lipids Flashcards
LDL >190
getting a statin
have DM, goal of LDL less than
70 (60 ideal)
get a statin
if have CAD
automatically get a statin
flowchart for
statin use
VLDL=
TAGS/5
LDL =
total cholesterol - HDL - TAGS/5
total cholesterol =
HDL + VLDL + LDL
LDL =
total cholesterol - HDL - TAGS/5 (if in mg/dL)
total cholesterol - HDL - TAGS/2.2 (if in mmol/L)
Familial hypercholesterolemia
Rare in the homozygous state (about one per million) is a condition in which the cell-surface receptors for the LDL molecule are absent or defective, resulting in unregulated synthesis of LDL
Homozygotes have extremely high levels present with atherosclerotic disease in childhood
- Heterozygotes* have LDL concentrations twice normal; persons with this condition may develop CHD in their 30s or 40s
- look normal, do lipid panel*
Familial hyperchylomicronemia
Have marked hypertriglyceridemia with recurrent pancreatitis and hepatosplenomegaly in childhood
factors affecting lipids
*see chart
obesity (inc. TAGs, dec. HDL) sedentary (dec. HDL) DM (inc. TAGs, inc. tot. cholesterol) etOH (inc. TAGs, but inc. HDL) hypothyroid (inc. total) hyperthyroid (dec. total) nephrotic syndrome (dec. total) CKD (inc. total, inc. TAGs) cirrhosis (dec. total) obstructive liver disease (inc. total) malignancy (dec. total) cushing's disease (or cort. steroid use) (inc. total) OCTs (inc. TAGs, inc. total) diruetics (inc. total, inc. TAGs) B-blockers (may be on for HTN) (inc. total, dec. HDL)
hyperlipidemia s/s
Most patients with high cholesterol levels have no specific symptoms or signs
Most are detected by the laboratory, either as part of the workup of a patient with cardiovascular disease or as part of a preventive screening strategy
Eruptive xanthomas
Red-yellow papules (especially on the buttocks)
Extremely high levels of chylomicrons or VLDL particles
*know pics
Tendinous xanthomas
On certain tendons (achilles, patella, back of the hand)
High LDL concentrations
*know pics
Lipemia retinalis
Cream-colored blood vessels (in the fundus)
Extremely high triglyceride levels
*know pics (slide 26)
hyperlipidemia epi
With known cardiovascular disease cholesterol lowering leads to a consistent reduction in total mortality and recurrent cardiovascular events in men and women and in middle-aged and older patients
Treatment algorithms have been designed to assist clinicians in selecting patients for cholesterol-lowering therapy based on their overall risk of developing cardiovascular disease
hyperlipidemia pathophysiology
The two main lipids in blood are cholesterol and triglyceride carried in lipoproteins
Lipoproteins are usually classified on the basis of density
High-density lipoproteins (HDL)
Low-density lipoproteins (LDL)
Very-low-density lipoproteins (VLDL)
hyperlipidemia screening
- All patients with cardiovascular disease and diabetes should have their lipids measured*
- Diabetes and LDL greater than or equal to 70 mg/dL should be treated with statins*
rest FYI
A complete lipid profile (total cholesterol, HDL cholesterol, and triglyceride levels) after an overnight fast should be obtained
According to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, however, such patients are treated with statins independent of their lipid levels
Similarly, patients aged 40–75 with diabetes should also have a complete lipid profile
For men without other risk factors, screening is recommended beginning at age ??
35 years
For women and for men aged 20 to 35 without increased risk, the USPSTF makes no recommendation for or against routine screening for lipid disorders
-decreased efficacy of screening entire population
Although there is no established interval for screening, screening can be repeated every 5 years for those with average or low risk and more often for those whose levels are close to therapeutic thresholds.
