CAD/Lipids Flashcards
True or false, heart disease is the leading cause of death in the US?
True.
This is true for BOTH genders.
What racial group has the highest incidence of CAD?
a) whites
b) hispanic
c) blacks
d) asians
Answer: C)blacks
Note: all races have seen declines since the 90’s
Which is not a risk factor for CAD?
a) HTN
b) obesity
c) DM
d) high HDL
e) high cholesterol
Answer: d) high HDL
HDL is the GOOD cholesterol.
High intensity statins include:
a) atorvastatin & simvastatin
b) rosuvastatin & atorvastatin
c) atorvastatin & pravastatin
d) pravastatin & rosuvastatin
Answer: b) Rosuvastatin and atorvastatin (atorvastatin 40-80 mg; Rosuvastatin 20-40 mg)
Statin guidelines recommend secondary prevention patients achieve an LDL of:
a) <100
b) <130
c) <70
Answer: c) <70
Most patients who have difficulty tolerating a statin can be helped with a different statin or some type of lower dosing.
a)True
b) False
c) Research is undecided about this
Answer: a) true
Statins can cause T2DM. However, most of the affected patients had several risk factors for diabetes already in place.
a) True
b) False
Answer: a) true
Patients with an intermediate risk for CVD (7.5% to 19.9%) who have metabolic syndrome may be good candidates for a statin.
a) Yes. A statin can reduce their risk.
b) No, metabolic syndrome has nothing to do with CVD risk.
c) The calculated risk of CVD has to be higher than 20%.
Answer: a) Yes.
Metabolic syndrome is judged by 5 criteria. These criteria do NOT include:
a) decreased HDL and increased Triglycerides
b) elevated BG
c) elevated LDL
d) hypertension
Answer: c) elevated LDL
A family history of premature heart disease should always be elicited and documented in the diagnosis list as it i a significant risk factor for Heart disease. It is defined as:
a) Males 55 or less; females 65 or less
b) males <60; females <70
c) males <45; females <55
Answer: a) males <55and females <65
Patients considered secondary prevention means they have established CVD. What is the recommendation for their use of a statin?
a ) High intensity statin
b) Too late to stop their CVD so no need for prevention
c) Moderate intensity statin
Answer: a) high intensity statin
Patients who are considered primary prevention for CVD and statin use include all EXCEPT:
a) Severe HTN
b) LDL >190
c) Calculated CVD risk score of >7.5%
d) Diabetes
Answer: a) severe HTN
MIs occur due to rupture of plaques in blood vessels that are _____ occluded:
A) >90%
B) <25%
C) >75%
D) <50%
Answer: D) <50%
Note: stress tests do not identify obstruction until 70-75% lesion present
Most MIs occur due to unstable coronary artery plaques. Statins help to harden and stabilize these plaques.
A) False: it’s all about the LDL level not the plaque
B) True: another reason to use statins other than to lower atherogenic particles
B) True.
Put the following races into descending order based on the U.S. age adjusted death rates for Heart Disease:
Black, Hispanic, White, & Asians.
Answer: Black, Whites, Hispanic, Asians
Who should be receiving statin therapy per the 2018 Cholesterol Guidelines? Select the one group for whom statins are NOT indicated.
a) TD2M–dosing depends on calculated risk score
b) LDL >190
c) Clinical ASCVD
d) HTN
Answer: d) HTN
Other individuals also have a recommendation for statin therapy. Select the one group for whom statins are NOT indicated.
A) Individuals with a calculated risk score of >7.5%
B) Individuals should be considered with strong family history or History of premature heart disease, a Coronary Calcium Score (CCS) that is elevated or other Enhanced Risk Factors such as metabolic syndrome, CKD. Please review the other indications.
C) Individuals with an LDL >130
Answer: C) individuals with an LDL>130
Which fact below is true about sudden death (CHD) without any previous symptoms?
A) 50% of men and 10% of women died suddenly of CHD had NO previous symptoms.
B) 50% of men and 64% of women who died suddenly of CHD had NO previous symptoms.
C) 20% of men and 80% of women died suddenly of CHD had NO previous symptoms.
