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CMT-uno > Lipid Disorders > Flashcards

Lipid Disorders Flashcards

1
Q

Types of Lipids

Cholesterol

A

Essential element of all animal cell membranes and the backbone of steroid hormones and bile acids

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2
Q

types of lipids

Triglycerides

A

Transfers energy from food into cells

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3
Q

types of lipids

lipoproteins

A

-Transport lipids
-Classified by density
-Apoprotein is dense
-Triglyceride is less dense

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4
Q

types of lipoproteins

Apolipoprotein B (apoB)

A

-Protein that carries LDL and helps it bind to the cell wall
-Contributes to atherogenesis (plaque forming)

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5
Q

lipoproetins

Lipoprotein (a)

A

Genetically determined subfraction of LDL (if elevated, increased risk for CAD)
Causal factor in atherosclerosis
One-time measurement recommended in patients with strong family history of ASCVD
Risk enhancing factor favoring early statin treatment

indepedent from rest of lipid panel for risk determination

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6
Q

lipoproteins

Chylomicrons

A

Least Dense

Found in blood after fat-containing meal

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7
Q

lipoprotein

Low-density lipoprotein (LDL)

A

carry most of the cholesterol

L for lousy. we want this Low.

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8
Q

lipoprotein

High-density lipoprotein (HDL)

A

Most dense and smallest
Participate in reverse cholesterol transport

H is for High and Happy, we want this number high.

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9
Q

lipoprotein

Very-Low-Density Lipoprotein (VLDL)

A

Least dense, large
Consists mostly of triglycerides that is transferred to cells

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10
Q

Which lipid value is most sensitive to fasting?

A

Trig

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11
Q

Which lipoprotein carries the most cholesterol?

A

LDL

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12
Q

Which lipoprotein is an independent risk for ASCVD?

A

Lp(a) is independent risk factor for CAD

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13
Q
A
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14
Q

how does exercise help cholesterol?

A

increasing muscles mass increases HDL

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15
Q

How can you reduce LDL?

A

Eat more fiber. Have to poop it out!

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16
Q

What is always the goal of lipid tx?

A

reduce LDL

unless TRIG is >500 due to increased risk of pancreatitis

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17
Q

Atherosclerosis

A

Plaque with large amounts of cholesterols build up in arterial walls
Associated with high LDL and low HDL
Mostly asymptomatic until plaque rupture or vessel occlusion (MI, CVA)

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18
Q

Familial Hypercholesterolemia

A

defective LDL receptors, genetic mutations of apolipoprotein B, or gain in function of proprotein convertase subtilisin/kexin type 9 (PCSK9)

Typically, patients have elevated total cholesterol and normal triglycerides
Heterozygous (1 in 250 people)
Homozygotes (1 in 1,000,000 people)

probably won’t be tested on this

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19
Q

Familial Chylomicronemia AKA

A

Lipoprotein Lipase Deficiency (LPLD)
Fredrickson Type 1 Hyperlipoproteinemia
Familial Hypertriglyceridemia

probably wont be tested on this

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20
Q

Familial Chylomicronemia

caused by, characterized by, risk for?

A

Caused by an abnormality of lipoprotein lipase (LPL) that is responsible for the ability of tissues to take up triglycerides (TG) from chylomicrons
Characterized by marked hypertriglyceridemia

Important for patient to abstain from ETOH, bc at VERY HIGH RISK FOR PANCREATITIS

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21
Q

Dysbetalipoproteinemia

A

Elevated levels of remnant lipoproteins
Rare familial disease
Associated with premature ASCVD

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22
Q

Familial combined hyperlipidemia

A

Polygenic combination of lipid abnormalities
Most common genes: LDLR, APOB, PCSK9 (don’t need to memorize these)

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23
Q

When should you suspect genetic disorders?

A

if you see LDL over 200

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24
Q

Conditions that Affect Lipids (aka. Secondary causes of dyslipidemia)

A

Metabolic syndrome
Type 2 diabetes
Uncontrolled hyperglycemia
Obesity
Hypothyroidism
Liver disease
Renal disease
Corticosteroid use
Progestin use
Anabolic steroid use
Alcohol use/abuse

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25
Q

You are treating a patient for high cholesterol. Current LDL is non-calculable, triglycerides > 450, HDL 40. TSH is elevated at 10 ( nl range < 4.0), HgA1C 9.8.

Why is her cholesterol not at goal in spite of compliance with cholesterol medications?

