hyperlipidemia module Flashcards
what is the leading cause of death in the US?
heart disease
what is the healthy people 2020 objective with regards to high blood cholesterol screening?
that 82.1% of adults will have been screened in the past 5 years
who should be screened for hyperlipidemia?
all males aged 35+, all femaales aged 45+
what is a borderline high LDL level?
130-159
what is an optimal LDL level?
<100
what is a high LDL level?
160-189
what is a very high LDL level?
> 190
what is the primary contributor to hypercholesterolemia?
LDL cholesterol
what is the maximum LDL level is they have 2 risk factors?
100-129
what is the maximum LDL if they have 0-1 risk factor?
130-159
what is the first sign of heart disease in 25% of people?
sudden death
what % of people with sudden heart attack have no family history of heart disease?
50%
what are secondary causes of lipid disorders?
diabetes, obesity, liver/kidney disease, other medications
what type of diet is recommended in TLC?
mediterranean diet-fish, nuts, olive oil, high fiber low fat
avoid high saturated fat-have lean protein
5 servings fruits/vegetables in day
are high protein low carb diets recommended?
no-cuts out high fiber, hard to maintain weight loss with this diet and hard to keep up
what is food sequencing?
eat food with high fiber and a lot of water-feel full longer
how much exercise is recommended?
at least 30 min aerobic exercise about 5-7 times a week, can be in intervals
what is the biggest reason people have unhealthy diets?
lack of knowledge, convenince
what is the best way to make sure pts stick to new healthy diet?
set up regular and frequent contacts, chek in with pts regularly by person or phone, refer to nutritionist or diet group or exercise program, help pt set realistic goals, do not have to achieve ideal body weight-even small amount of loss is good,
give them positive reinforcement, stick with them
what is the metabolic syndrome?
cluster of risk factors
secondary treatment target after lowering LDL, smoking increases risk of CHD in people with metabolic syndrome
what are the three things we can tell pts to focus on with metabolic syndrome?
diet
exercise
lipid medication
what are the major classes of hyperlipidemia medication and how do they each work?
statins: affect cholesterol production to lower LDL and triglycerides and increase LDL receptor production, first line of treatment in pts with high LDL
niacin: lower triglyceride and increase HDL, first line in pts with high triglycerides, most potent in terms of raising HDL
cholesterol absorption inhibitors: reduce absorption of dietary cholesterol and block reabsorption of cholesterol secreted in the bile, lower LDL
what are good cholesterol food groups?
oat bran, psyllium, nuts and soy products
how common is familial hyperchoelsterolemia?
1/500 americans have it
20% have a heart event by age 30
what should be done when a high risk familial hypercholesterolemic pt is identified?
all family members should be screened, including children
What is a rare side effect of statin? what can be done if a pt is having these symptoms?
muscle aches-(also can be due to diuretics) check
myaligias and arthraligia will reverse with lower dose
-alleviate by:
-lower dose and add ezetimide or bile acid resin
-dietary supplement: sterol marginine, nuts dietary fiber
-switch to another statin
-bile acid reabsorption blocker
what can make hypertriglyceridemia worse?
hormone replacement therapy (can also increase risk of cancer)
what is gemfirbrizil?
a fibric acid
thers-fenofibrate, clofibrate
What are the summary points from the ACC/AHA 2013 guidelines?
- there is no evidence to support titrating statins to reach a specific LDL
- 4 subgroups of patients benefit from a fixed dose, high intensity statin therapy, but do not beenfit from targeting a depcific therapy (CD< LDL>190, DM1 and DM2 40-75 with LDL, 10 year CVD risk >7.5%),
- there is insufficient evidence for or against statin in three subgroups: age 75+ (unless CVD), need for hemodialysis, NYHA class II, III IV heart failure
- there is no evidence base to recommend any treatment for cholesterol other than statins
what are the 4 subgroups that ACC/AHA guidelines recommend treating wit ha fixed, high dose statin therapy?
- clinically evident cardiovascular disease (ie not incidentally discovered on CT)
- LDL over 190
- DM1, DM2 age 40-75 with LDL
- 10 year cardiovascular risk of >7.5 (controversial)
which 3 groups does the ACC/AHA guidelines state there is insufficient evidence for or against statin therapy?
- age >75 years (unless clinical CVD)
- need for hemodialysis
- NYHA Class II, III, IV heart failure
what is LDL monitoring used for according to ACC/AHA guidelines?
to assess treatment adherence, and/or assess for the expected % drop in LDL level
NOT to assess treatment success in reaching a target LDL level
what is the primary target of cholesterol lowering therapy identified by ATP III?
