Cardiology_Lipid Lowering

Question 1

When hypercholesterolemia is identified, what further laboratory workup is indicated?

Answer 1

• Fasting blood glucose
• TSH
• liver function tests (LFTs)
• creatinine

Question 2

The primary target of cholesterol lowering therapy is low-density lipoprotein (LDL). How is the LDL goal established?

Answer 2

• By determining the patient’s risk of having a coronary heart disease (CHD) event sometime in the next 10 years

Question 3

List CHD risk factors.

Answer 3

• HTN
• high-density lipoprotein (HDL) <40 mg/dL
• smoking, male >45 years old
• female >55 years old
• family history of early CHD
  
  • first-degree male with CHD <55 years old
  • first-degree female with CHD <65 years old)

Question 4

What HDL level is considered a negative risk factor and may be counted as a “minus one” toward the overall number of CHD risk factors?

Answer 4

• HDL >60 mg/dL

Question 5

What lifestyle modifications can increase HDL?

Answer 5

• Increased aerobic activity and moderate alcohol consumption (1-2 drinks per day)

Question 6

List CHD equivalents.

Answer 6

1. Diabetes mellitus
2. Peripheral artery disease
3. Any combination of risk factors leading to a cumulative 10-year CHD risk of over 20% - as determined by a risk calculator
4. Symptomatic carotid artery disease
5. Abdominal aortic aneurysm

Question 7

Someone with known CHD or a CHD equivalent has a ___% risk of having another CHD event event sometime in the next 10 years.

Answer 7

> 20

Question 8

What lifestyle modifications can lower LDL?

Answer 8

1. Dietary modifications
2. Increased physical activity
3. Smoking cessation
4. Weight loss

Question 9

LDL treatment guidelines

Answer 9

Question 10

To lower cholesterol levels, what dietary modifications should be made in regards to fat intake?

Answer 10

1. Total dietary fat should be less than 35% of total caloric intake (<10% polyunsaturated fat, <7% saturated fat).
2. Cholesterol intake less than 200 mg/day.

Question 11

What is the LDL goal for patients with CHD or a CHD equivalent?

Answer 11

• LDL <100 mg/dL

Question 12

What is the LDL goal for patients with 0-1 risk factor(s) and no CHD or a CHD equivalent?

Answer 12

• LDL <160 mg/dL

Question 13

LDL <70 is an optional goal for which subset of patients?

Answer 13

• Very high-risk patients
  
  • recent myocardial infarction
  • metabolic syndrome
  • CVD with diabetes or severe or poorly controlled risk factors such as smoking

Question 14

How long after initial lifestyle modifications and/or medical therapy is started should lipids be rechecked?

Answer 14

6 weeks

Question 15

What class of drugs represents the current first line pharmacotherapy in the lowering of LDL?

Answer 15

Statins

Question 16

What is the mechanism of action of statins?

Answer 16

• Inhibit HMG-CoA reductase (enzyme in the pathway that produces cholesterol)

Question 17

Statins lower LDL levels by what percentage?

Answer 17

20%-40%

Question 18

Statins increase HDL by what percentage?

Answer 18

• 5%-15%

Question 19

What are the major contraindications to statin use?

Answer 19

• Acute or chronic liver disease
• concomitant use of certain drugs (eg, macrolides, alcohol)
• history of serious adverse effects with statins (eg, rhabdomyolysis)

Question 20

What percentage of patients on statins will experience by myalgias as a side effect?

Answer 20

5%

Question 21

What fat-soluble substance found in some foods (highest in meat and fish) that is also available as a vitamin supplement may be used to reduce myalgia symptoms in many patients?

Answer 21

• Coenzyme Q10 (ubiquinone): 100 mg PO daily as a supplement dose

Question 22

What percentage of patients on a statin will develop rhabdomyolysis?

Answer 22

• 0.1%

Question 23

What are the symptoms of rhabdomyolysis (should prompt patient to stop statin immediately)?

Answer 23

• Severe myalgias
• muscle weakness
• dark urine

Question 24

What are the risk factors for statin-induced myopathy?

Answer 24

• Concurrent use of a fibric acid derivative (especially gemfibrozil)
• older age
• female gender
• low weight
• acute physical stress

Question 25

If a patient is on a statin, how often should you monitor liver transaminases (assuming the patient has no history of chronic liver disease)?

Answer 25

• Check at baseline (after statin initiation or dose change) and assuming transaminases remain normal,
  
  • recheck them in 6-12 weeks
  • 3 months, and thereafter
  • every 6-12 months
• If transaminases are elevated, increase testing frequency to as often as clinically necessary.

Question 26

If a patient has no prior history of liver disease and the patient’s liver transaminases increase with statin treatment, the statin should be discontinued when the transaminases reach what level?

Answer 26

• Three times greater than the baseline levels

Question 27

If a patient has a history of chronic liver disease and the patient’s liver transaminases increase with statin treatment, the statin should be discontinued when the transaminases reach what level?

Answer 27

• Two times greater than the baseline levels

Question 28

Rank the following statins in order from least to most potent: atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin.

Answer 28

• Fluvastatin < pravastatin < lovastatin < simvastatin < atorvastatin < rosuvastatin

Question 29

Of these statins - atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin - which one is NOT metabolized by the CYP 450 system and thus is less likely to cause drug interactions?

Answer 29

• Pravastatin (greater renal metabolism)

Question 30

Of these statins - atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin - which ones are more favourable for usage in patients with renal impairment?

Answer 30

• Atorvastatin and fluvastatin

Question 31

What drugs should be considered for the treatment of hypertriglyceridemia?

Answer 31

• Fibric acid derivatives (fibrates)
• niacin
• fish oil supplements (>3 g per day)

Question 32

What are the absolute contraindications to use of fibrates?

Answer 32

• Pre-existing gallstones, hepatic or renal disease