A

Must correct DM and TSH

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26
Q

Specific Clinical Presentation of high cholesterol

A

Most patients do not have specific signs or symptoms
Primarily detected with laboratory studies

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27
Q
A

Eruptive Xanthomas/Xanthelasma

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28
Q
A

Tendinous Xanthomas

common in famial disorders

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29
Q
A

Lipemia Retinalis

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30
Q
A

Corneal Arcus (arcus lipoides)

Differs from arcus senilis
Gap between limbus and the lipid deposit distinguishes the two

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31
Q
A

Corneal Arcus (arcus lipoides)

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32
Q

Screening

fasting requirements

A

Fasting not required for screening; use Non-HDL-C for guidance

Guidelines vary by organization

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33
Q

Screening Children

A

Selective screening for children age >2 with family history or lipid disorder or premature ASCVD
Between ages 9-11
Again, between ages 17-21

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34
Q

Lipid screening for Adults

when do you stop screening? (no previous lipid issues)

A

One time- Adults at age 20 if not previously done as a child

Every 5 years for those at low risk after age
35 in men
45 in women

More often for those at moderate to high risk
Screening not recommended for those over age 75

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35
Q

Risk Levels

A
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36
Q

Risk-enhancing Factors

primary prevention

A
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37
Q

Cardiac Calcium Score

A

Helpful for deciding if they should be put on statins for having calcified vessels.

only catches calcification not lipids in blood which cause events.

Most useful in those with intermediate risk stratification (7.5-< 20%)
The higher the score, the higher risk of heart disease

May repeat every 3 to 7 years based on patient risk

“The single best test for additional risk stratification”

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38
Q

A patient with which of the following characteristics will a cardiac calcium score be most useful in a shared decision-making model?
a. Aged 75
b. Intermediate ten-year risk of heart disease
c. Low-density lipoprotein (LDL) 194
d. Type 2 diabetes
e. Smoker

A

B-Cac score may be helpful with intermediate ten –year risk

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39
Q

The Pooled Cohort Equation is used to estimate the ten-year risk of heart disease or stroke for an individual. The risk is reported to be 10%. What risk category is the result?
a. Borderline
b. High
c. Intermediate
d. Low

A

C-intermediate

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40
Q

CVD

Primary Prevention

A

Refers to therapy in persons with NO known cardiovascular disease
Studies indicate rates of cardiovascular events, heart disease mortality, and all-cause mortality are decreased in the right population

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41
Q

CVD

Secondary Prevention

A

Refers to therapy in persons with known cardiovascular disease
Studies support that cholesterol lowering leads to decreased mortality and recurrent cardiovascular events

42
Q

primary prevention for women who anticipate childbearing

A

Primary prevention with statins are not recommended for women who anticipate childbearing

43
Q

Primary prevention

Risk factors and LDL goals

A
44
Q

who gets statin treatment for primary prevention?

A

Anyone with LDL-C ≥190 mg/dL –> high intensity statin

Age 40-75 with diabetes –>moderate intensity statin.
Consider high intensity statin if risk enhancing factors or 10-year risk >20%

Age 40-75 without diabetes with LDL 70-189 mg/dL and intermediate or high risk –> moderate intensity statin. & high intensity statin if additional risk enhancers

slide 38

45
Q

CVD

Secondary Prevention is for

A

Among patients with established ASCVD, mortality benefits of cholesterol lowering are clear
Regression of atherosclerotic plaque
Slow or reverse carotid artery atherosclerosis

Established ASCVD
Acute coronary syndromes
MI
stable/unstable angina
Coronary/arterial revascularization
Stroke/TIA
Peripheral artery disease of presumed atherosclerotic origin

Persons over the age of 75 should continue statin therapy with decisions based on functional status, life expectancy, comorbidities, and patient preference

46
Q

Who is at very high risk of CVD?

A

ACS within the past 12 months
MI other than event listed above
History of ischemic stroke
Symptomatic PAD (ABI <0.85, amputation, previous revascularization)

Hx of plaque related event

47
Q

Risk factors that are High risk of CVD?

A

Age ≥65
Heterozygous familial hypercholesterolemia
Diabetes mellitus
Hypertension
CKD (GFR 15-59 mL/min/7.73m2)
Current smoker
LDL-C ≥100mg/dL despite maximally tolerated statin and ezetimibe
History of congestive heart failure

48
Q

What is the goal LDL for someone with secondary prevention?

A

less than 70 LDL

49
Q

Secondary Prevention

A

memorize this

50
Q

primary prevention

A

memorize this

51
Q

who gets statin for secondary prevention?

A

Everyone!
High or moderate intensity statin
LDL-C goal < 70 mg/dL

52
Q

Weight loss affect on Lipids

A

lowers LDL, increases HDL
For those who are overweight or obese

53
Q

Tobacco cessation

A

increases HDL

54
Q

Modest alcohol use

Will increase? And when is it contraindicated?

