Hyperlipidemia and HTN Flashcards
Most cholesterol is made in
Liver
LDLs do what?
Carry cholesterol from the Liver (where it’s made) to the body’s cells
HDL’s job
collect chol from bodys tissues and return it to the Liver
Chylomicrons
carry lipids from DIET
VLDLs carry
Triglycerides
Familial Hypercholesterolemia conditions
Tx w Statin
Secondary Hyperlipidemia
Risk factors
DM Exc Alcohol Smoking Obesity Hypothyroid CKD Liver dz Meds
What is more common- Secondary Hyperlipidemia or Inherited/genetic Hyperlipidemia?
Inherited
When to screen for High cholesterol?
9-11 YO
and again at
17-21 YO
When to screen lipids
age 9
age 17
Coronary Heart Dz Risk factors
HTN >140/90 DM Tobacco use Obese Hyperlipidemia HDL <40
What is affected more by eating: cholesterol or Triglycerides?
Trig way more, and since they are taken at the same time, this is why the labs are supposed to be FASTING
Total cholesterol includes
HDL + LDL + Trig/5
Cholesterol, LDL, and HDL levels can be falsely low after what?
MI
Acute coronary event
Desirable LDL level
60-130
many sources say <100
Normal LDL level
<100
Desirable Total Cholesterol
<200
Desirable HDL level
> 60
Normal HDL level for female
> 50 (or equal to)
Normal HDL level for male
> 40 (or equal to)
Approach to Lipid mgmt
Diet
Exercise
Meds
Diet for Elevated Lipids:
DASH
“Dietary approaches to stop HTN”
Rich fruits and veggies Moderate in low fat dairy Low animal protein Plant source of protein Low sodium
Benefits of DASH diet
Decrease BP
Decrease LDL
Decrease risk of CHD and Stroke
Exercise can increase HDL levels
3-4 sessions/week
40 min of mod-vigorous
What are Statins
HMG Co-A reductase inhibitors
How do Statins work
Stabilize vulnerable plaques and reduce underlying inflammation
Statin mechanism
Stop HMG-Co A Reductase enzyme from working in the Liver
This is the Rate limiting step in Cholesterol production
When should pts take Statins
Bedtime
SE/ risk of Statins
Liver toxic
Mild GI
Myalgia, Myositis, Myopathy –> RHABDO!!!!
muscle stuff
CONTRA to giving Statins
Pregnant
Active Liver dz
What labs do you need to take before starting a Statin?
Lipid panel
LFT (live fx)
Creatine kinase
How often to get labs after starting Statins?
every 4-12 wks at first
What Lipid med is Safe during Pregnancy
Bile Acid Seq
Synergistic w Statin
Bile Acid Seq
What is the bad thing about Bile Acid Seq?
Can increase Triglycerides
DO NOT USE if Trig are already >400, and caution use if they are >200
Niacin
increase HDl
SE: Flushing, liver damage, not rec to use w statin
Fibric Acid Derivative
- Gemfibrozil
- Fenofibrate
- Bezafibrate
Best known for LOWERING TRIGLYCERIDES
raise HDL
Meds that affect Triglycerides
Fibric Acid: good bc they LOWER triglycerides
Bile Acid: bad bc they can increase triglycerides
Fibric Acid Deriv
contra
Pre-existing Gallstones
Don’t use w other statin, Myopathy risk (muscle)
Ezetimibe
Block absorption of cholesterol
ADJUNCT for Statin
Contra to Ezetimibe
Active Liver dz
Pregnancy
PCSK9 Inhib
- Evolocumab
- Alirocumab
EXPENSIVE, requires injections
but very effective at lowering LDL, increasing role as Adjunct tx to Statins
Things that can be used ADJUNCT as Statin Add-on
Bile Acid seq
Ezetimibe
PCSK9 inhib
Cholestyramine
Colesevelam
Colestipol
are all:
Bile Acid seq
aka Resins
Safe in pregnancy
Cholestyramine
Colesevelam
Colestipol
(bile acid seq/ resins)
Bad things about Bile Acid Seq
Mess w Warfarin tx
Increase Triglyceride levels
Bad thing about Bile Acid Seq
- Cholestyramine
- Colesevelam
- Colestipol
Warfarin
Triglycerides
Evolocumab
Alirocumab
PCSK9 inhibitors
Good adjunct
but expensive
injections
NOT recommended to use with Statins
Niacin
Fibrates
What med is good to use if pt has High Triglycerides?
Fibrates
- Gemfibrozil
- Fenofibrate
- Bezafibrate
best at lowering trig
Which med increases HDL
Nicotinic ACid (Niacin)
Absolute CONTRA to taking Fibric Acid Deriv
Gemfibrozil, Fenofibrate, Bezafibrate
Taking Simvastatin
What two drugs can mess with Warfarin use
Bile acid Seq (“chol”)
Fibric acid deriv (“gemfibrozil, fenofibrate, bezafibrate”) - relative contra
4 Statin benefit groups.. aka Who should be on a Statin?
Clinical ASCVD
LDL>190
DM age 40-75 with LDL >70
Don’t have ASVCD or DM but LDL 70-189 and 10 year risk >7.5%
What is a “High intensity Statin” regimen?
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
What conditions are considered Clinical ASCVD?
