Dyslipidemia Flashcards
what is hyperlipidemia an independent risk factor for
coronary heart disease: angina, mi
cerebrovascular disease: ischemic stroke, tia
peripheral artery disease
modifiable risk factors for CVD
smoking hypertension diabetes bmi>27 excessive alcohol poor nutrition sedentary lifestyle waist circ <94 men <80 women
non modfiable risk factors for CVD
old age male family history of premature CHD <55male or <65 female family hypercholesterolemia chronic kidney disease ethnicity
four reasons to do a risk assessment
- identify patients most likely to benefit from pharmacotherapy**
- reassure low risk individuals without any treatable risk factors and a healthy lifestyle that theyre doing well
- advise individuals with treatable reisk factors and behaviours to address them
- engage patients in treatment decisions and increase adherance to therapy**
what is CVD
coronary death mi coronary insufficiency angina ischemic or hemorrhagic stroke transient ischemic attack peripheral artery disease heart failure
what are the advantages of ACC/AHA ASCVD
broader pop
narrower outcomes
what age group should we screen in
men and women over 40 years or postmenopausal (typically women not at CVD risk at this age)
describe LDL
low density
bad
high levels in the blood promotes build up of plaque in the artery walls
describe HDL
helps carry ldl away from artery walls
what are healthy lipid values
total chol; <5.2
ldl: <3.4
hdl >1 in men >1.3 women
tg <1.7
what are the effects of non fasting lipid profiles
min effect on LDL and HDL
modest effect on TG
predicts CVD similar to fasting
increases adherence, decrease lab demands and hypoglycemia
drug causes of hyprecholesterolemia
progestins thiazides - not sig anabolic steroids glucocorticoids beta blockers - not sig isotretinoin protease inhibitors cyclosporin mirtazapine sirolimus
genetic and condition causes of dyslipidemia
familial hypercholesterolemia type 2 diabetes chronic renal failure hypothyroidism nephrotic syndrome cholestatic liver disease
lifestyle causes of dyslipidemia
saturated fats increase lipids refined cabs and sugars increase triglycerides smoking decreases hdl aerobic increase hdl moderate alcohol increases hdl
name 3 things that cna positively affect lipid profile and decrease the risk of cv events
physical activity : 150 min/week
diet : mediterranean
stop smoking
torcetrapib decreases ldl significantly but whats wrong with it
increased CVD and mortality rates
not an improved outcome
what is the relative risk reduction with a statin***
25-30%
statins considered the same for efficacy, harm, and cost but differ in drug interactions, list from most to least
simvastatin and lovastatin > atorvastatin > pravastatin and rosuvastatin
what dose to start
equivalent to 10mg atorvastatin
many trials with statins had similar risk reductions using atorvastatin 10mg what didnt they target
did not target ldl, nor did they increase or decrease meds to reach the target, nor did they compare one ldl target to another
what does the top 2015 study recommend for primary prevention based on risk
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
compare canadian prevention guidelines: CCS and ACC/AHA
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
general side effects of statins
muscles aches GI upset upper GI sleep disturbance new onset diabetes - very low
describe the statin myopathy
muscle discomfort - weakness, cramps, heaviness
usually starts in larger muscles
diffuse - not unilateral
intermittent of variable duration
when does statin myopathy occur
1-12 months of therapy, or after dose increase, addition of interaction of drug
describe the management of myalgia
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
what is myositis
inflammation of skeletal muscle, muscle discomfort
myalgia plus plasma CK levels >2-4ULN but <10xULN
may be caused be strenuous exercise
potentially serious
describe the management f myositis
> 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
what is the serum creatinine in rhabdomyolysis
ck> 3-10x ULN and marked creatinine elevation or myoglobinuria (orange color urine)
describe rhabdomyolysis
symptoms and complications
severe progressive muscle aches, weakness, pain
muscle damage, mypglpburia, high risk of acute renal failure
medical emergency!
very rare
management of rhabdomyolysis
stop statin and hospitalization for supportive treatment
should you re initiate a statin after rhabdomyolysis
may rechallenge with low dose of diff statin once symptoms resolved - may take months to years
reassess risk vs benefit
alternative ldl lowering therapy
should you use coenzyme q or vit d to decrease myopathies
no
what do the ccs guidelines recommend for retesting if not on a statin
Cv risk assessment every 5 years for men and women 40-75, also a risk assessment
what does top 2015 recommend for retesting if not on a statin
no more than every 5 years, sooner if other cv risk factors develop
what is the time to 10% probability of crossing the FRS 20% high risk line in
- FRS < 5%
- FRS 5- <10%
- 10- 15%
- 19 years
- 8 years
- 3 years
who is in the high risk category
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
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
- 7%
1. 2 events?
what does ccs recommend for diabetes for statin therapy
all start on a statin
what do statins do
relative risk reduction of chd event or death 25%
mortality: NNT 30 x 5-6 years
what was the difference found from a big dose statin compared to a smal
additional 10% relative risk reduction (1% absolute risk reduction) in CHD events or death
what are questions to ask to determine if muscle pain due to the statin
any change in the urine
is it getting better - not statin
have you had this in the past
is it bilateral - statin
what is a food interaction with statins
grapefruit
what are drug interactions with statins
azole antifungal cyclosporin macrolide antibiotics amiodarone warfarin fibrate HIV protease inhibitor verapamil diltiazam
what is the result of adding niacin or fibrates with a statin
not significant in any outcome
how effective are fibrates
half as good as statins
what is the improve-it trial
improved reduction of outcomes vytorin efficacy international trial
1800 post mi patients
what was the intervention in the improveit trial
simva 40mg +ezetimibe vs simva alone for 7 years
what are the results of the improveit trial
decrease ldl by 15-20%
slight reduction in sv events, death, mi, stroke
no big differences in safety
when would you offer an ezetimibe
had an mi and only tolerate half dose of statin if patient thinks its worth it for a 2% risk reduction
what are pcsk9 inhibitor
monoclonal antibodies
how much did ldl decrease with pcsk9 inhibitors
50-70%
what did the fourier trial study
evolocumab and clinical outcomes in patients with cardiovascular disease on a statin for 2.2 yeas
what was the outcome of the fourier trial
reduced events from 5.1 - 4,5%
did not reduce deaths
should you use pcsk9 inhibitors
not a significant enough decrease in cv events and does not reduce deaths and very very costly
niacin effects on cvd
decrease triglycerides 20-35%
stopped due to futility no decrease in cvd risk
fibrates effects on cvd
decrease triglycerides by 20-50%
decrease non fatal mi no difference in overall cvd
omega 3 fatty acids effect on cvd
decreased triglycerides 25-30% no benefit in ay cv outcome
overall what can be said about lowering triglycerides
doesnt decrease cvd events
what are high tg a risk factor for
pancreatitis
what did jama find about statins and fibrates in pancreatitis
statins decrease pancreatitis, fibrates increased
compare TOP to ACC/AHA guidlines
TOP based on framingham risk alone
