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PGY 5 > Atherosclerosis Risk Factors > Flashcards

Atherosclerosis Risk Factors Flashcards

1
Q

Name 3 mechanisms by which smoking affects vascular biology

A
  1. Endothelial dysfunction:
    * decrases NO, increases reactive oxygen species. Flow mediated dilation diminished.
  2. Prothrombotic:
  • increases thromboxane A2, decreases prostacyclin = platelet aggregation
  • increases prothrombotic substances like vWF, thrombin and fibrin
  • decreases antrithrombotic/fibrinolytic substances like tpa, plasminogen activator inhibitor-1
  1. Inflammation:
    * increases leukocytes, IL-6, CRP, TNF-alpha, IL-1-B
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2
Q

What is the risk of heavy smokers (> 15 cigarettes a day) requiring an amputation after LE bypass compared with non-heavy smokers?

A

21% vs 2% at 3 years

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3
Q

Name 7 smoking cessation tools. Which is most effective?

A
  1. Varenicicline
  2. Buproprion
  3. Nicotine patch
  4. Nicotine gum
  5. Nicotine inhaler.
  6. Nicotine losenge
  7. Nicotine nasal spray

Varinecicline and nicotine patch most effective - abstinence 30-35%

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4
Q

What is the difference between type 1 and type 2 diabetes?

A

DM1 - Absolute deficiency of insulin secretion, 5-10% of diabetics, cellular mediated auto immune destruction of pancreatic beta cells

DM2 - combination of insulin resistance and inadequate compensatory insulin secretion - heterogeneous etiology

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5
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6
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7
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8
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9
Q

Name 3 large trials that looked at the impact of tight glycemic control (<6.5 %) vs. standard (7-8%) on macrovascular parameters.

What were the findings?

A

ACCORD, ADVANCE, Veterans Affairs Diabetes Trial.

All failed to demonstrate a reduction in CV outcomes and in fact increased the CV mortality in the ACCORD trial that was stopped early. This is why the treatment recommendation is to target A1c of 7

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10
Q

DDP-4 inhibitors (e.g. sitagliptin)

  1. What is the mechanism of action
  2. Expected A1C reduction
A
  1. Mechanism of action: inhibit degradation of endogenous GLP-1 thereby enhanceing effect of incretins
  2. A1C Reduction: 0.6-0.8%
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11
Q

GLP-1 Mimetics (e.g. exenatide)

  1. What is the mechanism of action
  2. Expected A1C reduction
  3. Adverse effects
A
  1. Mechanism of action: increases glucose dependent insulin secretion, decrease glucagon, delay gastric emptying
  2. A1C Reduction: 1%

3 Adverse effects: nausea/vomit

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12
Q

Thiazolidinediones (e.g. rosiglitazone, pioglitazone)

  1. What is the mechanism of action
  2. Expected A1C reduction
  3. Adverse effects
A
  1. Mechanism of action: activates PPAR-gamma nucrease receptor which increases peripheral insulin sensitivity and reduces hepatic glucose production
  2. A1C Reduction: 1-1.5%

3 Adverse effects: weight gain, edema, possible bone loss in women

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13
Q

Alpha - glucosidase inhibitors (e.g. acarbose, miglitol)

  1. What is the mechanism of action
  2. Expected A1C reduction
  3. Adverse effects
  4. Outcomes/Safety concerns
A
  1. Mechanism of action: slows gut carbohydrate reabsorption
  2. A1C Reduction: 0.5 - 1%

3 Adverse effects: gas, bloating

  1. Outcome/Safety: Imporves postprandial glucose excursions which may improve CVD
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14
Q

Glinides Nateglinide

  1. What is the mechanism of action
  2. Expected A1C reduction
  3. Adverse effects
  4. Outcomes/Safety concerns
A
  1. Mechanism of action: Bind to sulfonylurea receptors on pancreatic ilset cells stimulating insulin release
  2. A1C Reduction: 1-2%

3 Adverse effects: Hypoglycemia, weight gain

  1. Outcome/Safety: Hypoglycemia may precipitate ischemia or arrythmia
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15
Q

