • older age
  • male has higher risk
  • family history of premature CHD (MI or sudden death in 1 relative)
  • familial hypercholesterolemia
  • chronic kidney disease
  • ethnicity
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4
Q

What is CVD

A
  • coronary death
  • MI
  • coronary insufficiency
  • angina
  • ischemic or hemorrhagic stroke
  • TIA
  • PAD
  • heart failure
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5
Q

Who do we screen for dyslipidemia based on age?

A

Men > 40
Women > 40 (most women would not typically be at CVD risk at this age)
*or postmenopausal women

*consider earlier in ethnic groups at increased risk such as South Asian or First Nations individuals

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6
Q

What type of patients do we screen regardless of age? (just list a few)

A
  • diabetes
  • HTN
  • HIV infection
  • erectile dysfunction
  • family history

etc. slide 11

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7
Q

HDL is _____ cholesterol

A

good

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8
Q

LDL is ____ cholesterol

A

bad

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9
Q

What are the ranges for LDL cholesterol?

A 
Optimal = 2.59 mmol/L
Near optimal = 2.59-3.34
Bordeline high = 3.37-4.12
High = 4.15-4.9
Very high = > 4.9
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10
Q

What are the ranges for HDL cholesterol?

A

If HDL is less than 1.04 mmol/L = increased risk of heart disease
HDL between 1.04 and 1.17 = borderline
HDL greater than 1.17 is acceptable

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11
Q

What are the ranges for TG levels?

A

Acceptable: less than 1.30
Borderline high: 1.30-1.68
High: 1.7 mmol/L

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12
Q

If a patient has:
LDL = 4.2 mmol/L
HDL = 1.0 mmol/L
TG = 1.5 mmol/L

what does this mean?

A

LDL is high (which is bad)
HDL is low (which is bad)
TG is borderline high (not great)

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13
Q

What is the healthy value for TChol?

A

< 5.2 mmol/L

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14
Q

What is the healthy value for LDL?

A

< 3.4 mmol/L

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15
Q

What is the healthy value for HDL for men?

A

> 1.0 mmol/L

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16
Q

What is the healthy value for HDL for women?

A

> 1.3 mmol/L

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17
Q

What is the healthy value for TG levels?

A

< 1.7 mmol/L

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18
Q

Do patients need to fast or not before lipid values are taken?

A

Doesn’t make much difference.

Non-fasting lipid profiles have:

  • minimal effect on LDL & HDL
  • modest effect on TG
  • predicts CVD risk similarly to fasting
  • increased adherence, decreased lab demands, decreased hypoglycaemia
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19
Q

HDL = ?

A

good

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20
Q

LDL = ?

A

bad

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21
Q

High levels of ____ in the blood promotes buildup of plaque in the artery walls

A

LDL

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22
Q

____ helps carry LDL cholesterol away from the artery walls

A

HDL

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23
Q

List a few things that can contribute to causing dyslipidemia

A
  • genetics
  • drug-induced hypercholesterolemia (progestins, thiazide diuretics > 50mg/day, cyclosporine)
  • conditions (type 2 DM, chronic renal failure, hypothyroidism)
  • lifestyle (bad diet, eating lots of sugars, smoking, decreased exercise, lots of alcohol)
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24
Q

If you have someone’s lipid profile, what other info would you want to know?

A
  • any comorbid diseases
  • diet
  • smoker
  • BMI
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25
Q

What are the top 3 lifestyle changes that positively affect lipid profile and decrease risk of CV events?

A
  • Physical activity (150 mins of mod-big intensity/week)
  • Diet (mediterranean diet decreases CVD mortality by a similar magnitude to that of statins) (DASH diet)
  • Stop smoking
26
Q

see slide 23 for sure

A

ok

27
Q

For patients with a 10-year CVD risk of < 10%, what do you recommend?

A

Re-test lipids in 5 years with risk estimation

28
Q

For patients with a 10-year CVD risk of 10-19%, what do you recommend?

A

discuss and offer statins (preferably moderate intensity)

29
Q

For patients with a 10-year CVD risk of > 20%, what do you recommend?

A

discuss and strongly encourage statins (preferably high intensity)

30
Q

What is the relative risk reduction (RRR) of CV events with a statin? (KNOW THIS # FOR EXAM)

A

25-30%

31
Q

When choosing a statin:

Is any one more efficacious than another?

A

No - consider them to have all the same efficacy

32
Q

When choosing a statin:

Is any of them more harmful than another? (i.e. more side effects)

A

No - consider them to have all the same harm

33
Q

When choosing a statin:

Do any of them have more drug interactions?

A

Simvastatin & lovastatin > atorvastatin > prevastatin & rosuvastatin

34
Q

When choosing a statin:

Are any of them more expensive than others?

A

No - similar cost (all generic)

35
Q

What is the target LDL levels for a patient on a statin?

A
  • Do not target specific lipid levels.
  • Do not repeat lipid level testing for a patient on a statin.
  • We can’t measure LDLs as a target bc we don’t know what level you need to get to.
36
Q

List 3 reasons why we don’t target to a certain LDL level for patients on statins?

