H_Review_Lipids

Question 1

Choletral Transporet

Answer 1

Question 2

Lipid metabolism

Answer 2

Intestine : Chylomicrons : to Liver

Liver: VLDL and LDL : for cell structure / energy / synthetic subsrate

HDL back to liver (reverse cholestral transport to the liver so the hight HDL the better)

LDL Cholesteral rich

VLDL and Cholomicrons Trigceride rich Lipoproteins

Question 3

Lipid calculations

Answer 3

VLDL 20% of all triglycerides

LDL = TC - HDL - VLDL

Valid of TG < 400

Friedewald Equation : LDL = TC - HDL - TG/5

Question 4

Familial Hypercholesterolemia

Answer 4

lebanon

French canadians

Jews (lithuanian)

Question 6

Homozygous FH

Answer 6

• 2 mutant alleles
• 1:1 Million
• Characterized by receptor activity:
  
  • negative < 2%
  • defective 2-25 LDLR activity
• Present in childhood - cutaneous, tendinous xanthomas, corneal arcus
• TC > 500
• Tx : STATIN + Ezetimibe + Bile acid sequestrant, Ileal bypass, liver transplant, lipid apheresis

Question 7

Heterozygous FH

Answer 7

• 1:500
• TC, LDL, normal Tg elevated
• Tendinous xanthomas (virtually diagnositic)
  
  • achilles tendon, digit extensor MCP
• R/O hypothyroidis, obstructive liver dz

Question 8

4 S study -

Answer 8

• Intervention Simvastatine 20-40 mg /day
• 35% LDL lowering
• 30% reduction in death compare to placebo

Question 9

AFCAPs - in low risk patients (no prior CAD in the past)

Answer 9

Lovastatin 20-40 mg/day

lowered MI , CAD,

Question 10

Increased Risk of Statin-induced rhabdomyolysis

Answer 10

• Erythromycin
• Cyclosporin
• HIV antiviral inhibitors
• Grapefruit juice
• Combination of lipid therapy
  
  • Niacin
  • Fibrates (gemfibrozil) - f_inofibrate better tolerate_d

Question 11

Optimal LDL

Hearth protection study

Answer 11

3 groups

• CHD
• PVD
• Diabetes

Any high risk no matter where LDL is at will benefit from STATINs (no matter of baseline LDL)

Question 12

Prove it Study:

Answer 12

Pravastatin lowered LDL - 95

Atorvastatin lowered LDL - 70’s

Question 13

If patient is not able to reach the goal

Answer 13

Increasing stating X 2 will lower LDL by 6%

Question 14

Second Agents for LDL lowering

Answer 14

• Plant stanol ester
  
  • Margarines: benecol, take control / modest effect
• Fibrates Modest or no effect mainly TG
• Niacin Lowers LDL but mainly for TG
• Cholesterol uptake
  
  • Colesevelam : 3 tabs bid (bile salts)
  • Cholestyramine not with elevated TG’s
  • Ezetimibe (blocks uptake of cholestral absorption)

EZETIMIBE + STATIN = lowers by 15%

Question 15

Secondary causes of hypertriglyceridemia

Answer 15

1. Nephrotic syndrome
2. Thyroid abnormalities
3. Drugs(thaizides, HRT, BBLK)
4. Diet (excess carbs)
5. Diabetes: Inadequate control
6. ETOH
7. Obesity

Question 16

Does lowering TG and increasing HLD in the absence of change LDL have an impact on CAD?

Answer 16

• VA HIT
  
  • 2500 vets
  • No statins / only Gemfibrozil 600 mg bid
  • Did lower mortality
• However Field study no change on the end point

Question 17

CARDS study

Answer 17

Diabetics - statin is first in line

Atrovastatin ~40% risk reduction

Question 18

AIM HIGH

Answer 18

• Among statin tx patients with established vascular dz and lower HDL the addition of extended release niacin was not of benefit
• Niacin did not reduce composite adverse events

Question 19

CETP inhibitors

Answer 19

Torcetrapid

• increased 60% HDL
• no increase in plagues
• increased CVD events

Question 20

PCSK9 mutations

Answer 20

Associated with protection against CAD but no other abnormalities

Question 21

Apolipoproteing B

Answer 21

• Apo B may be most atherogenic parameter
  
  • LDL of two patient could be the same but one may have more APO B levels (particle levels which means worse)
• Distinguish CHD in pt with hyperTGs
• Highly correlated with nonHDL cholesterol