A

increases HDL, contraindicated for very high TG
(red wine)

someone with High TRIG will not benefit

55
Q

Benefits of Mediterranean Diet

A

Total fat 35-40% fat but saturated fat replaced with monounsaturated fat
Plant based, lean animal protein (preferably fish)
Lowers LDL without lowering HDL
Reduces endothelial dysfunction, insulin resistance, and vascular inflammatory markers

56
Q

Specific nutrition guidance for treatment of elevated triglycerides

A

Low carbohydrate
No simple sugars
No alcohol

57
Q

A 45-year-old woman with no risk factors for coronary heart disease is found to have a cholesterol level of 165mg/dL. What nutrition advice is most helpful?
a. Abstain from all alcohol
b. Begin a fish oil supplement
c. Cut carbohydrate intake to less than 30% of total calories
d. Decrease saturated fat to less than 15% of total calories
e. Increase soluble fiber to 20 grams daily

A

E. Increase soluble fiber to 20 grams daily

58
Q

Which of the following “natural” interventions has not been proven to reduce cholesterol?
a.Almonds
b.Walnuts
c.Increase fiber
dCo-Q-10
e.Plant stanols
f.Red-yeast rice extract

A

d. Co-Q-10

does not help reduce cholesterol, might help with Side affects from chole meds

59
Q

Pt is in primary prevention, what is their LDL goal?
what about secondary?
secondary over 75y?

A

100 if primary
70 if secondary with high intensity statin
70 with POSSIBLE moderate statin

60
Q

What is first line medication class for lipid management?

A

Statin

61
Q

If pt starts on statin, when do we check bloodwork again?

A

3 months

62
Q

what if lipid still elevated after check up on statins?

A

if moderate statin, move them to high intesity statin or consider adding another agent (second line) such as PSK9 inhibitor or Ezetimibe

63
Q

In what scenario is TRIG reduction more important that LDL reduction?

A

when TRIG is >500 due to risk of pancreatitis

64
Q

Fish Oil Medications

A

icosapent ethyl (Vascepa), omega-3-acid ethyl esters (Lovaza)

65
Q

Fish oil benefits

A

for reducing TRIG by up to 30%

Reduces apoB
Reduces hsCRP
Reduces CV death, MI, CVA, unstable angina and coronary revasularization

66
Q

Niacin (Niaspan) benefits and contraindications

A

Reduces LDL 15-25%
*Increases HDL 25-35%

Caution with cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors

67
Q

SE of Niacin (Niaspan)

A

Flushing
Pruritus
Hyperglycemia
Gout exacerbation
Peptic ulcer disease

68
Q

Fibrates

gemfibrozil (Lopid), fenofibrate (Tricor, Triglide, Lipofen)

A

Reduce TRIG 40%
Reduce LDL 10-15%
Increase HDL 15-20%
Reduces CHD and CV events

69
Q

Statins benefits

A

Reduces LDL by up to 50% (high intensity statin)
Increases HDL
Decreases TG
Decreases hsCRP
Dosed once daily

70
Q

Statin MOA

A

Work by inhibiting the rate-limiting enzyme in the formation of cholesterol in the liver and increases hepatic LDL receptors

71
Q

Statin Contra

A

Caution with niacin, fibrates, EES, antifungals, nefazodone, or cyclosporin
Liver failure

72
Q

Statin SE

A

Myalgias- bilateral mostly legs and shoulders
CK elevations
Myositis
Rhabdomyolysis
Elevated transaminases
Diabetes development

73
Q

Statin

Rule of 6 or 7

A

you get bigest reduction at initial dose, w/ each titration you get 6-7% off as you increase dose

40% at 10mg, then 46% at 20mg

74
Q

Which of the following statin medications and doses is high-intensity intervention?
a. Atorvastatin 40mg
b. Lovastatin 20mg
c. Pravastatin 40mg
d. Simvastatin 40mg
e. Rosuvastatin 10mg

A

A. Atorvastatin 40mg

75
Q

Which of the following statins would you select to reduce LDL by 35-50%
a. atorvastatin (Lipitor) 40 mg
b. atorvastatin (Lipitor) 80 mg
c. rosuvastatin (Crestor) 10 mg
d. rosuvastatin (Crestor) 20 mg
e. simvastatin (Zocor) 10 mg

(moderate intensity)

A

c. rosuvastatin (Crestor) 10 mg

76
Q

What is perc goal of LDL lowering for patient with clinical ASCVD taking a high-intensity statin?
a. 10%
b. 20%
c. 25%
d. 30%
e. 50%

A

e. 50%(high intensity)

