Dyslipidemia Flashcards
peripheral arterial disease
a condition in which narrowed arteries reduce blood flow to the extremities, typically the legs, due to atherosclerosis, leading to symptoms like pain, cramping, and impaired circulation.
Pooled Cohorts Equations are
race-and sex-specific equations used to predict a 10-year ASCVD risk and work best in individuals of age 40-75 years who have no history of ASCVD, severe hypercholesterolemia, or diabetes.
hypercholesterolemia
a medical condition characterized by abnormally high levels of cholesterol in the blood, increasing the risk of atherosclerosis and cardiovascular disease.
If atherosclerosis occurs in the coronary artery, it can result in
stable angina and ACS
ACS includes
unstable angina and myocardial infarction
If atherosclerosis occurs in the brain artery, then it can cause
ischemic stroke or TIA (Transient ischemic attack)
If atherosclerosis occurs in the major arteries in the limbs, then it can lead to
peripheral arterial disease, also called peripheral vascular disease.
reducing the risk for ASCVD is the main goal of
lipid-lowering therapy. This means that we determine the need for lipid-lowering therapy based on the individual’s risk for ASCVD, not just based on the individual’s blood lipid levels.
What is the primary reason for prescribing lipid-lowering therapy in a patient with a history of ASCVD?
Lipid-lowering therapy is prescribed to prevent the recurrence of ASCVD in patients with a history of the condition.
When is lipid-lowering therapy recommended for a patient with severe hypercholesterolemia (LDL cholesterol of at least 190) even if they have no history of ASCVD?
Lipid-lowering therapy is recommended for severe hypercholesterolemia, even without prior ASCVD, due to the high risk of developing ASCVD.
Why are patients with diabetes considered to have an increased risk of ASCVD?
Patients with diabetes are at an increased risk of ASCVD, which is why they are candidates for lipid-lowering therapy.
How is the need for lipid-lowering therapy determined for individuals who haven’t had ASCVD, don’t have severe hypercholesterolemia, or diabetes?
For those without ASCVD, severe hypercholesterolemia, or diabetes, the need for lipid-lowering therapy is determined by predicting their ASCVD risk using Pooled Cohorts Equations.
What do the Pooled Cohorts Equations predict, and why are they used?
Pooled Cohorts Equations predict a 10-year risk of fatal and non-fatal MI and ischemic stroke, which are part of ASCVD. They are used to assess the need for lipid-lowering therapy.
Why are the equations called “Pooled Cohorts”?
The equations are called “Pooled Cohorts” because they were derived from data compiled from 5 community-based cohorts representing the US population.
What patient factors are used in the Pooled Cohorts Equations to predict ASCVD risk?
The Pooled Cohorts Equations use age, sex, race, systolic blood pressure, total cholesterol, HDL-cholesterol, diabetes status, smoking status, and hypertension treatment status as variables to predict a 10-year risk of ASCVD.
How can a healthcare provider determine the right Pooled Cohorts Equation for a patient’s specific sex and race?
The American College of Cardiology has a website that can automatically select the appropriate equation based on the patient’s specific sex and race.
What are the four risk categories based on the 10-year risk of ASCVD?
- low risk (less than 5%)
- borderline risk (5% to less than 7.5%)
- intermediate risk (7.5% to less than 20%)
- high risk (at least 20%).
What are the limitations of the Pooled Cohorts Equations in predicting ASCVD risk?
- being less accurate for individuals who are not non-Hispanic whites or blacks
- those younger than 40 or older than 75
- the dominance of age in risk scoring, potentially overestimating risk in the elderly.
Why can advanced age alone lead to a high-risk classification, according to the Pooled Cohorts Equations?
Age dominates risk scoring in the equations, and advanced age can lead to a high-risk classification even if other variables are not significant.
What important risk factors for ASCVD are not included in the Pooled Cohorts Equations?
The equations do not include all known risk factors for ASCVD, such as chronic inflammatory diseases and family history.
What should be investigated for the treatment of hyperlipidemia, and what are some secondary causes to consider?
