Hyperlipidemia Flashcards
Leading cause of death in US
CVD
How adherent to statins must you be before you get benefits?
80%
6 months after initiation of statin therapy, adherence rates are 40-65%
What’s the history of statin trials?
Two types of trials:
primary prevention – patients without evidence of CVD
secondary prevention – patients with CVD
Both types demonstrate reductions in mortality and number of cardiovascular events
How do you establish very high risk according to ATPIII guidelines?
Very high risk= established CVD + Major risk factors (especially DM) Severe and poorly controlled risk factors (especially continued smoking) Multiple RFs of the metabolic syndrome Acute coronary syndromes
Definition and Goal/initiation LDL level for high risk
CHD or CHD risk equivalent
LDL goal is 100 (or 70 for very high risk)
If LDL ≥ 100: Initiate TLC and pharmaceutical treatment
Definition and initiation LDL level for moderately high risk
2+ risk factors (10 year risk 10-20%)
130 - lifestyle interventions
If LDL ≥ 160: Initiate pharmaceutical treatment
Definition and initiation LDL level for moderate risk
2+ risk factors (<10% 10 year risk)
130
Definitions and Goal/initiation LDL level for lower risk
0-1 risk factors
If LDL ≥ 160: Initiate TLC (therapeutic lifestyle changes)
If LDL ≥ 190: Initiate pharmaceutical treatment
What are lipids? (differentiate between kinds)
Chylomicrons transport fats from intestinal mucosa to liver
In the liver, the chylomicrons release triglycerides and some cholesterol and become low-density lipoproteins (LDL)
LDL then carries fat and cholesterol to the body’s cells
High density lipoproteins (HDL) carry fat and cholesterol back to the liver for excretion
When oxidized LDL cholesterol gets high, atheroma formation in the walls of arteries occurs, which causes atherosclerosis
HDL cholesterol is able to go and remove cholesterol from the atheroma
Atherogenic cholesterol = LDL, VLDL, IDL
Causes of HLD
Diet Hypothyroidism Nephrotic syndrome Anorexia nervosa Obstructive liver disease Obesity Diabetes mellitus Pregnancy Acute hepatitis Systemic lupus erythematousus AIDS (protease inhibitors)
Dietary sources of cholesterol (differentiate between what kinds of fat, sources, and what kind of cholesterol levels they raise)
monosatured
- olives, olive oil, canola, peanut, cashews, almonds, most nuts; avocados
- lowers LDL, raises HDL
polyunsaturated
- corn, soybean, safflower and cottonseed oil, fish
- lowers LDL, raises HDL
saturated
- whole milk, butter, cheese, and ice cream; red meat; chocolate; coconuts, coconut milk, coconut oil, egg yolks, chicken skin
- raises both LDL and HDL
transfats
- margarines; vegetable shortening; partially hydrogenated vegetable oil; deep-fried chips; many fast foods; most commercial baked goods
- raises LDL
Types of hereditary HLD
Familial Hypercholesterolemia (most common)
Codominant genetic disorder, occurs in heterozygous form
Occurs in 1 in 500 individuals
Mutation in LDL receptor, resulting in elevated levels of LDL at birth and throughout life
High risk for atherosclerosis, tendon xanthomas (75% of patients), tuberous xanthomas and xanthelasmas of eyes.
Familial Combined Hyperlipidemia (increased chol/trigs)
Autosomal dominant
Increased secretions of VLDLs
Dysbetalipoproteinemia
Affects 1 in 10,000
Results in apo E2, a binding-defective form of apoE (which usually plays important role in catabolism of chylomicron and VLDL)
Increased risk for atherosclerosis, peripheral vascular disease
Tuberous xanthomas, striae palmaris
types of tests for lipid levels
Nonfasting lipid panel
measures HDL and total cholesterol
Fasting lipid panel
Measures HDL, total cholesterol and triglycerides
LDL cholesterol is calculated:
LDL cholesterol = total cholesterol – (HDL + triglycerides/5)
ATPIII guidelines of when to check lipids
Beginning at age 20: obtain a fasting (9 to 12 hour) serum lipid profile consisting of total cholesterol, LDL, HDL and triglycerides
Repeat testing every 5 years for acceptable values
USPSTF guidelines for checking lipids
Women aged 45 years and older, and men ages 35 years and older undergo screening with a total and HDL cholesterol every 5 years.
