L8 - Hyperlipidemia Flashcards
What are the different types of lipoproteins? Are they “good” or bad”?
HDL = good
LDL = Bad
Triglyceride rich proteins (VLDL, IDL & Chylomicrons) = probably bad
What lipoproteins are measured individually in a lipid panel?
HDL
LDL
Triglycerides (VLDL, IDL & Chylomicrons)
Total Cholesterol (HDL + LDL + triglycerides/5)
What lipoproteins are not measured individually in a lipid panel?
VLDL, IDL & Chylomicrons are listed collectively as triglycerides
What is the relationship between total cholesterol & heart disease risk on a population basis?
Directly proportional in men & women of all ages
However on individual basis total cholesterol is misleading
Lowering cholesterol helps lower cardiac risk in who?
Almost everyone
He joked about putting statins in the water
What non-cardiac presentations can results from hypercholesterolemia?
Xanthomata = high levels of cholesterol leads to the deposition of cholesterol in nodular plaques on the skin, retina or tendons
Secondary consideration to cardiac issues
Generally related with really high cholesterol seen in familial conditions, but can also have benign forms with normal lipid panel
What is the relationship between total cholesterol & heart disease risk when looking at an individual?
Poor association
Can have high HDL lead to an inaccurate high total cholesterol reading when low LDL is present
Can have a low HDL level lead to an inaccurate normal total cholesterol when high LDL is present
Patient presents with high triglycerides, low HDL & high LDL. What do you focus on first?
LDL
Then can focus on either triglycerides or HDL (no diffinitive research suggesting which one should be treated second) after LDL is in desired range
Exception = if triglycerides are over 500, need to get those under 500 before LDL can be accurately measured
What is the relationship between LDL & heart disease risk when looking at an individual?
Strong directly proportional
More accurate than total cholesterol
What are the different ranges of LDL?
Optimal <70 can be beneficial
What is treatment goal for somebody with prior Coronary Heart Disease?
<100
Same as CHD equivalent
What is the treatment goal for somebody with 2 or more risk factors for CHD & no previous history of CHD?
<130
What is the treatment goal for somebody with 1 or less risk factors for CHD and no previous history of CHD?
<160
How do statins work?
HMG CoA reductase inhibitor –> blocks step of cholesterol synthesis in the liver
How do bile sequestrants work?
Interrupt entero-hepatic circulation –> excrete more bile –> need to make more bile –> use up cholesterol making new bile
What drug should not be used when trying to get triglycerides lowered?
Bile sequestrants, cuz may actually increase triglycerides
If trying to lower LDL, what drug do you use?
Use statin, but if patient can’t tolerate statin use bile acid sequestrant (less effective & more side effects)
Side effects related to statins? What to do if see these in a patient?
Myopathy
Increased LFTs (Liver function test = bilirubin, INR, PT, albumin)
If severe side effects –> switch to bile acid sequestrant
Side effects related to bile acid sequestrants?
GI problems = bloating, gas, diarrhea …
+ can raise triglycerides
Common. Part of reason why statins are first line
Types of bile acid sequestrants mentioned in lecture?
Cholestipol
Cholestyramine
Both start with Chol
What drug is best for raising HDL?
Niacin
What is another name for Niacin?
Nicotinic Acid
Actions of Niacin? Side effects?
Mainly raises HDL & lower triglycerides
Flushing (more severe form of blushing seen not just on the face). Common = why don’t use this drug if just targeting triglycerides
Action of Fibric Acid derivatives?
Mainly lowers triglycerides, but also helps HDL & LDL a bit
What Fibric Acid derivatives were mentioned?
Gemfibrozil
Fenofibrate
Both have fib in the middle
Side effects of Fibric Acid derivatives?
Myopathy
Y shouldn’t be used in conjunction with statin
Why should a fibric acid derivative not be used at the same time as a statin?
Both drugs can cause side effect of myopathy –> potentiated effect –> rhabdomyolysis
What is the effect of therapuetic lifestyle changes (TLC) on LDL?
20-30%, good so should be part of every treatment regimen but not great so usually not enough on its own
What is the relationship of statin dose on LDL level? Why is this important?
Dose dependent response = as increase does lower LDL
If not at goal can up dose and get better results
What is the difference between different statins and when are they used?