Answer: B) 50% of men and 64% of women who died suddenly of CHD had NO previous symptoms
In 2018, new cholesterol recommendations were added to those of 2013. These recommendations idientified 2 more specific risk groups for drug therapy: High Risk and Very High Risk. The 2 drugs added to statin use for these 2 groups are:
a) double doses of high intensity statins
b) fenofibrates
c) ezetimibe and PCSK9-inhibitors
Answer: c) ezetimibe & PCSK9-inhibitors
Research shows that we need universal screening in children to detect lipid disorders as opposed to only scrreeening those with a + family hisory. Universal non-fasting screening for non-hdl cholesterol level should be done using a lab order for TC and HDL only. Then assess that value against an appropriate chart.
The recommended age levels for universal screening include 2 age groups:
a) ages 6-10 & 15-17
b) ages 9-11 & 17-21
c) ages 5-7 & 10-12
Answer: B
The 5-3-2-1-almost 0 counseling framework for children is an east to use tool in the exam room. Select the correct answer for what it means.
5-servings of fruits and veggies daily
3- structured meals daily
2-hours of screen time or less
1-hour of activity daily
0-sugary sweetened beverages
A child <12 who needs a statin should be referred to a lipid specialist for best management?
a) true
b) false
Answer: a) true
______ is the good lipid and ____ is the “bad” lipid.
HDL is the good lipid & LDL is the bad lipid.
“HDL want high; LDL want low”
What was the biggest change between the 2013 previous methods for looking at global risk of CVD versus the 2018 Guidelines for cholesterol?
a) added very high risk group
b) removed LDL as the guiding criteria for treatment
c) added ASCVD risk enhancers
d) added coronary calcium score (CAC)
Answer: b) removed LDL [this was previously the main guideline for treatment]
What is not a component of managing global CVD?
a) tobacco cessation
b) HTN control
c) stress management
d) LDL goal of <130 if DM
Answer: d) LDL goal of <130 if DM
According to the 2013 AHA guidelines, what group does not REQUIRE a statin?
a) HTN
b) LDL 190+
c) established atherosclerosis
d) ASCVD risk 7.5%+
e) DM
Answer: a) HTN
HTN is not a sign of established CVD (we are talking about plaque)
Note: established atherosclerosis is history of MI/CVA/TIA/CABG/angina
Which patient needs a statin?
a) DM with LDL 130
b) DM with LDL 190+
c) patient with 10-year ASCVD risk 7.5%+
Answer: ALL of the above
Note: all diabetic patients aged 40-75 need statin regardless of LDL levels!!!
Strength of statin will be guided by ASCVD risk
If a patient has a 10-year ASCVD risk of 7.5%+ they need what type of statin:
a) high intensity
b) moderate intensity
c) high intensity only if other comorbidities
d) low intensity
Answer: a) high intensity
Unless ages 75+ (consider moderate)
What reduction is seen in LDL with a high intensity statin?
a) >50%
b) 30-50%
c) <30%
Answer: a) 50%+
Moderate intensity statins give a 30-50% reduction
Match the statin with the diagnoses
a) LDL 190+
b) DM only
c) DM with ASCVD risk 7.5%+
Answer: LDL 190+: high intensity;
DM only: moderate intensity;
DM w/ ASCVD 7.5%: high intensity
The new 2018 guidelines for cholesterol added what components?
“very high risk” and “high risk” groups
Note: the original 4 statin risk groups remain the same
When should ezetimibe or PCK9-inhibitors be considered?
a) LDL 190+ and treatment is being initiated
b) LDL 130+ and patient is on a high intensity statin
c) LDL 90+ and patient does not want a statin
d) LDL 70+ and patient is on a statin
Answer: d) LDL 70+ even with the statin use
Note: they are indicated as adjunct therapy to statins
Who is not considered “very high risk” according to the 2018 cholesterol guidelines for ASCVD events?
a) LDL 100+ with max statin and ezetimibe
b) HX of ischemic stroke
c) symptomatic PAD/ABI <0.85%
d) history of MI
Answer: a) LDL 100+ with maximal statin and ezetimibe
Note: very high risk are recent acute coronary syndrome, MI, ischemic stroke, symptomatic PAD or ABI <0.85%, any revascularization
{Think about plaques/perfusion issues/events which have occurred-those are VERY high risk patients}
Who is not considered “high risk” according to the 2018 cholesterol guidelines for ASCVD events?
a) previous revascularization
b) age 65+
c) DM
d) Heart failure
Answer: a) previous revascularization
The revascularization is VERY HIGH RISK because they required a revascularization due to a plaque/occlusion
ASCVD Risk enhancers were added with the 2018 guidelines. These suggest that treatment be considered even if ASCVD risk is less than 7.5%. Which is not one of these risk enhancers?
