Hyperlipidemia 2 Flashcards
Physical exam- Evidence of____:
–VS: elevated BP? BMI? waist circumference?
–Skin: xanthomas, rashes
–HEENT: corneal arcus, lipemia retinalis, AV nicking?
–Neck: thyroid exam, carotid bruits?
–Lung: adventitious sounds?
–Heart/CV: appropriate PMI? extra sounds?
–Abdomen: hepatomegaly? kidney masses? bruits?
–Extremities: pulses, edema, PAD? foot exam (DM)
–Neuro: evidence of prior “event”? DTRs?
Evidence of CVD or secondary causes of hyperlipidemia:
Although pts w/ hyperlipidemia are _____, the following may be seen on physical exam:
–Xanthomatous tendons
–Corneal arcus
–Lipemia retinalis
–Xanthelasma
–Eruptive xanthomas
Asymptomatic
The following are the steps of which guideline?
- Obtain fasting lipid profile (fast x9-12 hrs)
- ID presence of clinical atherosclerotic disease that confers high risk for CHD events (CHD risk equivalent)
- Determine presence of major risk factors (other than LDL)
- If 2+ risk factors present without CHD or CHD risk equivalent, asses 10-year CHD risk (Framingham)
- Determine risk category
- Initiate therapeutic lifestyle changes (TLC) if LDL is above goal
- Consider adding drug therapy if LDL remains above goal
- ID metabolic syndrome and treat, if present, after 3 months of TLC
- Treat elevated triglycerides and low HDL
NCEP ATP III guidelines
The following are CHD equivalents for step 2 of which guidelines?
CHD equivalents:
- Coronary artery disease
- Peripheral arterial disease
- AAA
- DM
ATP III guidelines
Step 2: ID presence of clinical atherosclerotic disease that confers high risk for CHD events (CHD risk equivalent)
What are the 5 major risk factors (other than LDL) for Step 3 of the ATP III guidelines
- Smoking
- HTN
- HDL < 40 mg/dL
- Family history of premature coronary disease
- Men > 45 years and women > 55 years
Step 4 of ATP III Guidelines states: If 2+ risk factors present without CHD or CHD risk equivalent, assess 10-year CHD risk (Framingham tables):
>____%= CHD risk equivalent
> 20% - CHD risk equivalent
ATP III guidelines step 5 (determine risk category): What is the LDL goal for the following risk categories:
CHD or CHD risk equivalents (10 yr risk >20%)
2+ risk factors (10 yr risk <20%)
CHD or CHD risk equivalents (10 yr risk >20%)= <70 mg/dL
2+ risk factors (10 yr risk <20%)= <100 mg/dL
The following recommendations are described as what and are recommended when?
- AHA low fat diet, < 30% total calories from fat
- Saturated fat < 7% of daily calories
- Fish 2 x per week
- Dietary cholesterol intake < 200 mg/day
- Increased viscous (soluble) fiber – 10-25 g/day
- Add plant stanols/sterols – 2 g/day
- Maximizing TLC can reduce LDL 25-30%
- Aggressive weight management
- Increased physical activity – 30 minutes most days
Therapeutic Lifestyle Changes
–> recommended to be initiated in step 6 of ATP III guidelines if LDL is above goal
The following are indications of what therapy if LDL remains above goal:
Indications:
–Simultaneously with TLC for CHD and CHD equivalents
–If LDL levels high after 3 months of TLC
Step 7 of ATP III guidelines-
Consider adding DRUG therapy if LDL remains above goal
3 or more of the following are risk factors of what condition?
- Abdominal obesity
- Waist circumference > 40” in men
- Waist circumference > 35” in women
- Triglycerides > 150 mg/dL
- Low HDL
- < 40 mg/dL in men
- < 50 mg/dL in women
- Increased blood pressure (>130/>85 mmHg)
- Impaired fasting glucose is > 100 mg/dL
Metabolic syndrome
Step 8 of ATP III guidelines: ID metabolic syndrome and treat, if present, after 3 months of TLC
What waist circumfrence in men vs. women is considered a risk factor for metabolic syndrome
Men= >40”
Women= >35”
What HDL levels in men vs women are considered risk factors for metabolic syndrome?
LOW HDL:
Men= <40mg
Women= <50mg
What BP is considered a risk factor of metabolic syndrome
>130/>85
What fasting glucose reading is considered a risk factor of metabolic syndrome?
>100
In step 9 of ATPIII guidelines, the primary aim of drug therapy is to reach_____ goal
LDL
*Want to first reach LDL goal and can use intensive TLC to increase HDL
What can be recommended to intensify TLC in order to increase HDL in step 9 of ATP III guidelines?
(step 9= tx elevated TG and low HDL)
–Remember exercise?
–Increase Monounsaturated fats
–Smoking cessation
–Moderate EtOH use (1-2 drinks/day)
In step 9 of ATP III guidelines, what do you do if TG is >200 mg/dL?
–Maximize statin therapy, then
–Consider Rx with non-statins
The following are major ASCVD events for which guidelines:
- Acute coronary syndrome (within past 12 months)
- Hx of MI
- Hx of ischemic stroke
- Symptomatic PAD
- Claudication with ABI < 0.85
- Previous revascularization surgery
- Amputation
ACC/AHA guidelines
According to ACC/AHA guidelines, what classifies as symptomatic PAD (a major ASCVD event)?
- Claudication with ABI < 0.85
- Previous revascularization surgery
- Amputation
What 2 meds are considered high-intensity statins?
Atorvastatin (40mg) 80mg
Rosuvastatin 20 (40mg)
These lower LDL by greater than or equal to 50%
How much do high-intensity statins lower LDL by?
greater than or equal to 50%
What are instensity are the following statins:
Atorvastatin 10mg (20mg)
Rosuvastatin (5mg) 10mg
Simvastatin 20-40mg
Pravastatin 40mg (80mg)
Lovastatin 40mg (80mg)
Fluvastatin XL (80mg)
Fluvastatin 40mg BID
Pitavastatin 1-4mg
Moderate-intensity
These lower LDL by 30-49%
The following statins are considered what level of intensity and lower LDL by <30%:
Simvastatin 10mg
Pravastatin 10-20mg
Lovastatin 20mg
Fluvastatin 20-40mg
Low instensity statins
How much do low intensity statins lower LDL by?
<30%
