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M103 T3 L17 Flashcards

1
Q

From what age can atherosclerosis start?

A

as early as the age 10

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2
Q

What are risk factors for atherosclerosis?

A

unhealthy lifestyle
obesity
physical inactivity
poor diet

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3
Q

How does atherosclerosis progress?

A

can become fibrotic
the fibrotic plaques are prone to calcification
it is irreversible at a later stage of life

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4
Q

What complications can fibrotic plaques cause to atherosclerosis patients? (MiSGA)

A

myocardial infarction
stroke
gangrene
aneurysm

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5
Q

What was the aim of the Framingham heart study (1948)?

A

to identify risk factors that contribute to CVS disease in a large group of participants living in Framingham, Massachussets, with no history of cardiovascular disease, and they follow them throughout their life

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6
Q

What were two locations of famous heart studies?

A

Framingham (1948)

Caerphilly (1979)

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7
Q

What did the Framingham and Caerphilly heart studies have in common?

A

the study was confined to a specific city each time which were well defined and had tough immigration laws

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8
Q

What did the Framingham Heart Study find to be major CVD risk factors?

A 
High blood pressure
High blood cholesterol
Smoking
Obesity
Diabetes
Physical inactivity 
blood triglyceride and HDL cholesterol levels
age, gender, and psychosocial issues
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9
Q

Why was the Cholesterol Treatment Trialists Collaboration (1994) established?

A

was set up after it was recognised that no single lipid intervention trial would be likely to have sufficient number of cases, reliably assess mortality outcomes or look at the events in particular type of patients

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10
Q

Which groups of people were involved in the Cholesterol Treatment Trialists Collaboration?

A 
statisticians
research scientists
cardiologists
epidemiologists
lipid allergy researchers 
clinical trialists
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11
Q

What was the aim of the Cholesterol Treatment Trialists Collaboration (1994)?

A

to conduct periodic meta-analyses of large-scale (≥1000 participants), long-term (≥2 years treatment duaration) unconfounded, randomized controlled trials of lipid intervention therapies

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12
Q

What did the Cholesterol Treatment Trialists Collaboration (1994) investigate?

A

treatment of high cholesterol and largely focussed on statin therapy and efficacy and safety

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13
Q

What did the Cholesterol Treatment Trialists Collaboration conclude?

A

a reduction of LDL cholesterol using statin therapy substantially reduces the risk of major CVS events
shows that statin therapy works regardless of age, gender, ethnicity, etc

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14
Q

What is the aim of the Copenhagen City Heart Study?

A

the prevention of CHD and stroke

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15
Q

What study group does the Copenhagen City Heart Study look at?

A

a random sample of white men and women aged 20–93 years

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16
Q

How does the Copenhagen City Heart Study collect information?

A

questionnaires
clinical assessment
biomarkers

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17
Q

What are the two major types of risk factors for CVD?

A

modifiable (smoking, obesity, diabetes, excess alcoholm hypertension, high cholesterol)
unmodifiable (age, gender, genetics)

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18
Q

What are the functions of the National Institute for Health and Care Excellence?

A

Provides national guidance advice
provides quality standards and information services for health, public health and social care
containsresources to help maximise use of evidence and guidance

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19
Q

What does the NICE lipid modification guideline CG181 state?

A

it advises to use key risk risk assessment tool to assess the risk for primary prevention in patients in the general population

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20
Q

Why do we treat lipid disorders that are asymptomatic?

A

to reduce the atherosclerotic process and the incidence of clinical vascular disease
to prevent pancreatitis which is associated with grossly increased serum triglyceride

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21
Q

What do LDLRs recognise?

A

ApoB-100 proteins

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22
Q

Where are ApoB-100s present?

A

they are embedded in the PPLPD outer layer of LDL particles

they are present on most cells but the majority on the liver

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23
Q

How are LDL particles removed from circulation

A

LDLR on hepatocytes binds to them and removes them from the circulation
the LDLR then return to the cell surface to repeat this process

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24
Q

What is the first line treatment in hypercholesterolaemia and why?