Investigate secondary causes of hyperlipidemia, including medications, when treating hyperlipidemia.
What lifestyle therapies should be a part of any lipid-lowering treatment regimen?
- healthy diet
- regular exercise
- weight loss
How can lipid-lowering medications be classified, and what is the priority for treatment unless certain conditions exist?
can be classified as LDL-C-lowering and TG-lowering, with the priority being to lower LDL-C unless the patient has severe hypertriglyceridemia.
What is the main goal of lipid-lowering therapy, and which medications have been shown to reduce the risk of ASCVD?
The main goal of lipid-lowering therapy is to reduce the risk of ASCVD, and medications like statins, statin plus ezetimibe, statin plus a PCSK9 inhibitor, and statin plus icosapent ethyl have been shown to achieve this goal.
Which lipid-lowering medications are primarily used to lower triglycerides?
Fibrates and omega-3 fatty acids are primarily used to lower triglycerides.
What is the concern regarding niacin when used with a statin in terms of ASCVD risk?
Niacin has been shown to cause harm without lowering the ASCVD risk when used in combination with a statin.
What should be checked when a patient presents with hyperlipidemia or difficulty in controlling blood lipid levels while on lipid-lowering medication?
Diet, medications, and other disease states should be evaluated to determine the cause of hyperlipidemia or difficulty in controlling blood lipid levels.
How can the intake of certain dietary components impact LDL cholesterol and triglyceride levels?
The intake of saturated or trans fats can increase LDL cholesterol, while high intake of refined carbohydrates and excessive alcohol can increase triglyceride
What are some medications that can increase LDL cholesterol levels, and what should be done if these medications are used without a clear indication?
Medications such as diuretics, amiodarone, glucocorticoids, and cyclosporine can increase LDL cholesterol. If used without a clear indication, they should be stopped, or an alternative medication should be considered if available.
Which medications can increase triglycerides, and what should be done if they are used without a clear indication?
Bile acid sequestrants, beta blockers (except for carvedilol), estrogen, glucocorticoids, anabolic steroids, and protease inhibitors can increase triglycerides. If used without a clear indication, they should be stopped, or alternative medications should be considered if available.
What co-morbidities can increase LDL cholesterol or triglycerides, and how should they be managed?
Co-morbidities such as hypothyroidism and diabetes, which can increase LDL cholesterol or triglycerides, should be evaluated and better controlled as part of the management of hyperlipidemia.
What are the two main categories of lipid-lowering therapies?
lifestyle
pharmacological therapies
What are the components of lifestyle therapies for managing lipid levels?
- maintaining a healthy diet
- engaging in regular physical activity
- controlling body weight.
How can pharmacological lipid-lowering therapies be categorized based on their primary targets?
divided into two groups:
1. those that primarily lower LDL cholesterol
2. those that mainly reduce triglycerides.
Which medications are primarily used to lower LDL cholesterol levels?
- statins, ezetimibe, bempedoic acid, bile acid sequestrants, PCSK9 inhibitors, and inclisiran are primarily used to lower LDL cholesterol.
Which medications are mainly used to reduce triglyceride levels?
Fibrates, omega-3 fatty acids, icosapent ethyl, and niacin are primarily used to reduce triglycerides.
Why are lifestyle therapies considered crucial in any lipid-lowering treatment regimen, even when a patient takes medication?
Lifestyle therapies are essential because, even with medication, if a patient consumes a diet high in saturated fats, the medication’s effectiveness may be limited.
What are the key dietary recommendations for a patient aiming to lower their lipid levels?
Patients should consume a diet high in vegetables, fruits, whole grains, legumes, low-fat dairy products, low-fat poultry, fish, seafood, and nuts. They should limit or avoid tropical vegetable oils high in saturated fats and reduce intake of sweets, sugar-sweetened beverages, and red meats. In the case of hypertriglyceridemia, a very low-fat diet should be implemented, avoiding refined carbohydrates and alcohol.
How should a patient engage in physical activity to benefit their lipid levels, and how often should they do this?
Patients should participate in aerobic physical activity with moderate to vigorous intensity for 3-4 sessions per week, with each session lasting about 40 minutes to help manage their lipid levels.
