dyslipidemia Flashcards
dyslipidemia
elevated total or LDL
low HDL
major source of cholesterol
de novo syn in liver
most cholesterol is converted to bile acids
3 hydroxy 3 methyl glut aryl CoA to mevalonate
lipoproteins
VLDL
LDL
HDL
chylomicron (largest, TG)
exogenous
chylomicron in gut
transports dietary fats
degraded releasing TG and apoproteins
remnants cleared by liver
endogenous
VLDL formed in liver and helps TG transfer
remnants of VLDL and LDL
LDL number and size related to atherogenicity
LDL, app B-100 binds to LDL receptors on liver
statins
inhibit HMG-CoA reductase, dec hepatic stores of cholesterol
inc LDL rec number leading to dec plasma LDL
pravastatin (Renal) lovastatin (grapefruit) atorvastatin (grapefruit, any time) rosuvastatin (renal) simvastatin (grapefruit, drug int)
statin clinical pearls
taken at night 1 mo for max effect CONTRA pregnancy RENAL dec LDL, TG/ inc HDL
statin side effects
GI upset
myopathy-rhabdo (CPK)
hepatotoxicity (LFT)
decrease cholesterol (FLP)
fibric acid derivatives
reduce TG
fenobrate (renal, contra in allergy)
gemfibrozil ( 30 min prior to meal, renal, not with other statins
fabric acid derivative clinical pearls
several days for max
LIVER
LFTs
CPK
CBC
FLP
fibric acid derivatives side effects
Dyspepsia Abdominal pain Cholelithiasis Impaired hepatic function Myopathy/rhabdomyolysis
Bile Acid Sequestrants
Decreasing bile pool which causes LDL receptor increase greater hepatic uptake of cholesterol from plasma
cholestyramine ( renal, use in hepatic dys, dec absorption of oral medication, TOOTH DISCOLORATION)
colestipol (dec aborptin of oral medication, ACIDOSIS)
colesevalam (DO NOT BOWEL)
Bile Acid Sequestrants clinical pearls
Fallen out of favor due to tolerability Decreases LDL Interferes with fat-soluble vitamin absorption Increases triglycerides and HDL Monitor FLP
Bile Acid Sequestrants adverse effects
constipation
bleeding
Niacin (Vitamin B3)
Decreases release of fatty acids from fat stores, decreases hepatic uptake of
fatty acids, and reduces production of VLDL particles.
Raises HDL
Decreases triglycerides and LDL
Niacin (Vitamin B3) clinical pearls
Administer long-acting preparations at bedtime
Fallen out of favor
Niacin (Vitamin B3) side effects
Flushing
Decreased by taking with food, ASA 325 mg, or taking SR formulation
GI (n/v/d, dyspepsia, flatulence, and PUD)
Hyperuricemia
Hepatotoxicity
Hyperglycemia
Omega-3-Fatty Acids [fish oil]
Decreases hepatic synthesis of triglycerides via inhibition of esterification of
fatty acids
Used for hypertriglyceridemia
Omega-3-Fatty Acids [fish oil] clinical pearls
Caution in patients with fish/shellfish allergy
Can be used in renal dysfunction
Monitor LFTs
Caution on patients prone to prolonged bleeding time
Do not freeze
OTC formulations do not contain same concentration as Rx
Omega-3-Fatty Acids [fish oil] side effects
GI Diarrhea Nausea Abdominal pain Eructation
Arthralgia
Prolonged bleeding time
Possible increase in atrial fibrillation (Afib) / atrial flutter incidence
Ezetimibe (Zetia®)
Selectively inhibits the absorption of cholesterol in the small intestine through the
NPC1L1 transporter
Ezetimibe (Zetia®) side effects
Diarrhea Arthralgia Myopathy Liver dysfunction Monitor LFTs
Ezetimibe (Zetia®) clinical pearls
Fallen out of favor
Use with caution in hepatic/renal impairment
class 1
no angina with normal act
angina with strenuous exertion
class 2
limitation of ordinary act
worse after meals, cold, stress
class 3
marked limitation of ordinary activity
class 4
angina occurs at rest
tissue markers for biomarkers
troponin (specific)
myoglobin
creatine kinase- MB
discriminate bt ischemia and infarction
beta blocker
initial therapy in ALL pt with CAD
dec angina symptoms
dec mortality in post MI, and heart failure
B1 rec Anta on SA and AV node
cardio selective beta blocker
Atenolol (Tenormin®)
Metoprolol tartrate/succinate (Lopressor®/Toprol XL®)
Bisoprolol (Zebeta®)
non selective beta blocker
Carvedilol (Coreg®)
Propranolol (Inderal®)
Labetalol (Normodyne®)
beta blocker side effect
Hypotension Bradycardia AV block Bronchospasm Lethargy Somnolence Vivid dreams Mask signs of hypoglycemia Except sweating Erectile Dysfunction
nitrates
Predominantly venodilation
Reduces myocardial demand by decreasing preload
Relax vascular smooth muscle in the systemic/coronary arteries
Provides symptomatic relief
No effect on mortality!!!
short acting nitrates
SL nitroglycerin or nitroglycerin spray is recommended for immediate relief of
angina in patients with CAD
• Should be prescribed for ALL patients
• Nitromist®
• 1-2 sprays onto or SL
• Nitrostat®
• 0.4 mg SL nitroglycerin tablets
• Storage
• Must be kept in the manufacturer’s (original) bottle
• Discard after 6 to 12 months of opening the bottle
• Max of 1.2 mg within 15 minutes
• Take at 5 minute intervals • If no relief – CALL 911
Short-acting nitroglycerin (NTG)
Sublingual (SL) – Nitrostat®
Spray - Nitromist®
Long-acting nitrates (LAN)
Isosorbide Mononitrate (Monoket®) Isosorbide Mononitrate ER (Imdur®) Isosorbide Dinitrate ER (Dilatrate SR®) Isosorbide Dinitrate (Isordil®) NTG patch (Nitro-Dur®) NTG paste (Minitran®)
nitrates clinical pearls
avoid with PDE5 inh
hypotension
nitrates side effects
Dyspepsia Headache Flushing Dizziness Hypotension Tachycardia
calcium channel blockers
limit Ca influx through L type Ca channels
negative inotropic effects (dec in myocardial oxygen
smooth muscle relaxation (dec vascular resistance)
provide symptomatic relief
NO effect on mortality
CCB drugs
dihydropyridine
amlodipine
felodipine
nifedipine**
non dihydropyridine
diltiazem
verapamil
CCB side effects of DHP
Reflex tachycardia • Hypotension • Dizziness • Flushing • GI effects • Headache • Lower extremity edema • Gingival hyperplasia
CCP side effects NON DHP
Bradycardia • AV node block • Hypotension • Dizziness • Headache • GI effects • Constipation • Exacerbation in HF patients • Gingival hyperplasia
substitution of gingival hyperplasia
verapamil
isradipine
chlorhexidine gluconate