A

1) Clinical data does not indicate what the target should be.
2) We do not know the magnitude of additional ASCVD risk reduction that would be achieved with one target lower than another.
3) It does not take into account potential adverse effects from multi drug therapy that might be needed to achieve a specific goal.

37
Q

Side effects of statins to tell patients about?

A
  • muscle aches
  • GI upset (rare)
  • sleep disturbances

*new onset DM2 (this is so rare so we don’t tell patients about this)

38
Q

How are aminotransferases (AST, ALT) affected from statins?

A
  • 3X ULN occurs in <2-3% of people on statins
  • liver failure is rare
  • get a baseline

**no follow up necessary unless concerning symptoms (ex. dark urine, upper ab pain, n/v, yellowing of skin or eyes, general itchiness, pale stools

39
Q

What is the most common complaint with statins?

A

Muscle discomfort (dull ache, weakness, cramps)

  • may be worsened with exercise
  • larger muscles affected
  • usually not unilateral
  • onset after 1-12 months of therapy
40
Q

What chance do they have of developing myopathy on a statin?

A

1/10

41
Q

Describe the management of myalgia

A

Obtain CK level +/- hold statin

  • No need to stop statin if low suspicion of myopathy (timing doesn’t fit, inconsistent symptoms, few risk factors)
  • Could continue for 1-2 weeks with monitoring

Hold for 1-2 weeks (or until symptoms resolve) and rechallenge

Different statin/dose reduction

Reassess risk vs benefit of restarting statin

  • Is the patient at high or low risk of CVD?
  • Primary or secondary prevention?
42
Q

What is myositis?

A
  • inflammation of skeletal muscle, muscle discomfort
  • myalgia plus plasma CK levels > 2-4xULN but < 10x ULN
  • may be caused by strenuous exercise
  • potentially serious
43
Q

Describe the management of myositis

A
  • If CK levels are > 2-4xULN but <10xULN = D/C statin
  • Follow until symptoms resolve/CK normal
  • Consider precipitating factors (thyroid, exercise, drug interactions)
  • Reassess risk vs. benefit of restarting statin
  • Change statin and/or reduce dose and titrate up slowly (q2-4 weeks)
44
Q

Describe rhabdomyolysis

A
  • urine will turn dark orangey color
  • severe, progressive muscle aches, weakness and pain with CK > 3-10X ULN and marked serum creatinine elevation or myoglobinuria
  • very rare
45
Q

Treatment for rhabdomyolysis

A
  • Stop statin + hospitalization for supportive treatment
  • May later rechallenge with low dose of different statin
  • Once symptoms resolved - can take months to years
  • Reassess risk vs. benefit
46
Q

When do you recheck lipids?

A

in the next 5 years

47
Q

If FRS < 5%, what is the time to 10% probability of crossing the FRS 20% line?

A

19 years

48
Q

If FRS = 5 to < 10%, what is the time to 10% probability of crossing the FRS 20% line?

A

8 years

49
Q

If FRS = 10 to < 15%, what is the time to 10% probability of crossing the FRS 20% line?

A

3 years

50
Q

If you have a 5% risk of CV event, and you start a statin, what is your % risk at now?

A
  • remember a statin reduces your risk of CV event by 25 - 30% so
    0. 75 x 5% = 3.7%
51
Q

If you have a 30% risk of CV event, and you start a statin, what is your % risk at now?

A
  • remember a statin reduces your risk of CV event by 25 - 30% so
    0. 75 x 30% = 22.5%
52
Q

Person is discharged from hospital after MI, on lots of meds including Atorvastatin 80mg daily. How would you explain the purpose and dose of his statin?

A

higher dose because he just had an MI so he’s at higher risk of recurrence and you’re trying to prevent the plaque formation so it doesn’t happen again (lead to reduction in future heart attacks and stroke)

53
Q

What food is absolutely contraindicated with statins?

A

grapefruit juice

54
Q

What are some potential drug interactions with statins?

A
  • azole antifungals
  • macrolide antibiotics
  • diltiazem
  • verapamil
  • HIV protease inhibitors

inhibitors of CYP 3A4

55
Q

see algorithm on page 58

A

ok

56
Q

If pt is only taking half dose statin after MI, what agent can we add on to improve outcomes of CV events?

A

add ezetimibe decrease LDL by 15-20%

*for CV events
RRR = 6%
ARR = 2%

*for CV death
ARR = 1.8%

57
Q

What are PCSK-9 inhibitors?

A

monoclonal antibodies inhibit pro protein converts subtilisinkexin type 9

58
Q

Are PCSK-9 inhibitors good?

A
  • expensive
  • little is known about long-term safety
  • 1.2 million/year to prevent 1 CV event

overall not worth it

59
Q

Does Niacin have any effect on lowering CVD risk?

A

No - stopped due to uselessness

60
Q

Do Fibrates have any effect on lowering CVD risk?

A

decrease of non-fatal MI by 10% (RRR), no difference in overall CVD

61
Q

Do Omega 3 fatty acids have any effect on lowering CVD risk?

A

No benefit in any CV outcome

Clinical 2 (Sam) (18 decks)

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