Harrison's 241 & 242 Atherosclerosis

Question 1

Among the most firmly established & best understood risk factors for atherosclerosis:

Answer 1

Abnormalities in plasma lipoproteins & derangements in lipid metabolism!

Question 2

The intensity of treatment for lipid disorders is determined by…

Answer 2

…an individual’s risk!

Question 3

What is the first step to achieving LDL goals?

Answer 3

TLC, or therapeutic lifestyle changes! Specific diet & exercise recommendations established by guidelines

Question 4

Is aggressive LDL management worth it?

Answer 4

YES! An extensive & growing body of rigorous evidence now supports the effectiveness of aggressive management of LDL.

Question 5

Very simple: lowering lipids…

Answer 5

…reduces coronary events!

Question 6

Most patients with diabetes die of…

Answer 6

…atherosclerosis & its complications.

Question 7

What ultimately causes the gravest complications of atherosclerosis?

Answer 7

THROMBOSIS.

Question 8

List some MAJOR risk factors that modify LDL goals in a patient

Answer 8

#Smoking
#Hypertension (>140/90 or on anti-hypertensive)
#Low HDL (< 40 mg/dL)
#Diabetes
#Family hx of premature CHD (male 1º relative <65 yr)
#Age (men ≥ 45, women ≥ 55)
#Obesity
#Physical inactivity
#Atherogenic diet

Question 9

List some EMERGING risk factors that modify LDL goals in a patient

Answer 9

#Lipoprotien(a)
#Homocysteine
#Prothrombotic factors
#Proinflammatory factors
#Impaired fasting glucose
#Subclinical atherosclerosis

Question 10

What are the LDL cholesterol goals for very high risk patients (known ACS, CHD w/ DM, or multiple risk factors)?

Answer 10

Goal < 1.8 (< 70)
Initiate TLC: ≥70
Consider drug therapy: ≥ 70

Question 11

What are the LDL cholesterol goals for high risk patients ( CHD or CHD risk equivalents, 10 yr risk > 20%)?

Answer 11

Goal: < 2.6 (< 100)
Initiate TLC: ≥ 100
Consider drug therapy: ≥ 100
If LDL in these patients is < 100, may consider optional goal of 70

Question 12

What are the LDL cholesterol goals for moderately high risk patients (2+ risk factors; 10 yr risk 10-20%)?

Answer 12

Goal < 2.6 (< 100)
Initiate TLC: ≥ 130
Consider drug therapy ≥ 130

Question 13

What are the LDL cholesterol goals for moderate risk factor patients (2+ risk factors, risk < 10%)?

Answer 13

Goal < 3.4 (< 130)
Initiate TLC: ≥ 130
Consider drug therapy: ≥ 160

Question 14

What are the LDL cholesterol goals for low risk patients (none or 1 risk factor)?

Answer 14

Goal < 4.1 ( < 160)
Initiate TLC: ≥ 160
Consider drug therapy: ≥ 190

Question 15

What are the defining factors of metabolic syndrome?

Answer 15

#Abdominal obesity
#Triglycerides ( > 150)
#HDL Cholesterol (< 40 in men, < 50 in women)
#Blood pressure ≥130/≥85
#Fasting glucose > 110

Question 16

Desirable total cholesterol range

Answer 16

≤ 200 mg/dL

Question 17

Borderline high total cholesterol range

Answer 17

200-239 mg/dL

Question 18

High total cholesterol range

Answer 18

≥ 240 mg/dL

Question 19

Normal triglyceride level

Answer 19

< 150 mg/dL

Question 20

Borderline high triglyceride level

Answer 20

150-199 mg/dL

Question 21

High triglyceride level

Answer 21

200-499 mg/dL

Question 22

Very high triglyceride level

Answer 22

≥ 500 mg/dL

Question 23

Optimal LDL level (non-specific population)

Answer 23

< 100 mg/dL

Question 24

Near-optimal LDL level (non-specific population)

Answer 24

100-129 mg/dL

Question 25

Borderline high LDL level (non-specific population)

Answer 25

130-159 mg/dL

Question 26

High LDL level (non-specific population)

Answer 26

160-189 mg/dL

Question 27

Very high LDL level (non-specific population)

Answer 27

≥ 190 mg/dL

Question 28

Low HDL levels

Answer 28

≤ 40 mg/dL

Question 29

High HDL levels

Answer 29

≥ 60 mg/dL

Question 30

Which is preferable HDL: high or low?

Answer 30

The higher the better! High HDL counts as a “negative” risk factor, & removes another risk factor from play.

Question 31

What is the role of homocysteine in hyperlipidemia/atherosclerosis risk?

Answer 31

Literature suggests a relationship between hyperhomocysteinemia and coronary events, but have not shown a robust utility of it in risk stratification. (Translation: we think there’s a relationship, but we’re not sure how to quantify it yet!)

Question 32

What diet change has lowered homocysteine levels in the population at large?

Answer 32

The addition of folic acid (originally done to reduce neural tube defects).

Question 33

In what populations should we measure homocysteine levels?

Answer 33

#Patients with atherosclerosis at a young age
#Patients with atherosclerosis out of proportion to established risk factors

Question 34

Treatment with folic acid may mask…

Answer 34

…pernicious anemia.

Question 35

What is the role of C-reactive protein in atherosclerosis risk?

Answer 35

It does add to the predictive value of the Framingham score, but studies do not support a CAUSAL role for CRP in CV disease.

Question 36

C-reactive protein is a _______ but not a _________ to pathogenesis of cardiovascular disease.

Answer 36

validated biomarker but not a direct contributor

Question 37

At what age should cholesterol screening begin?

Answer 37

20

Question 38

What are some contraindications to hyperlipidemia treatment with statins?

Answer 38

#History of liver disease
#Evidence of rhabdomylosis
#Use with caution in patients who consume lots of alcohol

Question 39

Under what circumstances might you treat cholesterol with multiple drugs?

Answer 39

If you reach LDL goals, but triglycerides are still high, clinician may:
#intensify therapy with LDL-lowering drug
#add nicotinic acid or fibrate to further lower VLDL level