If total cholesterol > 200 or HDL <40, then a fasting panel should be obtained
Cholesterol screening should begin at 20 years in patients with a history of multiple cardiovascular risk factors, diabetes, or family history of either elevated cholester0l levels or premature cardiovascular disease.
Direct evidence regarding benefits and harms of dyslipidemia screening or treatment in younger adults remains unavailable (2016)
ATPIII goals for lipid levels
LDL < 100 →Optimal 100-129 → Near optimal 130-159 → Borderline 160-189→ High ≥ 190 → Very High Total Cholesterol < 200 → Desirable 200-239 → Borderline ≥240 → High HDL < 40 → Low ≥ 60 → High Serum Triglycerides < 150 → normal 150-199 → Borderline 200-499 → High ≥ 500 → Very High
8 JNC risk factors for determining LDL goals
Cigarette smoking
Hypertension (BP ≥140/90 or on anti-hypertensives)
Low HDL cholesterol (< 40 mg/dL)
Family History of premature coronary heart disease (CHD) (CHD in first-degree male relative <55 or CHD in first-degree female relative < 65)
Age (men ≥ 45, women ≥ 55)
High risk/CHD/CHD Risk Equivalent
CHD and CHD Risk Equivalents: Peripheral Vascular/Arterial Disease Cerebral Vascular Accident Diabetes Mellitus MI Stroke Imaging evidence of atherosclerosis AAA Symptomatic CAD
Framingham Heart Study
General Cardiovascular Risk Profile for Use in Primary CareFramingham risk score effective, but only predicts CHD risk (not stroke etc.)
CV diseases share common risk factors
Set out to develop a way to predict risk for all CVD events It builds on prior models by:
Adding HDL
Being based on study with more events
Estimating absolute CV risk
Allows prediction of all CV events
Stroke, CAD, PVD, CHF
who should you do a Framingham Risk Assessment on?
For patients with multiple (2+) risk factors Perform 10-year risk assessment For patients with 0–1 risk factor 10 year risk assessment not required Most patients have 10-year risk <10%
Should you use statin in pts recovering from stroke?
In patients with recent stroke or TIA, treatment with 80 mg atorvastatin significantly reduced recurrent strokes and CV events when compared with placebo
There was a small increase in the incidence of hemorrhagic strokeHigh dose statins (started within 1-6 months) are proven effective
Starting statins in first 12 hours may be effective too—studies ongoing
Avoid stopping statins in pts with acute stroke
Benefit seen for all levels of cholesterol (elevated or not elevated)
How are the new guidelines different from ATPIII?
No longer have therapeutic targets
New risk calculator
Use medications proven to reduce risk, i.e. STATINS
Avoid medications or supplements that may lower cholesterol number, but have no data to decrease CV risk
Focuses on treatment to reduce ASCVD events
Not a comprehensive approach to lipid management
How do new guidelines define ASCVD?
CHD, stroke, PAD
What is the goal of new guidelines?
identify those most likely to benefit from cholesterol-lowering statin therapy
What does “healthy lifestyle” include?
Healthy diet
Regular exercise
No tobacco
Maintain “healthy” weight
Healthy lifestyle recommendations based on ACC/AHA?
Dietary pattern rich in fruit, vegetables, whole grains, fish, low-fat dairy, lean poultry, nuts, legumes, and non-tropical oils consistent with DASH or Mediterranean diet
Restrict: saturated fats, trans fats, sweets, sugars, sugar-sweetened beverages, and sodium
Exercise: aerobic 40 minutes, 3X/week
What are the 4 defined groups that could benefit from a statin under the new guidelines?
- Patients with clinical ASCVD
- LDL greater than 190 mg/dl
- Patients with DM, ages 40-75
- Age 40-75 years that do not meet above criteria, but have a 10 year risk > 7.5%
Who is included in category “Patients with clinical ASCVD” under new guidelines?
CAD or PAD Acute coronary syndromes Coronary of other arterial revascularization Stroke or TIA PVD presumed to be atherosclerotic
What are ways to identify clients with ASCVD?
