Dyslipidemia Flashcards
Why lipoproteins are necessary
Triglycerides are an energy source. Cholesterol needed to make: cell membranes, bile acids, and steroid hormones
What is hyperlipidemia
Elevated cholesterol, triglycerides, and/or LDL
Physical exam signs of dyslipidemia
Xanthelasma (hands/eyes), circumferential Arcus, PVD (shiny, discolored, hairless), thickened Achilles, htn
Primary hyperlipidemia: what it is, also referred to as
Genetic/inherited heterozygous condition resulting in elevated total cholesterol or TG level. Familial
Primary HLD: numbers, need to get what
Total chol >200, tg >500. Thorough family hx
Secondary hyperlipidemia: from what 4 other conditions. Drugs that negatively impact/how: 3
DM, hypothyroid, chronic renal failure, obstructive liver disease. Inc LDL dec HDL: progestin, corticosteroids, anabolic steroids
If not fasting, which labs you can use
What indicates need to retest while fasting
Only total cholesterol and HDL.
TC >200 or HDL <40
Total cholesterol: desired, borderline, high
<200, 200-239, >240
HDL: low, high
<40. >60.
LDL:optimal, near optimal, borderline high, high, very high
O- <100. 100-129 near optimal. 130-159 borderline. 160-189 high. >190 v high
Old guidelines focused on what
Hyperlipidemia, assessment of ASCVD and tx of HLD to a goal LDL number
New guidelines focus on what
Reduction of ASCVD using statins based on evidence in RCTs
Screening: who and how often
20 years or older, every 4-6 years
What to screen: 8
Fasting lipoprotein: TC, LDL, HDL, TG. ALT, CK, hba1c. Estimated 10 yr ASCVD risk.
Primary prevention
Therapeutic lifestyle changes:rec for everyone. Reduce sat fats and cholesterol, inc activity, wt control
HDL
Elevated by 3
Lowered by 4
Elev: alcohol (1-2), sat fats, weight loss
Low: low fat diet, sugar, excess calories, excess polyunsaturated fats
LDL:
Elev by 3
Lowered by 3
Elev: sat fat, trans fatty acids, dietary cholesterol
Lowered: MUFAs, complex carbs, soy
Total cholesterol
Elev by: 2
Lowered by: 2
Elev: sat fats and transfatty acids
Low: substituting MUFAs and complex carbs for sat fats and lowered by soy
TGs
Elev by 4
Lowered by 2
Elev: alc, sugar, high carb diet, excess calories
Low: wt loss and fish oils
What % of calls should be sat fat
Total fat
Sat <7%. Total 25-35%
Areas to assess for cv disease
Coronary heart disease (angina, MI, PCI, stents, CABG)
PAD (carotid artery disease, extremities, abdominal AA)
Stroke/tia
RFs in ASCVD risk assessment
9
Gender, age, race, tc, HDL, SBP, tx for high bp, dm, smoker
4 categories for statin therapy/secondary prevention ASCVD
Intensity of therapy depends on
Clinical ASCVD. LDL >190. DM. >7.5% estimated 10 yr risk. Depends on the category
Statin therapy reduces risk for who
Moderate intensity does what
High intensity does what
Anyone with LDL >70
Moderate: 30-50% reduction LDL
High: >50% reduction LDL
Statin therapy recommended for who
Anyone who would exp net benefit of ASCVD risk reduction over potential adverse effects
High intensity statin therapy drugs 2
Atorvastatin 80 mg
Rosuvastatin 20 mg
Moderate intensity statin therapy
Atorvastatin 40, rosuvastatin 10, simvastatin 20-40, pravastatin 40, love statin 40, fluvastatin 40, few others
Low intensity statin therapy
Pravastatin 10-20, lovastation 20, 3 others
Statins
Class
MOA
HMG COA reductase inhibitors. Inhibit the rate limiting enzyme in the formation of cholesterol. Decrease LDLs, decrease TGs, and increase HDLs
Statin therapy
If <75
If >75
Is less than: high intensity therapy. If greater than or with contraindications to high intensity, should get moderate intensity statin
Statin tx for primary HLD LDL > \_\_\_ Reduction by \_\_\_ reduces risk by 20% May require what Assess need to address what
>
- >
- Additional use of non statin lipid lowering agents to achieve acceptable lipid reduction. Hypertriglyceridemia.