a) family history of premature ASCVD
b) LDL 130+
c) Rheumatoid arthritis
d) Chronic Kidney Disease
Answer: b) LDL 130+
If LDL was 160+ this would be a risk enhancer. The other choices are correct. Other risk factors are metabolic syndrome, lipid markers (trigs 175+)
A 65 year old patient is high risk for ASCVD, what is the first line treatment?
a) moderate statin
b) high intensity statin
c) lifestyle changes
d) moderate statin and ezetimibe
Answer: b) high intensity statin
Note: if patient was 75+ the first line would be moderate OR high intensity statin
For a 65 year old high risk patient when high intensity statins are not tolerated, what is the next treatment option?
a) discontinue the statin & place on ezetimibe
b) use a moderate intensity statin
c) discontinue statin and place on fibrates; reinitiate the statin 2 weeks later
Answer: b) use a moderate intensity statin;
Note: if LDL remains above 70+ then consider adding ezetimibe
True or false, coronary calcium scores (CAC) are obtained as a CT wihtout contrast which measures the calcified coronary artery plaques. It does not measure soft plaque.
True. While the test is beneficial and provides strong evidence of risk, it DOES NOT measure the soft plaque (the one most likely to dislodge).
Define the following coronary calcium scores (CAC):
A) score 0
B) score 1-10
C) score 11-100
D) score 101- 400
E) score 400+
Answer: score 0 (no evidence of CAD); score 1-10 (minimal evidence); score 11-100 (mild); score 101-400 (moderate); score 400+ (extensive)
Which testing is not appropriate/recommended after statin initiation?
a) lipid testing 6-12 weeks later
b) lipid testing Q3-12 months after stable
c) ALT
d) CK
Answer: c) ALT & d) CK
These are not recommended for monitoring.
Lipid testing in 6-12 weeks after treatment initiation to see how the medication is working. Repeat lipids Q3-12 months thereafter.
Which is not true of fibrates?
a) They should not be used if GFR<30
b) Gemfibrozil should not be used with a statin EVER
c) They raise HDL
d) They are a suitable replacement for statin intolerant patients
Answer: d) they are a suitable replacement for statin intolerant patients
Fibrates are NOT a suitable replacement for statins EVER.
Additionally, they do not lower LDL
What is Non-HDL cholesterol?
The total number of atherogenic particles (BAD stuff) and is what ASCVD calculates. Calculated by total cholesterol minus HDL.
Early HTN in childhood is usually due to:
a) obesity
b) prematurity
c) familial hypercholesteremia
d) renal disease
Answer: d) renal disease
This is SECONDARY htn
A plaque is unstable due to:
a) hormones
b) genetics
c) inflammation
d) statin use which breaks down the plaque
Answer: C) inflammation
What interventions decrease inflammation (in terms of plaques)?
-ASA
- Weight loss
- Smoking cessation
- Exercise
- MUFAs (mono-unsaturated fatty acids, like Omega-3
Which is not true of dyslipidemia?
a) high LDL
b) low HDL
c) elevated Trigs
d) elevated total cholesterol
Answer: all are characteristic of dyslipidemia
Adolescent HTN is associated with ______ and is considered ______ (primary/secondary) HTN.
Answer: adolescent is associated with obesity and is primary HTN
HTN in kids aged 0-12 is defined as _____ for gender, age, and height on _____ occasions.
a) 90-95th %
b) 95%+
c) 120/80 mmHg
d) 130/80 mmHg
HTN in kids aged 0-12 is 95th%+ on 3+ occasions
Note: the 90-95th percentile is ELEVATED
HTN is adolescents (aged 13+) is defined as:
a) 90-95th %
b) 95%+
c) 120/80 mmHg
d) 130/80 mmHg
Answer: d) 130/80 (same as adult)
Stage 1 HTN for kids 12 and under is:
a) 90-95th %
b) 95%+
c) 120/80 mmHg
d) 130/80 mmHg
Answer:
b) 95%+ or 130/80+
Stage II HTN in this group is 95%+ or 140/90
Children aged 3+ should have BP measured:
a) at every visit
b) annually
c) once every 5 years
d) only if family history of premature heart disease
Answer: b) annually
The width of the BP cuff bladder should be at least ____ of the circumference of the upper arm?