Acute coronary synd
Hx of heart attack
Sx PAD
Stroke/TIA
4 Statin Benefit groups
Clinical ASCVD
LDL >190
DM 40-75 yo w LDL >70
Regular dude with LDL 70-189 but 10 yr risk >7.5%
Use with Statin
Bile acid seq “chol”
Ezetimibe
PCSK9 “umab”
PCSK9 inhib
Evolocumab
Aliocumab
Tx used to lower Triglycerides
GemFIBrozil
FenoFIBrate
BezaFIBrate
(fibric acid derivatives)
Med used to increase the healthy HDL
Niacin acid “Niacin”
Person is 40-75 YO and has Diabetes, what level would be an indication to start Statin?
LDL >70
What LDL level alone means person needs statin?
> 190
Person doesn’t have ASCVD or DM, but they have these levels —-> need Statin
ASCVD risk >7.5%
LDL >70
Stage 1 HTN
130-140 OR
80-89
only need one of those parameters
Anytime diastolic is over 80
you are in one of the classifications of HTN
Stage 2 HTN
> 140
OR
90
Primary HTN is the majority
Risk factors:
Smoking Eating unhealthily Excess alcohol Obesity Sedentary Dyslipidemia
Secondary HTN
meaning it’s d/t another condition like:
Kidney dz Atherosclerosis OSA Thyroid dz Coarc of Aorta (narrowing) Hyperaldosterone Cushings Pheo Med induced
When to start screening for HTN
18 YO
no risk factors- annual
risk factors- semi-annual
Gold standard to confirm HTN (out of office)
ABPM
Ambulatory Blood Pressure Monitor
Lifestyle mgmt for HTN
Lower sodium DASH diet Alcohol reduction Exercise 3-4x/week Healthy weight Stop smoking
4 first line medications for HTN
ACE-I
ARBs
Thiazide diuretics
CCBs
What is considered Resistant HTN?
Still not controlled with 3 meds
OR
Requiring 4 meds
Threshold goal for most people with HTN
<130/80
CONTRA to prescribing Thiazide and Loop diuretics
Allergy/hypersensitive to Sulfa
SE of ACE-I
“prils”
cough
hyperkalemia
ANGIOEDEMA
acute kidney failure
CONTRA to ACE-I
Pregnant
Angioedema
Kidney artery stenosis
Can you combine ACE-I and ARBs?
NO
too hard on the kidney
ARBs
“sartans”
CONTRA
pregnant
Kidney artery stenosis
CCBs broken down into 2 groups
Non-dihydro
- Verapamil
- Diltiazem
Dihydro
- Amlodipine
- Felodipine
- Isradipine
- Nicardipine
- Nifedipine
- Nisoldipine
Verapamil and Diltiazem are Non-Dihydro, meaning
More of a cardiac depressant effect
Dihydro CCBs have more of a
Vasodilator effect
less cardiac
Best tx for HTN post MI
ACE-I
B blocker
When you see ___dipines, it is a
CCB, Dihydro type meaning it has a more vasodilatory effect
CCBs with more of a Cardiac effect (Non-dihydro)
Verapamil
Diltiazem (Cardizem)
When to avoid Non-dihydro CCBs (more cardiac effect ones)
With B-blocker use
HFrEF
Avoid all CCBs in
HFrEF
Cardioselective B-blockers are those that are
B1 receptors
HTN and BPH
a1 blockers
African American with HTN
Thiazide
CCBs
HTN in HF pts
ACE-I
ARB
B-blocker
Diuretic
basically, just don’t use CCBs
B-blocker CONTRA
ASTHMA
bronchospastic dz
conduction abn
acute decomp of CHF
What to use if Pregnant
Methylodopa
Also, B-blockers are often used in pregnancy
Alpha blockers to use if BPH and HTN
Prazosin (minipress)
Terazosin
Doxazosin
What to use if you have Gout and HTN
CCBs or Losartan (the only ARB that doesnt inc uric acid)
Avoid abrupt cessation of
B-blockers
Methyldopa
(both of these are the ones used in pregnancy also)
HTN Urgency
DIASTOLIC (the bottom number) is >120
no evidence of end organ damage
HTN EMERGENCY!!
Diastolic >120 WITH evidence of end organ damage
BP reduction goal in HTN Urgency (no end organ damage)
reduce to <160/120 over hours to days
rest in quiet room increase current meds add another med Na restriction Make sure not to overcorrect
HTN EMERGENCY!! signs of end organ damage
ICU admission
Address underlying cause
Reduce BP no more than 25% in min-hour
160/110 over 2-6 hours
If stable, decrease to normal BP in 1-2 days
What to use in HTN emergency
IV Nitrate
CCB
Adrenergic blockers
Hydralazine
CONTRA in HTN emergency
Sublingual Nifedipine (CCB) can cause ACS
Orthostatic Hypotension
Supine for 5 min
Then stand
> 20 fall in systolic
10 fall in diastolic
Causes of Orthostatic Hypotension
Parkinson
DM
Volume depletion- dehydrated d/t vomiting, hemorrhage, etc
Meds (too much Anti-HTN meds in elderly)
What to consider ordering if pt has Orthostatic Hypotension
CBC
CMP
EKG
detailed history
review med list
neuro hx/exam
Often one of the first signs of shock
HYPOTENSION, low BP