Differing effectiveness
Crestor = most effective, but more expensive and individuality means some can’t handle it
What is secondary CHD prevention?
Lower cholesterol in somebody who has already had CHD so they don’t get another episode
<100 goal
If the patient is on a statin but still very far from goal, what should you do?
Raise dose, but in a stepwise fashion
Don’t jump up multiple dosages at once cuz more likely to get side effects
Follow up schedule for somebody that has an LDL >30 more than desired treatment goal at dianosis?
Start TLC & drug –> follow up in 6 weeks
Continue seeing every 6 weeks and up dose until get to treatment goal
What is the difference in HDL between sexes?
Pre-menopasual women have higher HDL cuz estrogen increases HDL (may have high total cholesterol but that isn’t bad)
What are CHD risk factors?
Smoking
HDL 45 men, >55 women)
1st degree relative with CHD (60, “eliminates” a risk factor
If LDL is less than 30 away from treatment goal on diagnosis, what should you do?
Start with just TLC
Follow up in 6 weeks. Give another 6 weeks if still not at goal
If still not at goal by third visit use drug
If no motivation for TLC just jump to meds
What are CHD equivalents?
Any CHD (stent, MI, angina …)
Carotid Stenosis
Peripheral Artery disease
Aortic aneurysm
Renal artery stenosis
Diabetes
*Familial hyperlipidemia is sort of an equivalent
How to proceed in a patient with CHD equivalent?
Suggested TLC + drug
For diabetes, must use drug + TLC (evidence shows it is helpful even if LDL is lower than treatment goal. Same for patients with previous CHD)
What is primary CHD prevention?
Trying to prevent first CHD in somebody with CHD equivalent
<100
If see somebody who is really young or has really healthy lifestyle with high LDL, what should you suspect?
Familial/genetic
Didn’t fast before test –> inaccurate
If see somebody with an LDL >160 what should you suspect?
Familial/genetic
Didn’t fast before test –> inaccurate
How is treating a genetic or familial cause different?
More aggressive
Drug & TLC from the start
What is the treatment goal for somebody with familial/genetic hyperlipidemia?
Treat as CHD equivalent –> <100
Secondary causes of Hyperlipidemia?
Diabetes Obesity Smoking Renal Failure Liver Disease Hypothyroidism Meds (progestins, estrogen, HIV drugs, steroids & corticosteroids)
High LDL with no apparent secondary cause. What should you consider?
Think familial
Patient has LDL >190. What do you do?
If familial, drug + TLC
If non-familial (just crazy bad lifestyle), just TLC
How is LDL measured?
Too expensive to measure directly
Measure other stuff & calculate with equation
If triglycerides over 500 equation doesn’t work. Can send out for direct measurement but takes too long & is expensive
What does LDL undetermined mean?
Triglycerides are over 500 so can’t calculate LDL
When would you focus on triglycerides before LDLs?
If triglycerides are > 500, need to treat it until < than 500 so can accurately measure LDL
Once <500 can treat LDL
Why is having a triglyceride >500 bad?
Pancreatitis is a concern
Can’t measure LDL accurately
How does triglyceride level correlate with CHD risk factor?
Directly proportional, but no proof that it is cause and effect. Could just be that people with high triglycerides tend to have other risk factors
What is treatment goal for somebody with CHD equivalent?
< 100
Same as prior CHD
What the action of bile sequesterants?
Main action is to lower LDL, but also help raise HDL. It is the only drug that actually may rise Triglycerides.
Which hyperlipedemia drug has a significant effect on 2 different classes of lipoproteins?
Niacin raises HDL & lowers triglyceride
43 yo female smoker with HTN and HDL of 43. Father had MI at 62. Treatment goal?
2 risk factors –> <130
Dad is not risk factor (he is too old)
40 yo female non-smoker with well controlled HTN on medication. Father had MI at 62. HDL is 67. Treatment goal?
1 for HTN, but - 1 for high HDL –> 0 RF
Goal <160
Dad is not risk factor (he is too old)
Treatment goal for diabetic 45 yo woman with HDL of 65 & no HTN. Non-smoker with no family history of CHD?
Diabetic = equivalent –> ignore other risk factors
<130
What type of hyperlipidemia can lead to pancreatitis?
Triglycerides > 500
