Dyslipidemia Flashcards
What is the importance of cholesterol in the body?
Cholesterol is an important component of healthy cells and tissues, including the brain. Cholesterol is a structural component of cell walls, a precursor in hormone synthesis and is used in the production of bile acids
What is enterohepatic recycling?
Bile acids travel from the liver through the bile ducts (with free cholesterol and waste products) and into the small intestine, where they are needed to absorb fat. The acidic environment in the intestine converts bile acids into bile salts, which are recycled from the intestine and returned to the liver
What is the result if the absorption of free cholesterol is blocked in the intestine or the enterohepatic recirculation of bile salts is blocked?
The end result is a decrease in cholesterol
What is atherosclerosis?
Atherosclerosis is the formation of plaque from a buildup of fats, cholesterol and other substances on the inner walls of arteries
What complication does atherosclerosis lead to?
Atherosclerosis leads to atherosclerotic cardiovascular disease, which includes myocardial infarction, stroke/transient ischemic attacks, angina and peripheral arterial disease
*Different types of cholesterol protect from or contribute to ASCVD risk
What lipoproteins is included in total cholesterol?
Low-density lipoprotein (LDL), high-density lipoprotein (HDL) and very-low density lipoprotein (VLDL)
Describe HDL
HDL takes cholesterol from the blood and delivers it to the liver for removal from the body. High LDL lowers ASCVD risk
What does non-HDL include and what does it predict?
Non-HDL includes the lipoproteins that contribute to atherosclerosis: LDL, intermediate-density lipoproteins, VLDL, chylomicron remnants and lipoprotein(a). Non-HDL is a strong predictor of ASCVD
How is non-HDL calculated?
Non-HDL = TC - HDL
What is lipoprotein (a)?
Lipoprotein (a) is a genetic variant of LDL. High lipoprotein (a) indicates high risk of ASCVD
What is a complication that can occur with high triglycerides (TGs)?
High triglycerides or hypertriglyceridemia, are associated with high ASCVD risk. TGs > 500 mg/dL can cause acute pancreatitis
What is dyslipidemia?
Abnormal lipoprotein levels are called dyslipidemias
What is primary (familial) hypercholesterolemias?
Genetic defects that cause severe cholesterol elevations. FHs include heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH)
How can familial dyslipidemias be categorized by?
Fredrickson classification
What are most dyslipidemias due to?
Most dyslipidemias are due to poor diet and lack of physical activity that result in central adiposity
What are some medical conditions that can cause dyslipidemia?
Medical conditions that cause dyslipidemia include hypothyroidism and diabetes
What are some key drugs that increase both LDL and TG?
Diuretics, Efavirenz, Steroids, Immunosuppressants, Atypical antipsychotics, Protease inhibitors
What is a key drug that increases LDL only?
Fish oil (except Vascepa)
What are some key drugs that increase TG only?
IV lipid emulsions, propofol, bile acid sequestrants (~5%)
What are some conditions that can increase risk of dyslipidemia?
Obesity, poor diet, hypothyroidism, alcoholism, smoking, diabetes, renal/liver disease, nephrotic syndrome
When are lipid panels taken?
Lipid panels are taken after a 9-12 hour fast
How can LDL be calculated if it is not reported?
Friedewald Equation: LDL= TC - HDL - (TG/5)
*The formula is not used when the TGs are > 400 mg/dL
What can happen to TG level if lipid panels are not taken after fasting?
If not fasting, the TG level can be falsely elevated, which can cause an incorrect LDL calculation
What is a desirable non-HDL level?
< 130
What is a desirable LDL level?
< 100
What is a very high LDL level?
> 190
What is a desirable HDL level in women?
> 50
What is a desirable LDL level in men?
> 40
What is a desirable triglycerides level?
< 150
What is a very high triglyceride level?
> 500
Which group provides guidelines for cholesterol management?
The American College of Cardiology and the American Heart Association
What is the ASCVD risk calculation used for?
The ASCVD risk calculation is used to provide an estimate of an individual’s risk of having a first cardiovascular event during the next 10 years. Healthcare providers use the estimated risk to determine whether they should prescribe risk-reducing treatments
What does a clinician input into the ASCVD calculator?
- The patient’s gender, age (20-79 years) and race
- TC and HDL
- Systolic blood pressure, and whether antihypertensive treatment is used
- The presence of diabetes and smoking status
How often should the ASCVD risk assessment be repeated?
Every 4-6 years in those found to be at a low 10-year risk (< 7.5%)W
How often should the ASCVD risk assessment be repeated?
Every 4-6 years in those found to be at a low 10-year risk (< 7.5%)
When is an ASCVD risk score not needed?
The risk score is not needed for patients with clinical ASCVD, diabetes or LDL > 190 mg/dL as all patients in these groups should be started on a statin
What are some risk-enhancing factors that can increase ASCVD risk?
