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Ambulatory Medicine > Hyperlipidemias > Flashcards

Hyperlipidemias Flashcards

0
Q

Primary causes of hyperlipidemia

A

familial dyslipidemia syndrome

types IIa, IIb, and IV account for >80% of all familial dyslipidemias

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1
Q

Hyperlipidemia basics

A

modifiable risk factor for coronary artery disease!

causes accelerated atherosclerosis

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2
Q

Secondary causes of hyperlipidemia

A
  1. endocrine disorders: hypothyroidism, diabetes mellitus, Cushing’s syndrome
  2. renal disorders: nephrotic syndrome, uremia
  3. chronic liver disease
  4. medications: glucocorticoids, estrogen, thiazide diuretics, beta blockers
  5. pregnancy
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3
Q

Clinical pearl: Risk factors for coronary artery disease in evaluation of patients with hyperlipidemia

(p. 433)

A

current cigarette smoking (dose-dependent risk), hypertension, diabetes mellitus, low HDL cholesterol (60 mg/dL) is negative risk factor (subtract 1 from total), age (male:>45 years, female: >55 years), male gender (if you count this as risk factor do not count age), family hx of premature CAD (MI/sudden death in male first degree relative <65 yo)

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4
Q

Dietary risk factors for hyperlipidemia

A

saturated fatty acids and cholesterol –> elevation in LDL + total cholesterol
high-calorie diets do not increase LDL or cholesterol levels (are “neutral”) but do increase triglyceride levels
alcohol –> increase triglyceride levels but does not affect total cholesterol levels

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5
Q

Risk factors for hyperlipidemia

A
  1. diet
  2. age (cholesterol levels increase with age until about 65 yrs;
    greatest increase in early adulthood 2 mg/dL per yr)
  3. inactive lifestyle, abdominal obesity
  4. family hx hyperlipidemia
  5. gender (men generally > cholesterol levels than women); when women reach menopause cholesterol levels equalize (and may be higher in women)
  6. medications: thiazides (increase LDL, total cholesterol, triglycerides (VLDL levels); beta blockers (propanolol-increases triglycerides (VLDL) and lower HDL levels); estrogens (triglyceride levels may further increase in patients with hypertriglyceridemia); corticosteroids and HIV protease inhibitors can elevate serum lipids
  7. genetic mutations that predispose to most severe hyperlipidemias
  8. secondary causes of dyslipidemia
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6
Q

LDL cholesterol and CAD risk

A

accounts for 2/3 of total cholesterol

CAD risk primarily due to LDL component bc LDL thought to be the most atherogenic of all lipoproteins

Levels > 160 mg/dL significantly increase CAD risk

–> LDL cholesterol not directly measured but calculated:
LDL = total cholesterol - HDL - TG/5

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7
Q

Threshold levels for hyperlipidemia: total cholesterol

A

all in mg/dL:
ideal: 240

remember: total cholesterol will be higher than LDL!

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8
Q

Threshold levels for hyperlipidemia (LDL)

A

all in mg/dL:

ideal: 160

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9
Q

Threshold levels for hyperlipidemia (triglycerides)

A

for Triglycerides high level is Two Times low level
“T”

all in mg/dL:
ideal: 250

uncertain whether lowering triglyceride levels reduces coronary risk

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10
Q

HDL cholesterol

A
    • protective effect (removes excess cholesterol from arterial walls) at least as strong as atherogenic effect of LDL
  • for every 10 mg/dL increase in HDL level, CAD risk decreases by 50%

Low HDL ( 60 mg/dL) = “negative” risk factor (counteracts one risk factor)

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11
Q

Total cholesterol to HDL ratio

A

average/standard risk: 5.0

desirable: <4.5

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12
Q

LDL levels in diabetic patients

A

goal for LDL in diabetic patient: 100 mg/dL or lower

all diabetics with LDL > 100 mg/dL should be started on statin

if patient has CAD and diabetes mellitus: goal for LDL is 70 mg/dL or less

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13
Q

Clinical features hyperlipidemia

A

most patients asymptomatic

if severe, may see:

  1. Xanthelasma: yellow plaques on eyelids
  2. Xanthoma: hard, yellowish masses found on tendons (finger extensors, Achilles’ tendon, plantar tendons)
  3. Pancreatitis can occur with severe hypertriglyceridemia
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14
Q

Diagnosis of Hyperlipidemia

A
  1. lipid screening
    - measure total cholesterol and HDL levels (nonfasting ok)
    - -> if either abnormal, order full fasting lipid profile
  2. full fasting lipid profile: triglyceride levels + calculation of LDL levels
  3. consider checking laboratory tests to exclude secondary causes of hyperlipidemia:
    a. TSH (hypothyroidism)
    b. LFTs (chronic liver disease)
    c. BUN and Cr, urinary proteins (nephrotic syndrome)
    d. glucose levels (diabetes)
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15
Q

Statins and fibrates and liver “function”!