77
Q

Bile Acid Sequestrants

cholestyramine (Questran), colesevelam (Welchol), colestipol (Colestid)

A

Reduces LDL by 15-25%
Safe in pregnancy
OK with liver disease

78
Q

Cholesterol Absorption Inhibitors

ezetimibe (Zetia)10mg daily

A

Reduces LDL 15-20%
Reduces hsCRP
Once daily dosing
Well tolerated

On boards, this is second step for with statins

(has reduced numbers but not shown to reduce events

79
Q

PCSK9 Inhibitors

alirocumab (Praluent), evolocumab (Repatha)
benefits

A

Decrease LDL 50-60%
Decrease Lp(a) 20-30%
Reduces CV events and death

shot

80
Q

Adenosine Triphosphate-Citrate Lyase (ACL) Inhibitors

Bempedoic Acid (Nexletol) Bempedoic Acid + ezetimibide (Nexlizet)
Benefits

A

Lowers LDL by 17-20%
In combo with ezetimibe (up to 38%)
Decreases hsCRP
Decreases diabetes risk
Once daily dosing

81
Q

You are treating a patient with CAD and high cholesterol They present in clinic for follow-up with labs: LDL 110, HDL 45, Tg 120. VS: 140/88, HR 12. Current medications include rosuvastatin 20 mg po at hs.
What is target LDL?

A

< 70

82
Q

Which of the following is indicated to get patient to goal?
continue rosuvastatin and add atorvastatin 20 mg ?
add ezetimibe 10 mg po daily (cholesterol absorption inhibitor)
start Praulent (PCSK9-I)
start Nexitol (ACL inhibitor)
start gemfibrozil ( bile acid sequestrant)

A

b- YES

a- NO dont prescribe 2 statins

83
Q

Primary prevention

age 40-75 with LDL 70-190
Low

A

Low < 5% - emphasize lifestyle to reduce risk

84
Q

primary prevention

age 40-75 with LDL 70-190
Borderline

A

borderline 5-7.5% 10 year risk
If risk enhancers present then DISCUSS moderate intensity STATIN

85
Q

Primary prevention

age 40-75 with LDL 70-190
Intermediate

A

7.5-20% risk
moderate intensity STATIN

86
Q

Primary prevention

age 40-75 with LDL 70-190
High risk

A

> or = 20%
high intensity STATIN

87
Q

primary prevention

age 40-75 with DM and LDL 190 or higher

A

no risk assessment necessary
high intesnity statin

88
Q

primary prevention

45-75 y with DM

A

moderate STATIN
risk assessment to decide if High intensity statin

89
Q
A
90
Q

primary

LDL levels

A
91
Q

primary

Chlesterol levels

A
92
Q

primary prevention

HDL levels

A
93
Q

Pooled Cohort Equations

A

Separate Equations for White and Black patients

Estimates 10-year risk of MI, CVA, CV death

Does over-estimate risk of middle to higher socioeconomic class patients

Disclaimer reads that it is not intended for those with previous MI/CVA, LDL >190, or <40-years-old or >79-years-old

94
Q

How to interpret cardiac calcium score

A
95
Q

SECONDARY prevention

Age < 75 ASCVD NOT at very high risk

Goal and Tx

A

goal: LDL 70 or less

High intensity statin

if not tolerated moderate statin with ezetimibe

96
Q

Secondary prevention

pt at very high risk ASCVD

goal and Tx (3 possible steps)

A

goal: 70 or less

  1. high intensity statin
  2. add ezetimibe if LDL not low enough
  3. if still not low enough add pcsk9
97
Q

Who is at VERY high risk?

A

ACS within the past 12 months
MI other than event listed above
History of ischemic stroke
Symptomatic PAD (ABI < 0.85, amputation, previous revascularization)

98
Q

who is at high risk?

A

Age ≥65
Heterozygous familial hypercholesterolemia
Diabetes mellitus
Hypertension
CKD (GFR 15-59 mL/min/7.73m2)
Current smoker
LDL-C ≥ 100mg/dL despite maximally tolerated statin and ezetimibe
History of congestive heart failure

99
Q

Individuals with clinical ASCVD should be on?

what kind of prevention?

A

STATIN
secondary

100
Q

Individuals with primary elevation of LDL cholesterol >190 mg/dL
should be on ..

A

primary prevention
STATIN

101
Q

Individuals aged 40-75 with diabetes and LDL ≥70mg/dL

A

primary prevention
statin

102
Q

Individuals aged 40-75 without clinical ASCVD or diabetes with LDL 70-189 and estimated 10-year CVD risk of 7.5% or higher

A

primary prevention
statin

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