Dyslipidemia Flashcards
CVD: Risk factors
- HTN
- DM
- Obesity
- Dyslipidemia
- Smoking
Trends: Ethnic Variations in Lipids
- Total lipids down: Except in Mexican-Americans
- HDL up: Except in non-hispanic black and mexican-americans
- LDL down
TG down
ATP-III Guidelines
- CHD Risk Equivalents: CAD, DM, AAA, carotid artery stenosis >50%, CVA or TIA, PAD, Framingham score >20%
- Risk Factors: Age (M>45, W>55), Family Hx CV event (M<40, HTN, smoking
ATP-III: LDL Goals
- CHD or risk equivalent: <160
ATP-III: Treatment Guidelines
- CHD or risk equivalent: >=130
- 2+ Risk factors: (10-20%) =190
ATP-III: Very high risk
- LDL goal <70 with established CHD and:
- Multiple risk factors
- Poorly controlled risk factors (smoking, DM)
- Metabolic syndrome
- ACS
High LDL: Pharmacotherapy
- HmgCoa Reductase Inhibitors: Statins (DOC)
- Bile Acid sequestrants: cholestyramine, colestipol
- Cholesterol Absorptions inhibitors: ezetimibe
Statin Equivalency
- Lovastatin: 40
- Pravastatin: 40
- Simvastatin: 20
- Atorvastitin: 10
- Fluvastatin: 80
- Rosuvastatin: 5
Statin-Induced Myalgias and Intolerance: Facts
- Hepatic statin transporter polymorphism that is associated with myopathy
- Severe myopathies are rare; myalgias are more common
Statin-Induced Myalgias and Intolerance: Risk factors
- Age >70
- polypharmacy
- female gender
- high-dose statin
- Low BMI
- Liver or kidney disease
- substance abuse
- Untreated hypothyroidism
Statin-Induced Myalgias and Intolerance: Prevention and treatment
- Use lowest effective dose
- Identify risk factors before initiation
- Obtain CK in any patient with myalgia on statin
- Myalgias resolve within 2mo
- Patients can be tried on another statin at a lower dose
What do you do with truly statin intolerant patients?
- Ezetimibe, BAS, Fibrate, Niacin
- Lifestyle modification
Low HDL (M <50): Causes
- Common in DM and CAD
- Extremely low (<20): may be r/t steroids, TZDs, malignancy, fibrates, disorders of ApoA-I
Low HDL: Facts
- Risk factor for CHD
- May be some benefit in lowering both HDL and LDL (Conflicting evidence)
Raising HDL
- Drugs: Statins and ezetimibe (slight increase), Fibrates, Niacin
- Lifestyle: smoking cessation, obesity, lack of physical activity, Mediterranean diet, Moderate ETOH consumption
Triglycerides: Pathophysiology
- Formed into chylomicrons in gut
- Some are synthesized in free fatty acids, remainder contain lipids
- Lipids particles are synthesized into VLDL
- VLDL in internal transit system for lipids
- TG levels include chylomicrons and concentration of TG in VLDL
- VLDL with high TG concentrations are not cleared efficiently and more readily converted to LDL
Hypertriglyceridemia: Causes
- Primary: Familial disorders, DM, Metabolic syndrome
- Secondary: ETOH, Poorly controlled DM, CKD, liver Dz, pregnancy, autoimmune disorders, certain drugs
Drugs that cause high TG
- TZ diuretics
- B-blockers
- Estrogens
- Isotretinoin
- Corticosteroids
- Bile-acid sequestrants
- Protease inhibitors
- Immunosuppressants
- Anti-psychotics
Endocrine Society Guidelines: TG
- Screen q 5yr in adults
- Use fasting to make diagnosis
- If high Tg found, look for secondary causes and other CV risks
High TG Risks
- Mild-to-moderate elevations are probably CV risk factors
- 2000): known to cause pancreatitis
- Severe (1000-1999)
Hypertriglyceridemia: Management (general)
- Decrease sugar and simple carbs (Fructose worse than sucrose or glucose); Exercise, Weight loss
- Meds: Fibrates, Niacin, n-3 fatty acids, Statins (esp. if CV risk)
Hypertriglyceridemia: Management (Specific)
- Mild (150-199): Lifestyle
- Moderate (200-999): Fibrate OR Niacin OR n-3 fatty acids with or w/out a statin
- Severe (1000-1999): Drug + Lifestyle, do NOT use statin as monotherapy
Ezetimibe (Zetia)
- Decreases absorption of cholesterol in gut
- Effectively lowers LDL; not shown to benefit cardiac events
- May reduce atherosclerosis in those with CKD
Other Investigational Drugs: Lipids
- Monoclonal antibody therapy to improve LDL clearance: increases degradation of LDL receptors on hepatocytes to lower LDL concentration
- Cholesterol ester transfer protein inhibitor (Anacetrapid): Raises HDL, Lowers LDL
Lipid-Markers
- Total cholesterol, HDL, LDL
- Apolipoproteins A-1 and B, lipoprotein (a), lipoprotein-associated psopholipase A2
- CRP: elevated levels along with high LDL has been shown to increase risk of CHD