A

statins and fibrates can induce transient elevation in serum transaminases

LFT must be monitored

all patients on statins should have AST and ALT monitored even if asymptomatic
(about 1% of patients on statins will develop elevations in AST and ALT such that statin will need to be discontinued)

16
Q

Treatment of hyperlipidemia

A

long-term goal: reduce coronary heart disease
short-term goal: reduce LDL levels

if patient has no established CHD: target LDL < 100 mg/dL

17
Q

Statin beneficial effects

A

significantly reduce rates of MI, stroke, coronary and all-cause mortality

statins are most common drugs used!
can reduce LDL by 20-60%

–> added benefit: statins also have antioxidant effect on endothelial lining of coronary arteries

18
Q

Coronary heart disease risk equivalents

A

diabetes mellitus, peripheral vascular disease, coronary artery disease, abdominal aortic aneurysm

19
Q

Therapy for hyperlipidemia: CHD or CHD risk equivalents

A

LDL goal: < 100 mg/dL
Initiate lifestyle changes: 100 mg/dL (all patients regardless of LDL)
Consider drug therapy: 130 mg/dL

20
Q

Therapy for hyperlipidemia (No CHD but > 2 risk factors)

A

all in mg/dL
LDL goal: <130
initiate lifestyle change: 130 (all pts regardless of LDL)
consider drug therapy: 130

21
Q

Therapy for hyperlipidemia (No CHD but 2 risk factors)

A

all in mg/dL
LDL goal: 130
initiate lifestyle changes: 130
consider drug therapy: 160

22
Q

Therapy for hyperlipidemia (No CHD and 0-1 risk factors)

A

all in mg/dL

LDL goal: 160
initiate lifestyle changes: 160
consider drug therapy: 190

23
Q

Therapy for high LDL cholesterol

A
  1. dietary therapy (lowering fat intake esp sat fat reduces serum cholesterol more than lowering cholesterol intake)
    - -> foods rich in omega 3 fatty acids (fish)

LDL can be reduced by 10% on avg:
<300 mg/day cholesterol

exercise (increases HDL, lowers BP, enhances efficiency of peripheral oxygen extraction)
weight loss (reduces myocardial work, risk of diabetes)
24
Q

HMG CoA reductase inhibitors (statins)

Drug therapy hyperlipidemia

A

effects: lower LDL levels (most potent for lowering LDL); minimal effect on HDL and TG levels
comments: have been shown to reduce mortality from cardiovascular events and significantly reduce total mortality
* drugs of choice for lowering LDL*

side effects: monitor LFTs (monthly for 1st 3 months, then every 3-6 months). Harmless elevation in muscle enzymes (creatine phosphokinase) may occur

25
Q

First line treatment hyperlipidemia

A

Patients given drug therapy should almost always be treated with statin

statins can reduce relative cardiovascular risk by 20-30% regardless of baseline LDL levels

26
Q

Niacin

drug therapy hyperlipidemia

A

effects: lowers TG levels, lowers LDL levels, increases HDL levels
comments: do not use in diabetic patients (may worsen glycemic control
- -> most potent agent for increasing HDL levels and lowering TG levels

side effects: flushing effect (cutaneous flushing of face/arms; pruritus may be present);
Check LFTs and Creatine phosphokinase levels as with statin drugs

27
Q

Bile acid-binding resins (cholestyramine, colestipol)

drug therapy for hyperlipidemia

A

effects: lowers LDL, increases triglyceride levels
comments: effective when used in combination with statins or niacin to treat severe disease in high-risk patients
side effects: adverse GI side effects, poorly tolerated

–> useful in treating bile salt-induced diarrhea (e.g., resection distal ileum) but worsens bile salt depletion (e.g., ileal resection > 100 cm)

28
Q

Fibrates (gemfibrozil)

drug therapy for hyperlipidemia

A

effects: lower VLDL and TG, increase HDL
comments: primarily for lowering TG levels
side effects: GI side effects (mild), mild abnormalities in LFTs, gynecomastia, gallstones, weight gain, myopathies

29
Q

.

A

.

30
Q

Amiodarone affects:

A

Statin metabolism

Ambulatory Medicine (19 decks)

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