CAD: Primary & Secondary Prevention Flashcards
What was the important point from MIRACL trial?
Lipitor has benefit as early as 16 weeks in pt’s w/ prior MI
What do fibrates do to cholesterol? Do they decrease CV events?
Dec TG, Inc HDL
YES
What age (by gender) is a risk factor for CAD?
Men >45
Women > 55 (or early menopause)
Define family hx of CAD
1st degree relative
Male < 55
Woman < 65
What is considered a CAD risk equivalent
Risk factors that confer 10 yr risk for CHD > 20%
PAD/AAA/symptomatic carotid dz
Components of Framingham risk score
Age SBP TC HDL smoker
NCEP ATP III: LDL goal and when to start Rx for high risk (>20% 10y risk)
Goal LDL<100
Start Rx at 100
NCEP ATP III: LDL goal and when to start Rx for moderately high risk (10-20% 10y risk)
LDL goal<130
Rx at 130
What % of total calories should saturated fat be?
<7%
Recommended intake of monounsaturated fats
Upto 20% of total calories
Recommended intake of total fat
25-35% of total calories
Recommended intake of fiber
20-30 grams per day
Recommended intake of cholesterol
<200mg/d
When instituting TLC for lipid lowering, how often do u bring pt’s back?
Q6 weeks for 3 visits, then q4-6 mo’s
How will statins effect cholesterol panel?
Dec LDL
dec TG
Inc HDL
Name 2 statins that are not lipophilic
Rosuvastatin
Pravastatin
Which statin is safe to use with erythromycin and ketoconazole?
Pravastatin
Which statins use Cytochrome 2C9?
Rosuvastatin
Fluvastatin
(“RF”)
Which statin does not use CYP450?
Pravastatin
Most statins bind completely to proteins. Which one does so only 50% of the time?
Pravastatin
Which statins use CA4 cytochrome system?
Lovastatin
Simvastatin
Atorvastatin
Rosuvastatin (also uses 2C9)
Name the statins in order from most potent to least potent
Rosuvastatin>atorvastatin>simvastatin>pravastatin
What to remember about statin induced myalgias
Dose related
Drugs assoc w/ statin induced myopathy
Verapamil Amio Nicotinic acid Fibrates (Gemfibrozil>>Tricor)*** EtOH P450 3A4 inhibitors
Risk factors assoc w/ statin induced myopathy (not including drugs)
Age >75
Frail/LOL
DM/CKD
periop
Cytochrome P450 inhibitors that are associated with statin induced myopathy
Cyclosporine
-conazole antifungals (ketoconazole, etc)
Macrolides (erythromycin, clarithromycin, nefazodone)
HIV PI’s
Grapefruit juice
What to do if statin induced myopathy?
Change statin or Dec dose by 1/2
Incidence and definition of statin induced myopathy
0.1%
CK> 10x ULN
Bile acid sequestration effect on lipid profile
Dec LDL by 15-30%*
Inc HDL by 3-5%
TG no effect or even increase!*
Do bile acid sequestration decrease mortality? Why not used?
Yes
GI sxs and expensive
Absolute contraindications to bile acid seq,
TG> 400 mg/dl
Familial Dysbetalipoproteinemia
Absolute contraindications to niacin
Severe Gout
Chronic liver dz
Does niacin effect all lipids favorably?
Does it dec mortality?
Does it reduce CHD risk?
Yes
No
Yes
AE’s of niacin
Upper GI distress
Flushing
Hepatotoxicity
Hyperuricemia
How much do fibrates dec TG by?
20-50%
Do fibrates dec CHD risk
Yes (moderately)
AE’s if fibrates
GI sxs
Gallstones
Myopathy
Fibrates contraindications
Severe hepatic dz or severe CKD
MOA of fibrates
Inhibits absorption of chol at small intestine brush border–> dec chol to liver, inc clearance from blood
Ezetimibe (zetia) indication
High LDL (in combo with statin or fibrate)
Does ezetimibe reduce CHD?
Yes
Which med increases HDL the most?
Niacin
Does metabolic syndrome inc CHD mortality?
Yes
Metabolic syndrome criteria
Need 3/5: BP > 130/85 FG > 100 TG> 150 mg/dl Waist: men- 40in/women- 35in HDL: men <50
Target for hypertriglyceridemia Rx levels?
<150
If TG>200 after LDL is treated, what to do?
Secondary goal for non HDL chol (total-HDL) is 30 above LDL goal
4 meds that can treat high TG
Niacin
Fibrates
Omega 3 FAs
Statins
What did the PROVE-IT trial show for death, MI, hospitalization for angina , and revasc?
High dose Lipitor 80 better than low dose pravastatin
What is the LDL goal for CHD risk of high, moderately high, mod, low?
100
130
130
160
In secondary prevention, if TG 200-499, what is the plan?
Non-HDL should be< 130
What to remember about treating TG> 500?
Rx w/ fibrate or niacin too recent pancreatitis BRFORE treating LDL
If nor intensive at age 55, what is one’s lifetime risk of developing HTN?
90%
When to initiate HTN therapy with TWO drugs (JNC 7)
When BP is >20/10 mmHg above goal
Is alcohol moderation a class I indication for BP control?
Yes
Punch line of ACCORD trial
Higher mortality with intensive glucose control (HbA1C<6%)
According to ADVANCE trial, what is the only potential benefit of intense glycemic control in DM?
Lowers incidence of nephropathy
What guideline class is measurement of non-standard lipid parameters (like lipoproteins)?
III
Class IIa indication to check CRP
Men>50, women >60 with LDL<130 and no other problems
Class III indication for checking CRP
- asymptomatic adults at high risk for CHD
- Low risk men<60
Side effects of varenicline and bupropion for smoking cessation
Suicidal ideation
Overweight BMI
Obese BMI
25-29.9
30
JNC 8 RCTs for age > 60
Treat at BP 150/90
JNC 8 recs for age <60
Treat BP of 140/90
JNC 8 recs for DM
Goal BP < 140/90
JNC 8 initial Rx for blacks
Thiazides or CCB
JNC 8 initial Rx for non blacks
Thiazides, ACE/ARB, CCB
JNC 8 recs for CKD
Rx with ACE/ARB to goal BP< 140/90
Which med is a class III rec for DM and SIHD?
Rosiglitazone
Over what age do you not start high dose statins?
75
If pt is age 40-75 and DM, do you start mod or high intensity statin?
Mod unless estimated 10yr ASCVD risk > 7.5%
At what LDL should you eval for secondary causes?
> 190
What labs to check before starting statins?
LFTs
DM screen
In primary prevention, do statins decrease CHD death, nonfatal MI and all-cause mortality?
Yes