What is the priority when considering pharmacological lipid-lowering therapies, and under what conditions might another approach be prioritized?
Lowering LDL cholesterol is the priority, but in the case of severe hypertriglyceridemia (defined as triglycerides ≥ 500), a focus on lowering triglycerides may be needed.
Why is it important to choose medications that have been shown to reduce the risk of ASCVD in lipid-lowering therapy?
The main goal of lipid-lowering therapy is to reduce the risk of ASCVD, and not all lipid-lowering medications have been consistently shown to achieve this in clinical trials.
Which lipid-lowering medication has the strongest evidence for reducing the risk of ASCVD and should be used first?
Statins have the strongest evidence for reducing the risk of ASCVD and should be the first choice for lipid-lowering therapy.
Which medications can be considered for use alongside statins if statin monotherapy does not achieve adequate responses?
If statin monotherapy does not result in adequate responses, medications that have been shown to reduce the ASCVD risk when added to a statin, such as ezetimibe, PCSK9 inhibitors, and icosapent ethyl, can be considered.
When might a patient need a medication that primarily lowers triglycerides, and what are some examples of such medications?
Patients with severe hypertriglyceridemia may be at an increased risk of pancreatitis and may need medications that primarily lower triglycerides, such as fibrates and omega-3 fatty acids.
Why is increasing HDL cholesterol with medication not typically chosen in lipid-lowering therapy?
Increasing HDL cholesterol with medication is not chosen because studies have not consistently shown that it reduces the risk of ASCVD.
Why is it important to be familiar with the expected percent reduction in LDL cholesterol and triglycerides by lipid-lowering medications?
Understanding the percent reduction in LDL cholesterol or triglycerides helps assess the effectiveness of lipid-lowering medications.
What is the typical range of LDL cholesterol reduction achieved by statins, and which statins can also lower triglycerides significantly?
Statins can reduce LDL cholesterol by 20-55%, with some statins like atorvastatin and rosuvastatin lowering triglycerides by about 30%. These statins can be used to treat severe hypertriglyceridemia.
How much can medications like ezetimibe, bempedoic acid, and bile acid sequestrants (BAS) lower LDL cholesterol?
by approximately 20%.
What important consideration should be made when using BAS to lower LDL cholesterol?
BAS can increase triglycerides and are contraindicated if triglycerides are over 300.
How much can PCSK9 inhibitors reduce LDL cholesterol levels?
by more than 50%.
What is the typical range of triglycerides reduction achieved by medications like fibrates, omega-3 fatty acids, and niacin?
These medications can lower triglycerides by 20-50%.
How much do purified omega-3 fatty acids, like icosapent ethyl, typically lower triglycerides?
by about 20%.
What are some potential side effects of statins, and should these side effects deter their use?
muscle-related symptoms, new onset diabetes, liver toxicity, and cognitive dysfunction. In general, the incidence of these side effects is low and should not deter the use of statins.
What is the significance of understanding the potential for drug interactions with statins, and which statins are mainly metabolized by CYP3A?
Understanding drug interactions is important because certain statins, such as simvastatin, atorvastatin, and lovastatin, are mainly metabolized by CYP3A and can interact with inhibitors of this enzyme, including medications like calcium channel blockers, amiodarone, clarithromycin, cyclosporine, and antifungals like itraconazole and ketoconazole.
Why might pravastatin be preferred in patients taking a medication that inhibits CYP enzymes, and how is it metabolized?
Pravastatin is often chosen in patients taking a medication that inhibits CYP enzymes because it is not metabolized by cytochrome P450, which reduces the potential for drug interactions.
What should be avoided or used carefully when taking statins, and why?
All statins, including pravastatin, are substrates of organic anion transporter peptides and should be avoided or used with caution when taking a strong inhibitor of this transporter, such as gemfibrozil, to prevent potential interactions.
What is the significance of ezetimibe in lipid-lowering therapy, and where can one find more details on its clinical outcomes?
