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Clinical 2.0 > Dyslipidemia > Flashcards

Dyslipidemia Flashcards

1
Q

what is hyperlipidemia an independent risk factor for

A

coronary heart disease: angina, mi
cerebrovascular disease: ischemic stroke, tia
peripheral artery disease

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2
Q

modifiable risk factors for CVD

A 
smoking 
hypertension 
diabetes
bmi>27 
excessive alcohol 
poor nutrition
sedentary lifestyle 
waist circ <94 men <80 women
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3
Q

non modfiable risk factors for CVD

A 
old age 
male
family history of premature CHD <55male or <65 female 
family hypercholesterolemia 
chronic kidney disease
ethnicity
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4
Q

four reasons to do a risk assessment

A
  1. identify patients most likely to benefit from pharmacotherapy**
  2. reassure low risk individuals without any treatable risk factors and a healthy lifestyle that theyre doing well
  3. advise individuals with treatable reisk factors and behaviours to address them
  4. engage patients in treatment decisions and increase adherance to therapy**
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5
Q

what is CVD

A 
coronary death 
mi 
coronary insufficiency 
angina 
ischemic or hemorrhagic stroke 
transient ischemic attack 
peripheral artery disease
heart failure
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6
Q

what are the advantages of ACC/AHA ASCVD

A

broader pop

narrower outcomes

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7
Q

what age group should we screen in

A

men and women over 40 years or postmenopausal (typically women not at CVD risk at this age)

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8
Q

describe LDL

A

low density
bad
high levels in the blood promotes build up of plaque in the artery walls

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9
Q

describe HDL

A

helps carry ldl away from artery walls

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10
Q

what are healthy lipid values

A

total chol; <5.2
ldl: <3.4
hdl >1 in men >1.3 women
tg <1.7

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11
Q

what are the effects of non fasting lipid profiles

A

min effect on LDL and HDL
modest effect on TG
predicts CVD similar to fasting
increases adherence, decrease lab demands and hypoglycemia

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12
Q

drug causes of hyprecholesterolemia

A 
progestins
thiazides - not sig 
anabolic steroids
glucocorticoids
beta blockers - not sig 
isotretinoin 
protease inhibitors
cyclosporin 
mirtazapine
sirolimus
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13
Q

genetic and condition causes of dyslipidemia

A 
familial hypercholesterolemia 
type 2 diabetes
chronic renal failure 
hypothyroidism 
nephrotic syndrome 
cholestatic liver disease
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14
Q

lifestyle causes of dyslipidemia

A 
saturated fats increase lipids 
refined cabs and sugars increase triglycerides 
smoking decreases hdl 
aerobic increase hdl 
moderate alcohol increases hdl
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15
Q

name 3 things that cna positively affect lipid profile and decrease the risk of cv events

A

physical activity : 150 min/week
diet : mediterranean
stop smoking

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16
Q

torcetrapib decreases ldl significantly but whats wrong with it

A

increased CVD and mortality rates

not an improved outcome

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17
Q

what is the relative risk reduction with a statin***

A

25-30%

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18
Q

statins considered the same for efficacy, harm, and cost but differ in drug interactions, list from most to least

A

simvastatin and lovastatin > atorvastatin > pravastatin and rosuvastatin

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19
Q

what dose to start

A

equivalent to 10mg atorvastatin

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20
Q

many trials with statins had similar risk reductions using atorvastatin 10mg what didnt they target

A

did not target ldl, nor did they increase or decrease meds to reach the target, nor did they compare one ldl target to another

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21
Q

what does the top 2015 study recommend for primary prevention based on risk

A

risk <10% retest lipids with risk estimation in 5 years
10-19% risk discuss and offer statins
>20% risk encourage high intensity statins
** do not retest lipid levels or try reach targets

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22
Q

compare canadian prevention guidelines: CCS and ACC/AHA

A

both agree to initiate therapy if LDL>5, or diabetes
but ACC/AHA opens up discussion with patient and estimates atherosclerotic cardiovascular risk before deciding to intiate therapy

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23
Q

general side effects of statins

A 
muscles aches
GI upset
upper GI 
sleep disturbance
new onset diabetes - very low
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24
Q

describe the statin myopathy

A

muscle discomfort - weakness, cramps, heaviness
usually starts in larger muscles
diffuse - not unilateral
intermittent of variable duration

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25
Q

when does statin myopathy occur

A

1-12 months of therapy, or after dose increase, addition of interaction of drug

26
Q

describe the management of myalgia

A

obtain CK level - hold statin?
hold for 1-2 weeks or until symptoms resolve then rechalenge statin,
different statin/dose reduction,
reasses risk vs benefit of restarting statin

27
Q

what is myositis

A

inflammation of skeletal muscle, muscle discomfort
myalgia plus plasma CK levels >2-4ULN but <10xULN
may be caused be strenuous exercise
potentially serious