LDL-bc is a major cause of coronary heart disease
how is ATP different in terms of treatment goals?
specfic target levels of cholesterol are made based on pts absolute risk and therapy is adjusted based on levels,
-risk is LDL levels, cardiovascualr risk facotrs and coronary heart disease, treatment is intensified until the target levels have been reached
what is ATP III mainly based on? ACC/AHA?
expert opinion for ATP III
RCTS and expert opnion for ACC/AHA
how do ATP II and ACC/AHA risk assessment differ?
both take LDL cholesterol and other accompanying cardiovascualr risk facotrs into account BUT
ATP III focuses on coronary heart disease and
ACC/AHA broadens this to include stroke
-Acc/AHA does not recommend monitoring of lipids
what are screening recommendations for ATP III? ACC/AHA?
ATP III: all adults 20+, fasting lipoprotein profile every 5 years
ACC/AHA: risk factor assessment (like ATP III) every 4-6 yers from 20-79, ACC risk calculator at the same time interval starting at age 40
what are the LDL goals of ATP III? ACC/AHA LDL goals?
LDL: 190 very high
total cholesterol: 240 high
HDL: 60 high
the ACC/AHA guidelines do not provide guidance on targets or definitions of cholesterol levels-the focus has shifted from absolute LDL level targets to expected percent LDL reduction with statins
what does the USPSTF have to say about screening for lipids?
strongly recommends:
men aged 35+
20-35 if they are at increased risk for coronary heart disease
-women aged 45+
20-45 if they are at increased risk for coronary heart disease
-unclear about optimal interval screening
How is 10 year cardiovascular risk assessed in ATP III?
step 2: assess high risk coronary heart disease equivalents atheroscleotic disease equivalents that confer high risk for coronary heart disease -clinical CHD -symptomatic carotid artery disease -peripheral arterial disease -AAA -diabetes step 3: assessment of major risk factors -cigarette smoking -HTN BP>140/90 or on meds -low HDL -family history of premature CHD -age men>45 women>55
How does ACC/AHA asses cardiovascular risk?
10 year cardiovascular risk calculator including
-gender, BP, meds for BP, total chol, HDL, DB, smoking,
how do ACC/AHA and ATP III differ in calculating 10 year cardiovasular risk?
AAA and DIabetes not included in ACC/AHA
CAD, CHD, cerebrovascular disease (Stroke) and PAD are together referrred to as ASCVD in ACC/AHA
what is the 4th step of ATP?
if 2+ risk facotrs present with or without CHD equivalents (clincal CHD, PAD, AAA, DIabetes) assess 10 year CHD risk using framingham tables,
how does ACC/AHA assess 10 year CVD risk?
in all pts, not necessarily only in those with 2+ risk facotrs
what do the levels of 10 year risk in ATP mean?
ie >20% means 20 out of 100 individuals will develop coronary heart disease or a coronary event within 10 years
what is the last step in ATP III methodology?
determine risk category by
- establishing LDL goal of therapy
- determining need fot TLC
- determining level for drug consideration
what is the method of determining treatment in ACC/AHA?
cardiovascualr risk should drive choice of statin therapy offered
-no recommendations for or against specific LDL or non HDL targets for either primary or secondary prevention of ASCVD
(no RCTS available to indicate)
-idenity pts in one of the 4 statin benefit groups
what are the 4 statin benefit groups according to ACC/AHA?
1) individuals with ASCVD: A recommendation
2) individuals with LDL >190: B recommendation
3) individuals 40-75 with diabetes with LDL 70-189, moderate intensity statin unless 10 year ASCVD risk >7.d%, then high intensity statin: grade E recommendation (Expert opinion)
4) individuals w/o clinical ASCVD or diabetes who are 40-75 years of age with LDL 70-189 and an estimated 10 year ASCVD risk of 7.5% or higher grade A recommendation
-do not provede recommendations for initiation of statin therapy in pts with CHF or need for hemodialysis due to insufficient RCT evidence
which guideline recommends initiating a heart healthy lifestyle?