Ezetimibe is one of the medications that have been shown to reduce the ASCVD risk when added to statin therapy. For more detailed clinical outcome data, you can refer to the IMPROVE-IT trial.
What are the recommendations regarding the use of ezetimibe in patients with liver impairment, and why?
The drug label recommends avoiding ezetimibe in patients with moderate or severe liver impairment because it can elevate liver enzyme levels in the blood, which could be a safety concern
What side effects can ezetimibe cause?
muscle-related symptoms.
What is the significant drug interaction to be aware of when using ezetimibe?
Ezetimibe can increase cyclosporine blood levels, which is an important drug interaction to consider.
Which two PCSK9 inhibitors have been shown to reduce the ASCVD risk when added to statin therapy?
evolocumab and alirocumab.
How are PCSK9 inhibitors administered, and how frequently do patients typically need injections?
PCSK9 inhibitors are not taken orally; instead, they require a subcutaneous injection, typically once or twice per month.
What is the main side effect associated with PCSK9 inhibitors?
injection site reactions, such as redness and itchiness.
Do PCSK9 inhibitors have clinically significant drug interactions, and why?
No, PCSK9 inhibitors do not have clinically significant drug interactions because they are not hepatically or renally cleared.
What is the notable aspect of PCSK9 inhibitors in terms of cost, and can you provide an example of their price?
PCSK9 inhibitors are available only as brand names and are very expensive. For instance, the list price of Repatha is about $550 per month in 2023.
Is there clinical outcome data for BAS when added to statin therapy?
No
What are the contraindications for using BAS, and how do they relate to triglycerides levels?
BAS are contraindicated if triglycerides are at least 300, as they can elevate triglyceride levels.
In which patient population should BAS be avoided, and why?
BAS should be avoided in patients at risk of bowel obstruction because they can slow down gut movement.
How are BAS typically administered, and what are the implications of this administration method?
BAS are given as a powder mixed with liquid or multiple pills once or twice daily, which can be inconvenient and result in a high pill burden for patients.
What is the main side effect associated with BAS, and how can it be minimized?
The main side effect is GI-related, particularly constipation. To minimize GI-related side effects, BAS should be started at a low dose and titrated slowly.
How do BAS potentially affect the absorption of drugs and nutrients, and what measures can be taken to avoid this interaction?
BAS can reduce the absorption of drugs and nutrients like fat-soluble vitamins by decreasing the amount of bile acids available in the gut. To avoid this interaction, other drugs should be administered 1 hour before or 4 hours after BAS administration.
What is the primary use of fibrates, and what is their goal in patient management?
mainly used to reduce triglycerides in patients with severe hypertriglyceridemia to prevent pancreatitis. They have not been shown to reduce the ASCVD risk when added to statin therapy.
Which fibrates are available in this drug class, and how do their dosing regimens differ?
Gemfibrozil and fenofibrate are available in this drug class. Gemfibrozil is given twice daily, while fenofibrate is a once-daily medication.
Why is gemfibrozil contraindicated with certain statins, and what is the alternative choice when fibrates need to be used with a statin?
Gemfibrozil is contraindicated with certain statins like atorvastatin and simvastatin because it increases statin blood levels by inhibiting organic anion transporter peptides. As an alternative, fenofibrate is generally a better choice when fibrates need to be used with a statin.
What are the contraindications for fenofibrate, and why?
Fenofibrate is contraindicated in patients with eGFR < 30 due to its potential to increase serum creatinine levels. It is also contraindicated in active liver disease and gallbladder disease because it can cause liver toxicity and increase cholesterol excretion into the bile
What are the potential side effects of fenofibrate, and what interactions should be considered when using this medication?
Fenofibrate can cause muscle-related symptoms and increase liver enzyme levels in the blood. It can also affect INR in patients on warfarin and increase cyclosporine and tacrolimus blood levels.
What is the main difference between most omega-3 fatty acid products and icosapent ethyl in terms of their components and effects on ASCVD risk?
Most omega-3 fatty acid products are mixtures of EPA and DHA and have not consistently shown to reduce the ASCVD risk. In contrast, a purified form, icosapent ethyl, has been shown to reduce the ASCVD risk in specific patient groups.
