25 - Hyperlipidemia Treatment Flashcards
What is a dyslipidemia?
Dyslipidemia: disorder of lipid and lipoprotein absorption and synthesis
What are lipoproteins?
Lipoproteins = cholesterol transport mechanisms
What is LDL-C and HDL-C? Triglycerides?
- LDL-C: Low Density Lipoprotein – Cholesterol
- HDL-C: High density Lipoprotein – Cholesterol
- Triglycerides: fatty acid
There is a clear causal relationship between dyslipidemia and…
CAD - coronary artery disease
There is a clear benefit in dyslipidemias by lowering…
Serum cholesterol (total LDL)
What is the leading cause of death in the US?
Heart disease
What is the general concept between the ACC/AHA guidelines for treating hyperlipidemias?
- There seems to be no evidence supporting a treatment plan which aims to lower cholesterol to a certain level
- Instead, treating with the appropriate intensity of statin therapy has been shown to reduce cardiovascular risk
- This means that you titrate the intensity of the therapy to the degree of risk the patient is at, don’t just aim to hit a certain cholesterol level
What is a “primary strategy” in treating hyperlipidemia?
Preemptive treatment of high risk persons before any disease state has developed
- Primary is based on the risk level of the patient, so you are trying to push the first event back as far as possible, based on their risk level **
What is a “secondary strategy” in treating hyperlipidemia?
Repeat treatment in known disease state
- Secondary means you’re too late – they already have the disease, you’re trying to prevent the next event or progression **
- Statins drug of choice; others might work (less robust evidence)
What is a “pooled cohort risk assessment”?
“Pooled Cohort Risk Assessment Equations”
- Developed by the Risk Assessment Work Group to estimate 10-year risk*
- 10-year risk for (ASCVD): coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke
- Can use online calculator for equation
What is the basic principle of dyslipidemia risk assessment?
Calculate 10 year risk, let treatment titration follow
What are the factors that the risk assessment considers?
Risk influenced by age, gender, and other risk factors:
Hypertension
Smoking
Family history (premature CHD in first-degree relative)
* Diabetes not usually considered in screening guidelines for primary prevention (risk of CHD is known to be high)
Describe a high risk patient
Patients at higher risk generally have several risk factors or a single severe risk factor (e.g. patient siblings with CHD in their 40s or very heavy smoking
What are the major risk factors outside of high cholesterol?
- Cigarette smoking
- Hypertension (BP 140/90 mmHg or needing meds)
- If you don’t need meds, you decrease your risk - this is a goal
- Diabetes mellitus
- Family history of premature CAD
- CAD in male first degree relative
When would it be reasonable to do a lipid screening?
- Adults ages 20 to 79, free from CVD with risk factors (smoking, HTN, diabetes, total cholesterol, HDL-C)
- Every 4 to 6 years to calculate 10-year CVD risk
When would you possibly consider doing a lipid screening?
- Adults 20 – 59, free from CVD without other risks (10 year
What do you need to remember about diabetes and ASCVD?
ASCVD = atherosclerotic cardiovascular disease
Diabetes is not a “risk factor” it IS the disease
Remember: Diabetes = known ASCVD!
When you get a 7.5% or lower chance of an ASCVD in the next 5 years, what do you do?
Tell the patient to keep up the good work
What is the drug of choice for dyslipidemia treatment?
HMG-CoA inhibitors (statins)
What are the 4 major benefits of statins?
1 - Effective in secondary prevention of all individuals with clinical cardiovascular disease
2 - Effective in primary prevention for patients with isolated LDL-C
3 - Effective in primary prevention for patients with diabetes, 40-75 yo and LDL-C elevation
4 - Effective in primary prevention for patients with a 10-year CVD risk of greater than 7.5%, 40-75 yo and LDL-C elevation
What is the primary prevention of LDL-lowering therapy?
Public health approach is mostly education - NON-DRUG
- Address lipid levels in asymptomatic (presumably disease-free) individuals
- Increase physical activity (aerobic)
- Weight control (BMI
What is the secondary prevention of LDL-lowering therapy?
Non-drug
- Increase physical activity (aerobic)
- Weight control (if BMI>25)
- Dietary modification to reduce intake of saturated fat and cholesterol
- Control of other ASCVD risk factors
Drug of choice
- Statins *** (moderate or high intensity)
- Moderate intensity in 75+
- High intensity in
What are the benefits of statin drug therapy?
- reduced total mortality & coronary mortality
- fewer major coronary events
- fewer coronary procedures
- reduced incidence of stroke
What are side effects of statins?
= Myopathy
- Increased liver enzymes
What are the contraindications of statins?
- Absolute: liver disease
- Relative: use with certain drugs
- Not-recommended: with class II-IV heart failure drugs or patients on hemodialysis