Sulfonylureas (e.g. Gliclazide)

  1. What is the mechanism of action
  2. Expected A1C reduction
  3. Adverse effects
  4. Outcomes/Safety concerns
A
  1. Mechanism of action: Bind to sulfonylurea receptors on pancreatic ilset cells stimulating insulin release
  2. A1C Reduction: 1-2%

3 Adverse effects: Hypoglycemia, weight gain

  1. Outcome/Safety: Hypoglycemia may precipitate ischemia or arrythmia
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16
Q

Biguanide (Metformin)

  1. What is the mechanism of action
  2. Expected A1C reduction
  3. Adverse effects
  4. Outcomes
  5. Safety concerns
A
  1. Mechanism of action: Decreases hepatic glucose production
  2. A1C Reduction: 1-2%

3 Adverse effects: Diarrhea, nausea, lactic acidosis, decreased B12

  1. Outcome: may improve CVD outcomes
  2. Contraindicated in decompinsated or unstable heart failure due to lactic acidosis
17
Q

According to the American Diabetes Association - what is the algorithm for the initiation and adjustment of therapy:

  1. First step
  2. Second step
  3. Third step
A
  1. Lifestyle interventions
  2. Metformin
  3. If A1c not less than 7 - add sulfonyl urea or insulin

Other OHG relegated to “second tier”

18
Q

What are very high LDL, low HDL and very high TG according to the Adult Treatment Panel III Guidelines?

A

LDL >4.9

HDL <1.04

TG >5.65

19
Q

What is the optimal LDL, HDL and TG according to the Adult Treatment Panel III Guidelines?

A

LDL < 2.6

HDL >1.55

TG <1.7

20
Q

What specific lifestyle recommendations can you make for patients to decrease risk associated with fasting lipid profiles?

A
  1. LDL Raising nutrient: keep sat fat < 7% and dietary cholesterol <200 mg/day

  1. LDL Lowering: Plan sterols, soluble fibers, total calories adjusted to prevent weight gain, exercise at least 200 kcal/day
21
Q

Which landmark trial supports the use of statins in PAD?

A

HPS - Heart protection study. 6000 patients with PAD showed benefit. Overall 19.8% risk for a first major vascular event on statin vs. 25.2% with placebo - a 24% relative risk reduction.

22
Q

Which medications block the intestinal absorption of cholesterol (particularly effective when combined with a statin for HLD)

A

Ezetimibe and bile acid sequesterants. Both can be used esp when patients cannot tolerate max dose of statin.

23
Q

Name 7 agents used for hyperlipidemia

A
  1. Statins
  2. Ezetimibe
  3. ER Niacin
  4. Fenofibrate
  5. Omega 3
  6. Bile acid sequestrants
  7. Cholesterol ester transfer inhibitors
24
Q

If unable to meet LDL targets in patients with homozygous familial hypercholestorlemia despite maximal diet/therapy, what treatment can you offer?

A

LDL apheresis is available at some centres. PCSK9 inhibitors may also redule LDL in HFH patients.

25
Q

According to the JNC-8 (Joint National Committee on Prevention/Detection/Eval/Tx of HTN), what should be the target BP in adults over 60 years old?

26
Q

What is the criteria for “resistant hypertension”

A

Uncontrolled BP despite adequate doses of 3 antihypertensives, including a diuretic

27
Q

Name 9 causes of secondary hypertension

A

“TOOK A CRAP”

  1. T - Thyroid disease
  2. O- OSA
  3. O - OCP
  4. K - kidney disease (proteinuria, elevated cr)
  5. A - Coarctation of aorta
  6. C - cushing
  7. R- renal artery stenosis
  8. A - Primary aldosteronism
  9. P - Pheochromocytoma
28
Q

Which part of the kidney does Angiotensin 2 vasoconstrict?

A

Efferent arterioles

29
Q

Which study showed that Ramipril lowers cardiovascular risk in patients with PAD?

A

HOPE study (Heart Outcomes Prevention Evaluation)

PGY 5 (25 decks)

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