What are the specific criteria and clinical trial data related to the use of icosapent ethyl in reducing ASCVD risk?
Icosapent ethyl has been shown to reduce the ASCVD risk in patients who received statin therapy and had LDL and triglyceride levels of 41-100 and 135-500, respectively. For more details, the REDUCE-IT trial provides comprehensive information.
What is the brand name of icosapent ethyl, and how does it differ from another prescription omega-3 fatty acid product, Lovaza?
The brand name of icosapent ethyl is Vascepa, and it differs from Lovaza, which is a mixture of EPA and DHA. Both are usually given twice daily.
What are the main side effects associated with omega-3 fatty acids, and what caution should be taken in patients on certain medications?
The main side effect is GI-related. Omega-3 fatty acids can also increase the risk of bleeding and should be used with caution if the patient is on an anticoagulant and/or an antiplatelet.
What adverse event did icosapent ethyl increase the risk of in the REDUCE-IT trial?
Icosapent ethyl increased the risk of atrial fibrillation in the REDUCE-IT trial.
What are the clinical outcomes of niacin when used with statin therapy, and what serious side effects have been associated with niacin in multiple clinical trials?
When used with statin therapy, niacin not only has not been shown to reduce the ASCVD risk but has also been shown to increase the risk of serious side effects such as hemorrhagic stroke, glucose intolerance, and infection in multiple clinical trials. Therefore, niacin should be used as a last resort after exhausting all other options.
What are the two oral formulations of niacin, and how do they differ in terms of side effects?
Niacin has immediate and extended-release formulations. Niacin can cause flushing due to its ability to directly dilate blood vessels. The extended-release formulation has a lower incidence of flushing than the immediate release formulation because of its slow absorption.
In what patient populations is niacin contraindicated, and why?
Niacin is contraindicated in patients with active liver disease because it can directly cause liver damage. It is also contraindicated in patients with active peptic ulcers because it can increase the secretion of peptic acid.
What are some potential side effects of niacin?
Niacin can cause muscle-related symptoms, hyperglycemia, and hyperuricemia.
How are patients categorized into different groups based on their ASCVD risk?
- clinical ASCVD
- severe hypercholesterolemia
- diabetes (DM)
- individuals without clinical ASCVD
- severe hypercholesterolemia
- DM.
What is the recommended treatment approach for patients in the clinical ASCVD group, and when might additional lipid-lowering therapy be needed?
Patients in the clinical ASCVD group generally need a high-intensity statin. Additional lipid-lowering therapy may be needed for patients with very high risk.
What is the primary goal for patients in the severe hypercholesterolemia group, and when might additional lipid-lowering therapy be considered?
Patients in the severe hypercholesterolemia group generally need LDL reduction ≥ 50%. Additional lipid-lowering therapy may be considered for patients with severely elevated baseline LDL cholesterol.
What is the recommended treatment approach for patients in the DM group, and when might more intensive lipid-lowering therapy be needed?
Patients in the DM group generally need a moderate-intensity statin. More intensive lipid-lowering therapy may be needed for patients with elevated ASCVD risk.
What is the criteria for initiating statin therapy among individuals without clinical ASCVD, severe hypercholesterolemia, and DM?
Among individuals without clinical ASCVD, severe hypercholesterolemia, and DM, the Pooled Cohorts Equations should be used to estimate a 10-year ASCVD risk. Those with a 10-year ASCVD risk ≥ 7.5% need initiation of statin therapy.
What are the four patient management groups according to the 2018 AHA cholesterol guideline?
- secondary ASCVD prevention
- severe hypercholesterolemia (defined as baseline LDL cholesterol at least 190)
- diabetes
- primary prevention.
What is the primary recommendation for the secondary ASCVD prevention group, and why?
The primary recommendation for the secondary ASCVD prevention group is a high-intensity statin because they have the highest risk of ASCVD. If the patient does not tolerate a high-intensity statin, a moderate-intensity statin should be considered.
What are the two main issues with the secondary ASCVD prevention group, and how do they affect treatment decisions?
