Hyperlipidemia Flashcards
With ATP III, what is the primary target of cholesterol lowering therapy?
LDL
According to ATP III, what are the screening recommendations?
According to 2013 ACC/AHA, what are the screening recommendations?
ATP III: all adults 20+ 9-12 hr fasting lipoprotein profile every 5 years
2013 ACC/AHA: every 4-6 years from age 20-79 + new risk calculator at same interval starting at age 40
ATP classification of LDL, total, and HDL cholesterol
LDL: <100 optimal
100-129 near optimal
130-159 borderline high
160-189 high
>190 very high
Total cholesterol: <200 desirable
200-239 borderline high
>240 high
HDL: <40 low, >60 high
ATP III steps 1 through 9
STEP 1: Determine lipoprotein levels - obtain complete lipoprotein profile after 9- to 12-hour fast
STEP 2: Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD) events (CHD risk equivalent)
STEP 3: Determine presence of major risk factors (other than LDL)
STEP 4: If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk
STEP 5: Determine risk category
STEP 6: Initiate therapeutic lifestyle changes (TLC) if LDL is above goal
STEP 7: Consider adding drug therapy if LDL exceeds levels shown in Step 5 table
STEP 8: Identify metabolic syndrome and treat, if present, after 3 months of TLC
STEP 9: Treat elevated triglycerides
What are the required steps for assessment in ATP III? (steps 2-3 and possibly 4)
Required steps for assessment for 2013 ACC/AHA?
ATPIII:
Step 2: Assess if high risk coronary heart disease equivalents are pressent:
- clinical CHD
- symptomatic carotid artery disease
- peripheral arterial disease
- AAA
- diabetes
Step 3: assess major risk factors
- cigarette smoking
- hypertension (bp 140/90 + or on antihypertensive med)
- low HDL
- family history of premature CHD in first degree male relaive <55 or female <65
- age (men >45, women >55)
Step 4: if 2+ major risk factors other than LDL are present (with or without CHD risk equivalent), then assess the 10 year CHD risk using Framingham tables (based on age, total cholesterol, smoking status, HDL, bp)
2013 ACC/AHA: 10 year CV risk calculator
What are the cholesterol goals and cutoff points for therapeutic lifestyle changes and drug therapy in different risk categories acording to ATP III?
CHD or CHD Risk Equivalents (10 year risk factor >20%)
- goal is <100 mg/dL
- initiate TLC if LDL above 100
- Consider drug therapy if LDL >130
2+ risk factors (10 year risk <20%)
- goal is LDL <130
- initiate TLC if LDL >130
- consider drug therapy if (1) 10 year risk 10-20% start meds when LDL <130 or (2) 10 year risk is <10% wait until LDL >160
If 0-1 risk factors
- goal LDL is <160
- start TLC if LDL >160
- Consider drug therapy if LDL >190 mg/dl
What are the 2013 ACC/AHA recommendations for cholesterol reducing therapy?
Treat if patient is in one of the 4 statin benefit groups:
- Grade A recommendation: individuals with clinical ASCVD
- Grade B: individuals with primary elevations of LDL-C > 190
- Grade E: individuals 40-75 with diabetes with LDL 70-189
- moderate intensity statin
- high intensity statin if 10 yr ASCVD risk >7.5 - Individuals without clinical ASCVD or diabetes age 40-75 with LDL 70-189 and 10 yr ASCVD risk of 7.5%
- moderate to high intesnity statin
* No rec’s on dialysis and CHD
** Individualized treatment in pt with diabetes <40 or >75 based on ASCVD risk reduction benefits, potential for adverse SE, and drug drug interactions
Which groups did the 2013 guidelines not address in terms of whether to initiate statin therapy?
CHF class II, III, or iV
Need for hemodialysis
Due to insufficient RCT therapy
What are the therapeutic lifestyle changes? Outlined in ATPII but also recommended in 2013 guidelines
- Saturated fat <7% of calories, cholesterol <200 mg/day. Strength of recommendation: Strong
- Follow a dietary pattern that emphasizes intake of vegetables, fruits and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limit intake of sweets, sugar-sweetened beverages and red meats (DASH diet, USDA Food Pattern, or AHA diet). Strength of recommendation: Strong
- Reduce percent of calories from saturated fat. Strength of recommendation: Strong
- Reduce percent of calories from trans fat. Strength of recommendation: Strong
- Increased aerobic activity: 3-4 sessions per week or moderate- to vigorous intensity activity lasting at least 40 minutes/session. Strength of recommendation: Moderate
- Weight management (considered cornerstone of lifestyle changes in ATP III and 2013 ACC/AHA guidelines; Strength of recommendation: not evaluated)
- Consider increased viscous (soluable) fiber (10-25 g/day) and plant sterols (2 g/day) as therapeutic optiosn to enhance LDL lowering (not evaluated in 2013 guidelines)
Low, medium, and high intensity statin therapy recommendations
High: 50% lowering of LDL
- atorvastatin 40 mg
Moderate: 30-<50% LDL lowering
- atorvastatin 10 mg
- simvastatin 20-40 mg
- pravastatin 40 mg
- lovastatin 40 mg
Low: <30% LDL lowering
- pravastatin 10-20 mg
- lovastatin 20 mg
Statin: mechanism, effect on lipids, SE, contraindications, results of clinical trials
HMG-CoA reductase inhibitors
Lipid/lipoprotein effects: lower LDL 18-55%, increase HDL 5-15%, lower TG up to 30%
SE: myopathy, increased liver enzymes
Contraindicaitons: active/chronic liver dz; avoid mixing with grapefruit juice; watch out for drug drug interactions
Clinical trials show reduce major coronary events, CHD, deaths, need for coronary procedure, stroke, total mortality
Bile acid sequestrants: SE, contraindications, results
SE: Gi distress, decreased absorption of other drugs
Contrindications: dysbetalipoproteinemia, TG>400
Reduces major coronary events and CHD deaths
Nicotinic acid: SE, contraindications, results
(Niacin)
SE: Flushing; hyperglycemia; hyperuricemia (or gout); upper gastrointestinal distress; hepatotoxicity
Contraindicatoins:
Absolute: chronic liver disease; severe gout
Relative: diabetes; hyperuricemia; peptic ulcer disease
Results:Reduced major coronary events, and possibility total mortality
Fibric acids: SE, contraindications, results
SE: Dyspepsia; gallstones; myopathy; unexplained non-CHD deaths in WHO study
Contraindications: Absolute: severe renal disease; severe hepatic disease
Results: Reduced major coronary events
Ezetimibe
New drug, inhibits intestinal absorption of cholesterol and phytosterols
Used as adjunct to statin
Really lowers LDL and CRP when used with a statin BUT in patients with familial hypercholesterolemia, combined therapy with ezetimibe and simvastatin did not result in a significant difference in changes in intima media thickness, as compared with simvastatin alone