Heart catheterization Q waves on ECG TEE Coronary CTA Non-invasive: Carotid duplex, UE/LE arterial duplex Peripheral angiography
Who is included under category “LDL greater than 190 mg/dl” in the new guidelines?
One of the few times level of cholesterol mentioned in guideline
For patients with familial hyperlipidemia
They deserve special consideration
Often may start with untreated LDL of 325-400 mg/dl
Who is included in category “Patients with DM, ages 40-75” under the new guidelines?
All have indication for statin
Level of intensity of statin depends on 10 year risk
Who is included in category “4. Age 40-75 years that do not meet above criteria, but have a 10 year risk > 7.5%” in the new guidelines?
10 year and lifetime risk as determined by CV Risk Calculator
Specifically designed for this trial
Downloadable on AHA or ACC site
Not without controversy, as the calculator has never been published or validated
Risk factors used: Sex, age, race, total cholesterol, HDL, Systolic BP, treated for HBP, DM, smoker
http://www.cvriskcalculator.com
What is the new risk calculator for new guidelines?
Pooled cohort risk assessment
What does the Pooled cohort risk assessment equation include?
"Gender" Age Race Total cholesterol HDL Systolic BP "receiving treatment for HTN?" DM Smoker
When should you consider non-statin therapies?
only if: Less than anticipated response to statin, inability to tolerate a less than recommended intensity of statin, or complete statin intolerance
Adherence to lifestyle and statin therapy should be emphasized before addition of non-statin drug
Other factors to consider when deciding how to manage HLD
Family history of premature CAD
LDL > 160 mg/dl
Increased CRP greater than 2.0 (high sensitivity)
Coronary calcium greater than 300 (correlates to atherosclerotic plaques)
ABI < 0.9
What should you do about statin intolerance?
What is statin intolerance?
Readdress lifestyle issues
Decrease dose of statin
Try another statin
Check Vitamin D levels and replace
Evaluate for other conditions causing muscle weakness
What is a high intensity statin?
High: defined as > 50% reduction of LDL with daily statin
All patients with CAD, regardless of age, should receive high intensity statin therapy if tolerated
High dose atorvastatin
What is a moderate intensity statin?
Moderate: 30-50% reduction
simvastatin
How do you treat a person with LDL > 190?
These patients get high intensity statin treatment
If they cannot tolerate high intensity statin therapy, use Zetia or other agent to achieve >50% reduction of baseline LDL.
Patients with FH are frequently unable to achieve previous goals even with multiple cholesterol lowering agents
In this special case, the authors felt that data has shown significant reductions of ASCVD by decreasing LDL > 50%
Can include statin plus another agent
How do you treat a person with DM age 40-75?
Diabetics with > 7.5% 10 year risk get high intensity statin therapy
Diabetics with < 7.5% 10 year risk of CAD get moderate intensity statin therapy
Statin indicated in all patients with diabetes
How do you treat a person with Non-diabetic with known CAD >7.5% 10 year risk?
Statin indicated in these patients
Moderate to high intensity statin therapy recommended
In what higher risk conditions are there no new guidelines?
No indication for starting or discontinuing statins in the following: NYHA class 2-4 Or those on dialysis HIV patients Solid organ transplant patients Older adults >79 years
What are some statin safety recommendations?
Select the appropriate dose
Keep potential side effects and drug-drug interaction in mind (Grade A)
If high or moderate intensity statin not tolerated, use the maximum tolerated dose instead
Check baseline ALT prior initiating the statin (Grade B)
Check LFTs if patient develops symptoms of hepatic dysfunction (Grade E)
If 2 consecutive LDL <40, consider decreasing the statin dose (Grade C, weak recommendation)
It may be harmful to initiate simvastatin 80mg, or increase the dose of simvastatin to 80mg (Grade B)
What are injectable statins?
Repatha and Praluent every other week injections
Approved for patients with heterozygous familial hypercholesterolemia and rarer homozygous form of disease OR patients with CV disease who require additional cholesterol lowering
$$$$$: $14,560/year
More potent than Lipitor
Not known if use will translate into reduced number of heart attacks