The first issue is safety, as many statin side effects are dose-dependent, and patients over 75 years of age may have low statin tolerance, making a moderate-intensity statin a safer choice for this age group. The second issue is efficacy, as not all patients with a history of ASCVD have the same level of elevated ASCVD risk. Some may be at very high risk, and for this group, more aggressive therapy than just a high-intensity statin may be preferable.
Who belongs to the very high-risk group in the secondary ASCVD prevention category, and why might they require more aggressive therapy?
The very high-risk group includes those who have had multiple major ASCVD events or those with one major ASCVD event who also have multiple high-risk conditions. They might require more aggressive therapy because they are at a very high risk of ASCVD.
What are the major ASCVD events that are considered in determining ASCVD risk?
- ACS within the past 12 months
- any history of MI
- ischemic stroke
- symptomatic peripheral arterial disease.
What are the high-risk conditions that contribute to ASCVD risk?
- age at least 65
- co-morbidities increasing the risk of ASCVD such as hypertension, diabetes, chronic kidney disease, and heart failure
- current smoking
- history of CABG or PCI due to stable angina
- persistent elevation of LDL cholesterol of at least 100 despite being on a maximally tolerated statin
- heterozygous familial hypercholesterolemia.
When is a patient considered to be in the very high-risk category in the secondary ASCVD prevention group?
if they have had at least two major ASCVD events or one major ASCVD event plus two or more high-risk conditions.
What is the recommended treatment approach for the secondary ASCVD prevention group at very high risk?
- For patients at very high risk, high-intensity or maximally tolerated statin therapy is initially recommended.
- If the patient still has LDL cholesterol of at least 70 even after statin therapy, adding ezetimibe is recommended.
- If the patient still has LDL cholesterol of at least 70 despite being on both statin and ezetimibe therapy, the guideline recommends adding a PCSK9 inhibitor, but PCSK9 inhibitors are recommended after a trial of ezetimibe due to cost-effectiveness considerations.
What is the recommended treatment approach for the secondary ASCVD prevention group who are not in the very high-risk category?
- For patients not in the very high-risk category, the treatment approach depends on the patient’s age.
- If the patient is no more than 75 years old, high-intensity or maximally tolerated statin is recommended.
- If the LDL cholesterol level is still not below 70 after statin therapy, adding ezetimibe may be considered.
- If the patient is over 75 years old, either a moderate or high-intensity statin is recommended.
- If the patient has been tolerating a high-intensity statin before turning 75, they can continue with high-intensity statin therapy.
Why are patients with diabetes separated from the primary prevention group in the guidelines?
Patients with diabetes are separated from the primary prevention group because they have an increased risk of ASCVD comparable to that of those with a history of ASCVD.
What is the main issue with therapeutic decision-making for patients with diabetes in the age range of 40-75?
For patients with diabetes aged 40-75, a moderate-intensity statin is generally recommended. The main issue in this age group is whether this intensity is sufficient, particularly for those with an elevated ASCVD risk, such as those with additional ASCVD risk factors or an estimated 10-year ASCVD risk of at least 20%.
What are some examples of “additional risk factors” for patients with diabetes, as mentioned in the guidelines?
While the guidelines do not explicitly define these “additional risk factors,” they appear to refer to traditional risk factors such as age at least 65, hypertension, and current smoking.
What is the main issue with therapeutic decision-making for patients with diabetes who are over 75 years of age?
For patients with diabetes over the age of 75, the main issue is whether to initiate statin therapy due to safety concerns about statin therapy in this age group.
What is the recommended statin intensity for patients with diabetes aged 40-75, and under what conditions is a high-intensity statin or ezetimibe considered?
For patients with diabetes aged 40-75, a moderate-intensity statin is generally recommended. If the patient has multiple ASCVD risk factors, the guidelines recommend a high-intensity statin to reduce LDL cholesterol by at least 50%. Alternatively, if the estimated ASCVD risk is at least 20%, the guidelines recommend adding ezetimibe to maximally tolerated statin if the percent LDL cholesterol reduction with statin monotherapy is less than 50%.