Very high LDL, family history of premature ASCVD, metabolic syndrome, chronic kidney disease, history of preeclampsia or premature menopause, chronic inflammatory disorders, high CRP, high coronary artery calcium score (CAC) and abnormal ankle brachial index
What is the CAC measurement beneficial for?
The CAC measurement is helpful in deciding if statins should be initiated in those with 10-year ASCVD risk of 7.5-19.9%. A CAC score > 100 Agatston units indicates statins should be initiated
What are some lifestyle modifications that are an important part of management of dyslipidemia?
- Consume a diet to maintain a healthy weight
- Diet should be rich in vegetables, fruits, whole grains and high-fiber foods
- Consume fish, especially fish with high-fat content
- Limit intake of saturated fat, trans fat and cholesterol by choosing lean meats, non-meat alternatives and low-fat dairy products. Aim for 5-6% of calories from saturated fat
- Limit intake of added sugars and salt
- Engage in aerobic physical activity 3-4 times per week, lasting 40 minutes/session
- Avoid tobacco products and limit alcohol consumption
What is a natural product that contains naturally occurring HMG-CoA reductase inhibitors?
Red yeast rice
What are some natural products that are effective in lowering LDL?
Plants stanols, sterols, fibrous foods (found psyllium, barley, oat bran) and a specific type of artichoke extract are each effective in lowering LDL
What is a product that can lower TG?
OTC fish oils can be used to lower TG, but some products can increase LDL
What is the purpose of statin-benefit groups?
Patients are classified into statin-benefit groups to determine the appropriate intensity of statin treatment
What is the drug of choice in treating high non-HDL and LDL?
Statins
What are some other cholesterol-lowering drugs that may be used that aren’t statins?
Ezetimibe and PCSK9 inhibitors
When should many cholesterol-lowering drugs not be used?
Many cholesterol-lowering drugs cause liver damage. These drugs should not be used if the AST or ALT is > 3 times the upper limit of normal
What are the different statin benefit groups?
- Secondary prevention: clinical ASCVD
- Primary prevention: primary elevation of LDL > 190 mg/dL, diabetes and age 40-75 years with LDL between 70-189 mg/dL, age 40-75 years with LDL between 70-189 mg/dL
What is the patient criteria for secondary prevention of clinical ASCVD?
Includes CHD, stroke, TIA or peripheral arterial disease thought to be of atherosclerotic
What is the recommended statin treatment for those with clinical ASCVD?
High-intensity
What is the statin treatment for those with primary elevation of LDL > 190 mg/dL?
High intensity
What is the statin treatment for those with diabetes and age 40-75 years with LDL between 70-189 mg/dL?
- Multiple ASCVD risk factors: High-intensity
- Regardless of 10-year ASCVD risk: Moderate-intensity
What is the recommended statin treatment for someone age 40-75 years with LDL between 70-189 mg/dL?
- 10 year ASCVD risk > 20%: High intensity
- 10 year ASCVD risk .5-19.9% + risk-enhancing factors: moderate-intensity
What are considered high intensity statins?
- Atorvastatin 40-80
- Rosuvastatin 20-40
What is considered moderate intensity statins?
- Atorvastatin 10-20
- Rosuvastatin 5-10
- Simvastatin 20-40
- Pravastatin 40-80
- Lovastatin 40
- Fluvastatin 40 BID/80 XL
- Pitavastatin 2-4
What is considered a low intensity statin?
- Simvastatin 10
- Pravastatin 10-20
- Lovastatin 20
- Fluvastatin 20-40
- Pitavastatin 1
What is the most important adverse effect of statins?
Muscle damage
How does muscle damage present after the use of statins?
This generally presents as muscle soreness, tiredness or weakness that is symmetrical in large adjacent muscle groups in the legs, back or arms
When do symptoms of the adverse effect of muscle damage typically occur?
Symptoms usually occur within 6 weeks of starting treatment, but can develop at any time
How can the severity of muscle damage be presented?
- Myalgias: muscle soreness and tenderness
- Myopath: muscle weakness +/- CPK elevations
- Myositis: muscle inflammation
- Rhabdomyolysis: muscle symptoms with very high CPK (>10,000) + muscle protein in the urine (myoglobinuria), which can lead to acute renal failure
What are some strategies to reduce the risk of myalgias with statins?
- Avoid drug interactions, including OTC products
- Do not use simvastatin 80 mg/day
- Do not use gemfibrozil + statin
How do you manage myalgias from statins?
- Hold statin, check CPK, investigate other possible causes
- After 2-4 weeks; re-challenge with same statin at same or decrease dose. Most patients who did not tolerate a statin will tolerate it when re-challenged, or will tolerate a different statin
- If myalgias return, discontinue statin. Once muscle symptoms resolve, use a low dose of a different statin; gradually increase dose
What are some examples of statins?
Atorvastatin (Lipitor), Fluvastatin (Lescol), Lovastatin (Mevacor), Pitavastatin (Livalo), Pravastatin (Pravachol), Rosuvastatin (Crestor), Simvastatin (Zocor)