28
Q

describe the management f myositis

A

> 2ULN but <10ULN : discontinue statin
follow until symptoms resolve/CK normal
consider precipitating factors
reasses risk vs benefit before restarting stain
change statin/reduce dose/titrate up slowly

29
Q

what is the serum creatinine in rhabdomyolysis

A 
ck> 3-10x ULN and marked creatinine elevation 
or myoglobinuria (orange color urine)
30
Q

describe rhabdomyolysis

symptoms and complications

A

severe progressive muscle aches, weakness, pain
muscle damage, mypglpburia, high risk of acute renal failure
medical emergency!
very rare

31
Q

management of rhabdomyolysis

A

stop statin and hospitalization for supportive treatment

32
Q

should you re initiate a statin after rhabdomyolysis

A

may rechallenge with low dose of diff statin once symptoms resolved - may take months to years
reassess risk vs benefit
alternative ldl lowering therapy

33
Q

should you use coenzyme q or vit d to decrease myopathies

A

no

34
Q

what do the ccs guidelines recommend for retesting if not on a statin

A

Cv risk assessment every 5 years for men and women 40-75, also a risk assessment

35
Q

what does top 2015 recommend for retesting if not on a statin

A

no more than every 5 years, sooner if other cv risk factors develop

36
Q

what is the time to 10% probability of crossing the FRS 20% high risk line in

  1. FRS < 5%
  2. FRS 5- <10%
  3. 10- 15%
A
  1. 19 years
  2. 8 years
  3. 3 years
37
Q

who is in the high risk category

A 
FRS > 20 
clinical vascular disease
abdominal aortic aneurysm 
chronic kidney disease
high risk hypertension
diabetes and >40, or >15 yrs duration and >30, or microvascular disease
38
Q

if someone has a 5% risk of CHD death, MI, or stroke over 10 years what would a statin decrease it to? how many events would it save in 10 years

A
  1. 7%

1. 2 events?

39
Q

what does ccs recommend for diabetes for statin therapy

A

all start on a statin

40
Q

what do statins do

A

relative risk reduction of chd event or death 25%

mortality: NNT 30 x 5-6 years

41
Q

what was the difference found from a big dose statin compared to a smal

A

additional 10% relative risk reduction (1% absolute risk reduction) in CHD events or death

42
Q

what are questions to ask to determine if muscle pain due to the statin

A

any change in the urine
is it getting better - not statin
have you had this in the past
is it bilateral - statin

43
Q

what is a food interaction with statins

A

grapefruit

44
Q

what are drug interactions with statins

A 
azole antifungal 
cyclosporin 
macrolide antibiotics 
amiodarone
warfarin 
fibrate
HIV protease inhibitor 
verapamil 
diltiazam
45
Q

what is the result of adding niacin or fibrates with a statin

A

not significant in any outcome

46
Q

how effective are fibrates

A

half as good as statins

47
Q

what is the improve-it trial

A

improved reduction of outcomes vytorin efficacy international trial
1800 post mi patients

48
Q

what was the intervention in the improveit trial

A

simva 40mg +ezetimibe vs simva alone for 7 years

49
Q

what are the results of the improveit trial

A

decrease ldl by 15-20%
slight reduction in sv events, death, mi, stroke
no big differences in safety

50
Q

when would you offer an ezetimibe

A

had an mi and only tolerate half dose of statin if patient thinks its worth it for a 2% risk reduction

51
Q

what are pcsk9 inhibitor

A

monoclonal antibodies

52
Q

how much did ldl decrease with pcsk9 inhibitors

A

50-70%

53
Q

what did the fourier trial study

A

evolocumab and clinical outcomes in patients with cardiovascular disease on a statin for 2.2 yeas

54
Q

what was the outcome of the fourier trial

A

reduced events from 5.1 - 4,5%

did not reduce deaths

55
Q

should you use pcsk9 inhibitors

A

not a significant enough decrease in cv events and does not reduce deaths and very very costly

56
Q

niacin effects on cvd

A

decrease triglycerides 20-35%

stopped due to futility no decrease in cvd risk

57
Q

fibrates effects on cvd

A

decrease triglycerides by 20-50%

decrease non fatal mi no difference in overall cvd

58
Q

omega 3 fatty acids effect on cvd

A

decreased triglycerides 25-30% no benefit in ay cv outcome

59
Q

overall what can be said about lowering triglycerides

A

doesnt decrease cvd events

60
Q

what are high tg a risk factor for

A

pancreatitis

61
Q

what did jama find about statins and fibrates in pancreatitis

A

statins decrease pancreatitis, fibrates increased

62
Q

compare TOP to ACC/AHA guidlines

A

TOP based on framingham risk alone

Clinical 2.0 (24 decks)

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