What is the recommended approach for patients with diabetes who are over 75 years of age, and how is the decision to initiate statin therapy made in this group?
For patients with diabetes over the age of 75, statin therapy should be initiated only if the benefits outweigh the risks. The decision is based on assessing the patient’s co-morbidities, concomitant medications, functionality, and family support. Although the guidelines do not specify statin intensity in this group, it is presumed to be a moderate intensity, given their recommendation for a moderate intensity statin for diabetes patients. If the patient has been tolerating a statin before turning 75, the statin should be continued.
What is the main issue in the primary prevention group, and how is the ASCVD risk estimated for this group?
The main issue in the primary prevention group is to identify patients who need statin therapy. The ASCVD risk for this group is estimated using the Pooled Cohorts Equations, which are recommended for ages 40-75. However, because of the limitations of these equations, other factors known as ASCVD risk-enhancing factors or coronary artery calcium scores can also be considered to supplement the 10-year risk estimation.
What are ASCVD risk-enhancing factors, and how can they be used in identifying individuals who need statin therapy in the primary prevention group?
ASCVD risk-enhancing factors are additional risk factors not included in the Pooled Cohorts Equations but associated with an increased risk of ASCVD. They can be considered in combination with the 10-year risk estimation to determine the need for statin therapy in the primary prevention group.
What additional test results can be used to supplement the 10-year risk estimation by the Pooled Cohorts Equations in the primary prevention group?
Coronary artery calcium scores, measured with a coronary artery CT scan, can be used as test results to supplement the 10-year risk estimation by the Pooled Cohorts Equations in the primary prevention group.
How are therapeutic decisions made for patients in the primary prevention group aged over 75?
For patients in the primary prevention group aged over 75, therapeutic decisions regarding statin therapy are based on assessing the risks and benefits. If the benefits outweigh the risks, a moderate-intensity statin can be initiated. If the risks are greater than the benefits, statin therapy should not be initiated, and even de-prescribing the statin should be considered if the patient is already on one.
What does the coronary artery calcium (CAC) score measure?
The CAC score measures the amount of calcified plaque in the coronary arteries.
How is the CAC score typically classified?
The CAC score is classified into three levels: 0, 1-99, and greater than or equal to 100.
In general, what does a CAC score of 0 indicate regarding statin therapy?
A CAC score of 0 generally suggests that statin therapy is not needed, even for individuals in borderline or intermediate ASCVD risk groups.
When might statin therapy be considered for individuals with a CAC score in the range of 1-99?
Statin therapy may be considered for those with a CAC score of 1-99, especially if the individual is over the age of 55.
What does a CAC score of at least 100 suggest regarding statin therapy?
A CAC score of at least 100 often suggests that statin therapy is recommended, as it indicates a higher risk of ASCVD events.
What are the four ASCVD risk categories based on the 10-year risk of ASCVD estimated by the Pooled Cohorts Equations?
The four ASCVD risk categories are low, borderline, intermediate, and high.
What is the recommended approach to statin therapy for individuals in the low-risk category?
Statin therapy is generally not recommended for individuals in the low-risk category.
What is the primary goal for individuals in the high-risk category?
Individuals in the high-risk category should aim for a percent LDL reduction of at least 50%, although the guidelines do not specify the statin intensity.
What is the typical recommendation for individuals in the intermediate risk category?
For individuals in the intermediate risk category, a moderate-intensity statin is generally recommended.
What additional considerations can be applied in the intermediate risk and borderline risk categories?
In the intermediate risk and borderline risk categories, if there are concerns or doubts about statin therapy, ASCVD risk-enhancing factors and/or coronary artery calcium scores can be considered to guide the decision. If risk-enhancing factors or an elevated coronary calcium score are present, statin initiation is favored.
Hypertension and diabetes are considered as ASCVD.
TRUE/FALSE
False
The Pooled Cohort Equations estimate 10-year risk of fatal and non-fatal MI as well as ischemic stroke in patients with a history of myocardial infarction.
T/F
False
Advanced age can dominate risk scoring in the Pooled Cohort Equations.