Diabetes
Benefits from statins
Which intensity
Substantial. Moderate is acceptable. High if 10 yr risk greater than 7.5%
Ascvd risk assessment should be completed for who
Pts without ascvd or dm and ldl <190
Non statin cholesterol therapy indic for who
High risk (ascvd, ldl >190, diabetes and 40-75) should take it if less than anticipated response to statins, unable to tolerate intensity, or are intolerant. Weigh benefits v risks and drug-drug
Areas that need further research 4
Non HDL cholesterol/other biomarkers to guide tx, non invasive imaging to guide risk assessment, 10 yr risk assessment vs lifetime when age to begin statins, others: HF, ESRD on HD, HIV, transplant (groups that haven’t been researched)
Secondary tx goals 2
Tx elev TGs: if >200 and ldl has been achieved, tx TGs
Tx low HDLs <40: if ldl and tg goals have been met, target HDL
Bile acid sequestrants
MOA
3 ex
Bind bile acid in intestines, liver uses hepatic cholesterol to produce more bile acids. Effect is to decrease LDL and inc HDL. Questran, colestipol, colesevelam
Nicotinic acid
MOA
Reduces production of VLDLs. Reduce LDLs, TGs, and inc HDLs
Fibrin acid derivatives
MOA
Agents
Reduce synthesis and inc breakdown of VLDLs. Reduce LDLs and TGs and inc HDL. Gemfibrozil, fenofibrate, clofibrate
Zeta
MOA
No effect on 2
Intended for use with
Inhibits cholesterol and phytosterol absorption from brush border of intestines. No effect on abs of vit ADEK, no effect on CYP450, use w a statin
Zetia
Effect on LDL, other events
When added to simvastatin reduced LDL by 24% and reduces pt of cv death, coronary events, or nonfatal CVA
Reduction of LDL by bile acid sequestrant
8-16% when used w statin
Statin and fibric acid derivatives
Primarily used to what
Risk of
Contraindicated in
Decrease TGs. Risk myopathies. Dont use in severe liver disease
Statin and niacin
Inc risk of
Hepatic dysfunction
Lovastatin and simvastatin
Interact with which drugs: 6
Itraconazole, ketoconazole, erythromycin, clarithromycin, gemfibrozil, grapefruit juice
Side effects statins
Major one
Occur with what
Indiv at risk: 4
Myopathies, occur w any statin. >80, small frame/frail, imp renal or hepatic system, alcohol abuse
Myopathies w statins: drug combos w statins that inc risk 6
Niacin, gemfibrozil, cyclosporine, hiv protease inhibitors, verapamil, amiodarone
Pregnant and nursing women should avoid which 4
One they can use
Dont use: statins, ezetimibe, niacin, fibric acid derivatives
Can use bile acid binding resins
PCSK9 inhibitors
Benefit seen where
59% ldl reduction. Benefit seen across age, sex, and type of ASCVD regardless of starting LDL level
Lopitamide
What it is
Tg transfer protein inhibitor, resides in ER and prevents assembly of Apob lipoproteins in enterocytes and hepatocytes. Inhib synth of chylomicrons and vldl in liver.
What is no longer recommended, now what is the goal
No longer: tx to ldl or non HDL cholesterol. Now goal is intensity of statin therapy for ascvd reduction
Focus should be assessing for what and If pts fall into which of 4 groups
Risk for ascvd. Clinical ascvd, ldl >189, indiv 40-75 w dm and ldl 70-189 w/o ascvd, indiv 40-75 with dm and ldl 70-189 and a 10 yr risk of 7.5% or higher
Intensity of statin therapy based on 4
Presence of clinical ascvd, risk of developing ascvd, presence of dm w/without HLD, or presence of isolated hyperlipidemia (genetic)