Both ATP II and ACC/AHA
TLC in ATP III
what is the recommendation regarding exercise?
increase aerobic activity 3-4 times a week for 40 minutes
-recommendation is moderate
where should most calories come from according to TLC?
carbohydrate
least amount of calories from saturated fat
what are the different categories of statins?
high (lowers >50%): atorvastatin >40mg
moderate (lowers <30%): pravastatin 10-20mg, lovastatin 20mg
what are the side effects of statins? (HMG CoA reductase inhibitors) contraindications?
affect HDL, LDL and reduce Tgs
side effects: myopathy, increased liver enzymes
contraindications: absolute: active or chronic liver disease, avoid mixing with grapefruit juice,
what are bile acid sequestrants? side effects/contraindications
(cholestyramine, colestipol, colesevelam)
reduce LDL by 15-30%, increase HDL by 3-5% and do not change TG
- side effects: GI, constipation, decreased absorption of other drugs
contraindications: dysbetalipoproteinemia, TG >400
relative: tg>200
what is the only drug type shoen to reuce stroke?
statins
what does nicotinic acid do to choelsterol? side effects? contraindiciations?
LDL lower by 5-25%
HDL raise by 15-35%
TG lower by 20-50%
side effects: flushing, hyperglycemia, hyperuricemia (gout), upper GI distress, hepatotoxicity
contraindications: chronic liver dz, severe gout
relative: diabetes, hyperuricemia, peptic ulcer disease
what do fibric acids primary improve?
triglycerides
decrease 20-50%,
raise hdl 10-20% and lower LDL 5-20%
what are the side effects/contraindications of fibric acids?
side effects: dyspepsia, gallstones, myopathy, unexplained non CHD in WHO study
contraindications: renal disease, severe hepatic disease
what is ezetimibe? how does it work?
antilipidemic drug,
inhibits the intestinal absorption of choelsterol and related polysterols
, used as an adjunct with statins
are omega 3 fatty acids recommended?
may reduce risk for major coronary events in persons with established CHD (secondary prevention) but more clinical evidence is needed to make recommendation
what is the first line treatment after lifestyle modifications?
statins
what does ATP III recommend when a pt has not reached thier cholesterol goals?
either raise statin or add another drug
which combination therapy is best?
insufficient evidence to recommend any one combination therapy
what are the ACC/AHA guidelines regarding medication therapy?
1-statins ar ethe only evidence based treatment for choelsterol
2-medium or high intensitry fixed dose statin therapy is recommended based on cardiovascular risk (low dose only in the case of tolerability concerns
3-combination drugs are no longer recommended
what is the final step of ATP?
identify metabolis syndrome and treat, if present after 3 months of TLC
how is the metabolic syndrome identified?
any 3 of the following must be present: -abdominal obesity via waist circumference (men >102cm, 40in, women>88cm, 34in) -triglycerides: >150mg/dl -HDL: men130/>85 fasting glucose: >110 mg/dL
why is waist circumference used to identify insulin resistance in the metabolic syndrome?
abd obesity more highly correlated with metabolic risk factors than elevated BMI
how is the metabolic syndrome treated?
treat underlying causes:
-intensify weight management, increase physical activity
treat lipid and non lipid risk factors if they persist despite these lifestyle therapies:
-treat HTN, use aspirin for CHD pts to reduce pro-thrombotic state, treat elevated triglycerides and/or low HDL
how are triglycerides values classified?
per ATP III
500 very high
what is the primary aim of triglyceride treatment?
primary aim is to reach LDL goal
how are triglycerides treated?
intensify weight management, increase physical activity, if triglycerides are >200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total-HDL) 30mg/L higher than LDL
- if triglycerides are 200-499 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal
- intensify therapy with LDL lowering drug or add nicotinic acid or fibrate to further lower VLDL
- if triglycerides are >500, first lower triglycerides to prevent pancreatitis
- very low fat diet <500 mg/dL turn to LDL lowering therapy
how is HDL treated?
first reach LDL goal then
-intensify weight management and increase physical activity,
if triglycerides 200-499 achieve non HDL goal
if triglycerides <200 in CHD or CHD equivalent consider nicotinic acid or fibrate
what are the ACC/AHA guidelines for treating high hypertriglcerides, low HDL or non HDL cholesterol?
no recommendations due to lack of RCT evidence
what are some of the controversies surrounding the lipid management?
- a 7.5% 10 year risk is not universally recognized as the proper threshold at which to consider statin therapy
- pooled cohort equations appear to overestimate cardiovascular risk and also contain an error
- primary care organizations where not invited to participate in the 2013 lipid guideline development process after the NHLBI handed the task over to the ACC and AHA
- 20 of 46 recommendations are graded “expert opinion” rather than RCTs
- 6 of 15 panelists of new guidelines reported having recent or current ties to drug markers that already sell or are developing cholesterol medications
- 1 of 2 co chairs of the new guideline panel has ties to a drug maker, which ignores institute of medicine recommendations about managing conflict of interest on panels