T/F
True
Fibrates and niacin have not been shown to reduce the risk of ASCVD when they are used with a statin.
True
MJ is a 60-year-old, non-smoking white man (he/his/him) with no known medical history who has blood pressure 135/70 mmHg, heart rate 75 bpm, LDL 120 mg/dL, HDL 35 mg/dL and triglyceride 200 mg/dL. MJ does not take any medications and has no known drug allergies. Which the following is MJ’s estimated 10-year ASCVD risk?
a. 2.3%
b. 4.8%
c. 5.7%
d. 9.9%
e. 11.9%
e. 11.9%
Which of the following options is the most appropriate non-pharmacological treatment to address the ASCVD risk of MJ?
a. Increase in consumption of palm oil.
b. Increase in consumption of whole grains.
c. Decrease in consumption of regular Coke.
d. Decrease in aerobic activity.
B, C
Which of the following options is the most appropriate drug treatment to address the ASCVD risk of MJ?
a. No drug treatment
b. Pravastatin (Pravachol) 10 mg po daily
c. Rosuvastatin (Crestor)10 mg po daily
d. Atorvastatin (Lipitor) 40 mg po daily
e. Ezetimibe (Zetia) 10 mg po daily
C. Rosuvastatin (Crestor)10 mg po daily
Three months later, MJ comes to your pharmacy with the following prescription. Below are the medications included in the prescription. Which one of them is most likely to increase LDL-C?
a. Aspirin
b. Amlodipine (Norvasc)
c. Carvedilol (Coreg)
d. Colesevelam (Welchol)
e. Furosemide (Lasix)
e. Furosemide (Lasix)
Which of the following medications can lower TG by at least 30%?
a. Evolocumab (Repatha)
b. Ezetimibe (Zetia)
c. Gemfibrozil (Lopid)
d. High intensity statin
e. Icosapent ethyl (Vascepa)
c. Gemfibrozil (Lopid)
d. High intensity statin
BZ is a 56-year-old person status post kidney transplantation who is taking cyclosporine as immunosuppressants. Today, BZ is diagnosed with hypercholesterolemia. Which of the following statins is the safest option(s) for BZ?
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Which of the following should be monitored for BZ’s statin therapy?
a. Atrial fibrillation
b. Constipation
c. Drug-drug interactions with fat soluble vitamins
d. Flushing
e. Muscle-related symptoms
e. Muscle-related symptoms
AP is a 60-year-old African-descent woman (she/her/her) with a history of MI and HTN who comes to her PCP for a regular check-up. Today her lipid panel shows LDL 110 mg/dL, HDL 55 mg /dL, and triglyceride 150 mg/dL. Her BP is 120/70 mmHg with HR of 70 bpm. She is currently taking aspirin, carvedilol (Coreg), and lisinopril (Zestril). She does not smoke and has no known drug allergies. Which of the following options is the most appropriate drug treatment to reduce AP’s ASCVD risk?
a. No drug treatment.
b. Pravastatin (Pravachol) 10 mg po daily.
c. Rosuvastatin (Crestor) 10 mg po daily.
d. Rosuvastatin (Crestor) 40 mg po daily.
e. Gemfibrozil (Lopid) 600 mg po BID.
d. Rosuvastatin (Crestor) 40 mg po daily.
PA is a 45-year-old white man (he/his/him) with a history of HTN who is newly diagnosed with diabetes mellitus type 2. Today his lipid panel shows LDL 90 mg/dL, HDL 40 mg /dL, and triglyceride 100 mg/dL. His BP is 120/70 mmHg with HR of 70 bpm. He is currently taking lisinopril (Zestril). He does not smoke and has no known drug allergies. Which of the following options is the most appropriate drug treatment to reduce PA’s ASCVD risk?
a. No drug treatment.
b. Pravastatin (Pravachol) 10 mg po daily.
c. Rosuvastatin (Crestor) 10 mg po daily.
d. Rosuvastatin (Crestor) 40 mg po daily.
e. Gemfibrozil (Lopid) 600 mg po BID.
c. Rosuvastatin (Crestor) 10 mg po daily