*controversial
A2013 ACC/AHA guidelines recommend screening of all adults aged ?? or older for high blood cholesterol
21 years
United States Preventive Services Task Force (USPSTF) suggests beginning at age 20 years only if there are other cardiovascular risk factors such as tobacco use, diabetes, hypertension, obesity, or a family history of premature cardiovascular disease
hyperlip. Risk stratification**
Without cardiovascular (coronary) disease should have their 10-year risk of CHD calculated
LDL cholesterol greater than 190 mg/dL are recommended for treatment independent of their 10-year risk of cardiovascular disease, all other patients are recommended for treatment based on their overall cardiovascular risk
Women-low HDL may be most important risk factor
Elderly >75 cholesterol may not be a risk factor
The best method for estimating 10-year risk is controversial
2013 ACC/AHA guidelines
(link)
Framingham 10-year calculator (Table 28–1) includes CHD but not stroke risk (not tested on?)
if pts >25, your 10 year risk for coronary heart disease is ??
30%
Initial cholesterol measurement
Total cholesterol alone
Total cholesterol and HDL cholesterol
LDL cholesterol**
Numerous other risk factors have been studied in an attempt to better predict future CHD events
**High-sensitivity C-reactive protein (hs-CRP) (ppl who are already sick have higher levels of CRP, confounding)
Electron beam computed tomography (EBCT) Homocysteine Fibrinogen Lipoprotein (a) LDL subfractions (certain fractions of LDL are worst than others) Ankle-brachial index
Treatment decisions
Clinical cardiovascular disease or diabetes
Patient age
LDL cholesterol greater than 190 mg/dL
Estimated 10-year risk of developing cardiovascular disease
hyperlip. tx: diet
Low fat, low cholesterol (original thought)
Mediterranean diet
Soluble fiber, garlic, vitamin C, pecans, plant sterols
Other risk factor reduction
Smoking cessation**
HTN control
ASA use
Raise HDL
who should get ASA (high risk)
after HA/CVA, hypercoaguable risk factors
DM
LDL> 190
controversial for others: negative effects
how to Raise HDL
aerobic exercise
healthy fats
moderate etOH use
when to tx
CAD/CVD : high intensity statin or moderate if >75
LDL >190 : high intensity statin
age 40-75, +DM, LDL >70 mg/dL : moderate statin or high if 10 yr CVD risk >= 7.5%
age 40-75, no CAD/CVD/DM, LDL 70-189 mg/dL, est. 10 yr CVD risk 7.5% or higher : moderate to high statin
low-intensity statins
lowers LDL on average by less than 30%
moderate-intensity statins
lower LDL by about 30% to less than 50%
high-intensity statins
lowers LDL by about greater than 50%
- atorvastatin
- rosuvastatin
atorvastatin
lowers LDL, raises HDL and lowers TAGs
statin SEs
myopathies
liver toxicity
new drug
PCSK9 inhibitors (won't be tested on) slide 39 -know statins
how to tx high TAGs
Dietary:
Avoid alcohol, simple sugars, refined starches, saturated and trans fatty acids, and restricting total calories
Control of secondary causes of high TAG levels
Drug therapy (niacin, a fibric acid derivative, omega-3-acid ethyl esters, or an HMG-CoA reductase inhibitor (statin MOA)) is indicated. Combinations of these medications may also be used
?? are made in the gut and travel via the portal vein into the liver and via the thoracic duct into the circulation
Normally completely metabolized, transferring energy from food into muscle and fat cells.
Chylomicrons
The plaques in the arterial walls of patients with atherosclerosis contain large amounts of ??
cholesterol
The higher the level of low-density lipoproteins (LDL) cholesterol, the greater the risk of atherosclerotic heart disease
The higher the high-density lipoproteins (HDL) cholesterol, the lower the risk of coronary heart disease (CHD)
High total cholesterol levels are also associated with an increased risk of CHD
know slide 9
flow chart algorithm
if have CAD, getting tx
if not, check LDL
>190 get statin
if have DM get statin
