Lipids Flashcards
If patient has VERY high triglycerides- they’re “vasculopaths”, meaning
all arteries are filled with plaques, have xanthomas, ocular effects
With known cardiovascular disease, _________ leads to a consistent reduction in total mortality and recurrent cardiovascular events in men and women
cholesterol lowering
The two main lipids in blood are ________, carried in lipoproteins.
cholesterol and triglyceride
Classification of lipoproteins
High-density lipoproteins (HDL)
Low-density lipoproteins (LDL)
Very-low-density lipoproteins (VLDL)
Chylomicrons are made in ______ and travel via the _____ into the liver and via the ________ into the circulation.
Normally completely metabolized, transferring energy from food into muscle and fat cells.
the gut
portal vein
thoracic duct
The plaques in the arterial walls of patients with atherosclerosis contain large amounts of cholesterol, the higher the level of______, the greater the risk of atherosclerotic heart disease
low-density lipoproteins (LDL) cholesterol
The higher the ________, the lower the risk of coronary heart disease (CHD)
high-density lipoproteins (HDL) cholesterol
High total cholesterol levels are also associated with an increased risk of
CHD (coronary heart disease)
Arteriosclerotic cardiovascular disease requires treatment of
high to moderate intensity statin
LDL-C at or over 190 requires
High intensity statin
Goal for diabetics is to have LDL of
less than 70
LDL of 60 is ideal
Treatment for diabetics is
moderate intensity statin, unless they have a ASCVD risk of over 7.5%, then use a high intensity statin
Composition of cholesterol may be more important than just total cholesterol number
-Discrepancies on how to screen (athletes vs regular people)
Equation for calculating total cholesterol:
HDL + VLDL + LDL
Equation for VLDL cholesterol
Triglycerides / 5
Equation for LDL cholesterol
Total cholesterol - HDL - (Triglycerides / 5)
Familial hypercholesterolemia is
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
Familial hypercholesterolemia- Homozygotes have extremely high LDL levels present with ___________
atherosclerotic disease in childhood
Familial hypercholesterolemia- Heterozygotes have LDL concentrations _________; persons with this condition may develop _________
twice normal
CHD in their 30s or 40s
Familial hyperchylomicronemia-
notes say NOT on exam
Have marked hypertriglyceridemia with recurrent pancreatitis and hepatosplenomegaly in childhood
Factors that increase triglycerides and total cholesterol
- obesity (decreases HDL)
- sedentary lifestyle (decreases HDL only)
- DM
- hypothyroidism
- nephrotic syndrome
- chronic kidney disease
- obstructive liver disease
- Cushing disease (corticosteroid use)
- oral contraceptives
- diuretics
- beta blockers (decrease HDL)
Factors the decrease total cholesterol
- cirrhosis
2. malignancy
Alcohol use and cholesterol
controversial (1-2 glasses of wine increases HDL)
-may increase triglycerides
What will increase HDL?
ACTIVITY
How do most patients with high cholesterol present
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
Tendinous xanthomas
- On certain tendons (achilles, patella, back of the hand)
- High LDL concentrations
- On biopsy- may look like squamous cell carcinoma
Lipemia retinalis
- Cream-colored blood vessels (in the fundus)
- Extremely high triglyceride levels
KNOW PICTURES OF XANTHOMAS
WILL BE ON EXAM
Who should have their lipids measured?
All patients with cardiovascular disease and diabetes should have their lipids measured (ALWAYS TRUE- EXAM)
A complete lipid profile (total cholesterol, HDL cholesterol, and triglyceride levels) after an overnight fast should be obtained
LDL cholesterol greater than_____ 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.
190 mg/dL
For women, _____ may be more important than LDL.
Elderly >75 cholesterol may not be a risk factor.
low HDL
Framingham 10-year calculator (Table 28–1) includes CHD but not stroke risk
very controversial
Flow chart on slide 30
Criteria to asses risk:
Sex, age, total cholesterol, smoker/non smoker, HDL levels
Add all factors to get a 10 year risk; higher number= WORSE
Risk stratification looks at:
- Initial cholesterol measurement (mostly LDL, some subtypes of LDL are worse than others)
- high sensitivity C reactive protein (CRP), only indicates people will have coronary event who are already sick!!
- EBCT
- Homocysteine
- Fibrinogen
- Lipoprotein
- LDL subfractions
- ankle brachial index
Treatment is based on
KNOW FOR EXAM
- Clinical cardiovascular disease or diabetes
- Patient age
- LDL cholesterol greater than 190 mg/dL
- Estimated 10-year risk of developing cardiovascular disease
Diet as part of treatment
- Older thinking: Low fat, low cholesterol
- Current thinking: Mediterranean diet (fish, red wine, olive oil, omega 3; “good fats”)
Soluble fiber, garlic, vitamin C, pecans, plant sterols
Other risk factor reduction
- Smoking cessation
- Hypertension control
- ASA use, for pts after heart attack or stroke, or hypercoagulable patients, diabetic patients, LDL over 190
- Raising HDL? How? EXERCISE (aerobic), healthy fat, and low levels of alcohol (wine)
Treatment if clinical atherosclerotic CV disease (ASCVD) is present
EXAM
high intensity statin
moderate if over age 75
Treatment if primary elevation of LDL is over 190
EXAM
high intensity statin
Treatment if age 40-75, diabetic, LDL > 70
EXAM
moderate statin OR
high statin if 10 yr CVD risk is 7.5% or higher
Treatment is age 40-70, no clinical ASCVD or diabetes, LDL 70-189, estimated 10 year CVD risk is 7.5% or higher
EXAM
treat with moderate to high intensity statins
High intensity statins (lowers LDL by over 50%
Atorvastatin (high dose)
Rosuvastatin (high dose)
*Need a higher statin for people who have had a coronary event
Moderate intensity statins (lowers LDL by 30-50%)
Atorvastatin (low dose) Rosuvastatin (low dose) Simvastatin Pravastatin Lovastatin Fluvastatin
Low intensity statins
lowers LDL by less than 30%
Pravastatin (lowest dose)
Lovastatin (lowest dose)
Reason statins work so well
Decrease LDL and triglycerides and increase HDL
Side effects of statins
muscle aches and myopathies (cant start someone on high dose), GI issues, liver toxicity
Fibric acid- good for reducing _________
triglycerides
Gemfibrozil
Fenofibrate
First way to treat high triglyceride levels
TREAT WITH DIET FIRST!
Diet for treating high triglyceride levels
- Avoid alcohol, simple sugars, refined starches, saturated and trans fatty acids, and restricting total calories
- Control of secondary causes of high triglyceride levels
Drug therapy for treating high triglyceride levels
- Niacin: a fibric acid derivative
- Omega-3-acid ethyl esters
- HMG-CoA reductase inhibitor) is indicated
- Combinations of these medications may also be used