a) 40%
b) 60%
c) 80%
Answer: a) 40%
Note: the length should be 80% of the circumference of the upper arm
When is an echo indicated in children with HTN?
a) never
b) only if secondary to renal disease
c) if starting medication
Answer: c) if starting medication
When is an EKG recommended to evaluate confirmed HTN?
a) never
b) only if secondary to renal disease
c) if starting medication
Answer: a)never
What type of treatment should be initiated (if indicated) for kids with HTN?
a) low dose concurrent anti-HTN med and diuretic
b) single drug
c) diuretic alone
Answer: b) single medication
What is target BP for blood pressure management in teens?
a) <95th%
b) <120/80
c) <130/80
d) 90-95th percentile
Answer: c)<130/80 or less than 90th percentile
True or false, a teen with stage 2 HTN can be approved for sports participation as long as they confirm this is the only elevated BP reading?
False. They need to be referred/evaluated.
True or false, there is no convincing evidence for a relationship between statins and cancer/erectile dysfunction/tendonitis/etc.
True.
Myopathy is _________________ and myalgia is ____________.
Definitions:
1) unexplained muscle pain/weakness accompanied by CK concentration 10x upper normal limit
2) muscle ache or pain
3) muscle issues during statin therapy
4) CK greater than 40x; can lead to acute renal failure
Answer:
myopathy: 1) muscle pain/weakness accompanied by CK 10x
myalgia is: 2) muscle ache or pain
Which is not a risk for statin-associated muscle symptoms (SAMS)?
a) metabolic syndrome
b) age 75+
c) male gender
d) vitamin D deficiency
Answer: c) male gender
Females are more likely to have SAMS than men.
Note: other drugs may affect statin levels and increase chance for SAMS (macrolides, fluoxetine, grapefruit juice, etc)
Name two fat loving (lipophilic) statins:
Atorvastatin and Simvastatin
“think ASS and FAT in the booty”
Name two water loving (hydrophilic) statins:
Pravastatin & Rosuvastatin
“think I just got a PR on my Peloton so I want to drink water”
Which statin might be better suited if a patient is having SAMS?
a) liphilic (fat loving)
b) hydrophilic (water loving)
Answer: b) water loving statins because they stay out of the muscle/brain tissue which are areas full of fat
Which organization recommends universal screening for lipid abnormality in kids?
a) AAP
b) USPSTF
Answer: a) AAP
Note: previously screening was based on family history (<55 men; <65 women) but this is problematic because as much as 60% of kids may be missed- hence why the AAP guideline is better
Which lipid screening is appropriate to order for universal screening in kids?
a) fasting
b) non-fasting
Answer: b) non-fasting
Non fasting is appropriate for universal screening because the fasting component is difficult for children.
Which childhood co-morbidities are appropriate for selective screening (fasting)?
a) child has HTN
b) child is a smoker
c) family history of premature CAD
d) child is diabetic
Answer: all of the above
What does a fasting lipid show (choose all that apply):
a) LDL
b) HDL
c) Triglycerides
d) total cholesterol
Answer: all of the above
What does a non-fasting lipid panel show (choose all that apply):
a) LDL
b) HDL
c) Triglycerides
d) total cholesterol
Answer: b (HDL) and d (total cholesterol)
Non-HDL is calculated
Non-HDL=TC-HDL
Which lab value is the most predictive for dyslipidemia in kids?
a) high LDL
b) low HDL
c) total cholesterol
d) Non-HDL
Answer: d) Non-HDL
Which (child) patient does not need to be referred?
a) one needing statins
b) TG 500+
c) LDL 250+
d) HDL 45
Answer: d) HDL 45
The other patients should be referred to a lipid specialist (and those under the age of 10).
When should confirmation testing be done if fasting lipid is abnormal?
a) immediately
b) 2-4 weeks
c) 2 weeks- 6 months (twice)
d) 2 weeks- 3 months (once)
Answer: d) 2 weeks-3 months (once)
When should confirmation testing be done if non-HDL screen is abnormal?
a) immediately
b) 2-4 weeks
c) 2 weeks- 3 months (twice)
d) 2 weeks- 6 months (twice)
Answer: c) 2 weeks- 3 months (twice) with a fasting lipid profile
Note: initial Non-HDL is a non-fasting lab