A

Statins - they inhibit HMGCoA reductase inhibitor so the concentration of cholesterol eventually goes down

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25
How does ezetimibe work?
it's metabolised into ezetimibe glucuronide this inhibits the NPC1L1 membrane transporter reduces biliary cholesterol reabsorption
26
What is the active metabolite of ezetimibe?
Ezetimibe glucuronide
27
What is the effect of 10 mg/day of ezetimibe?
20% reduction in LDLC | 8% reduction in TG
28
What is the function of PCSK9 protein?
it controls the number of LDLRs on the surface of hepatocyte by stopping them getting back from inside the cell it increases the concentration of LDL
29
What happens when PCSK9 proteins are inhibited / blocked?
there is increased LDLR to remove LDLC from circulation
30
What medication involves PCSK9 proteins?
PCSK9 inhibitor drugs
31
How often are PCSK9 inhibitor drugs administered and how?
bimonthly - subcutaneous injections
32
What observation resulted into research to develop PCSK9 inhibitors?
that naturally occurring loss-of-function polymorphisms caused the under-expression of PCSK9 and led to lower LDLC levels
33
What are the three main patterns of lipoprotein abnormality?
Hypercholesterolaemia Mixed hyperlipidaemia Hypertriglyceridaemia (less common)
34
What type of patients is Mixed hyperlipidaemia usually seen in?
patients with glucose intolerance | diabetics
35
What is Mixed hyperlipidaemia caused by?
increased production and reduced breakdown of triglyceride-rich lipoproteins
36
What are features of Mixed hyperlipidaemia?
raised TC, LDLC and TG | often low HDLC
37
What is the total cholesterol level in hetero and homozygotic patients with FH?
het- 9 mmol/L | homo- 15–30 mmol/L
38
What conditions will a patient with Hypertriglyceridaemia usually have?
metabolic syndrome glucose intolerance low level of physical activity poor diet
39
What is Hypertriglyceridaemia usually caused by?
increased production and reduce breakdown of triglyceride
40
Which patients might have a very high level of triglycerides
patients with familial conditions | patients who drink excessive amount of alcohol
41
Which patients might have an isolated raised level of triglycerides in their patient lipid profile?
patients with familial conditions patients who drink excessive amount of alcohol patients presenting with new onset diabetes
42
What does lipoprotein a contain?
a LDL-like particle ApoB Apo(a)
43
What is an increase in Lp(a) concentrations associated with?
myocardial infarction stroke aortic valve stenosis
44
What Lp(a) concentrations show an intermediate or high risk of CVD?
≥3% over 10 years of fatal CVD | >10% over 10 years of fatal and non-fatal CVD
45
Which conditions are associated with a higher concentration of Lp(a)?
``` premature CVD, FH recurrent CVD (even with statins) ```
46
How is a high Lp(a) concentration in the blood treated?
drugs (approved & investigational) that lower Lp(a) | three effective therapies on continued trial
47
What are the three effective therapies on trial that have the potential to lower Lp(a) concentration in the blood?
Lipid apheresis PCSK9i Antisense therapy
48
What is the effect of lifestyle changes a on blood Lp(a) concentration?
lifestyle changes have marginal effects on the concentration
49
What is the statistical effect of lipid apheresis therapy on major CVS event rates?
80-90% reduction
50
What is the statistical effect of PCSK9i therapy on blood Lp(a) concentration?
reduce levels by 25%
51
What is the statistical effect of antisense therapy on blood Lp(a) concentration?
can reduce LP(a) levels by up to 90%
52
What happens during antisense therapy?
small molecules of PCSK9i directly bind to apo(a) mRNA in the nucleus of hepatocytes
53
What are two disadvantages of LDL-apheresis?
the procedure is very invasive | patients have to get it done often
54
How is PCSK9i administered?
injections
55
Has PCSK9i been approved?
no, it is still in trial phase 3 in India
56
What is the level of Lp(a) that is associated with increased risk of cardiovascular disease?
values of Lp(a) above 300 mg/L
57
How common is FH?
1 / 200-250 in the UK
58
Where are the different places the mutations responsible for FH might be?
in the LDLR gene (most common, loss of function) in the Apo(b) gene (loss of function) in the PCSK9 gene (gain of function)
59
At what age does FH usually present in heterozygous patients?
50 year old - male | 60 year old - female
60
How does FH present?
tendon xanthoma | corneal arcus
61
What is tendon xanthoma caused by?
the accumulation of fat in macrophages in the skin
62
What age group is corneal arcus uncommon in?
under 40s
63
How is FH treated?
Low Saturated Fat Diet and exercise Statins Possible addition of cholesterol absorption inhibitor (ezetimibe) Rarely resins/surgery/LDL apheresis Anti–PCSK9 Involve patient self help group, offer DNA testing and get the family tested.
64
What does ezetimibe do?
a inhibits cholesterol absorption in the small bowel
65
When Ezetimibe is absorbed in the SI, what percentage is metabolized into Ezetimibe Glucuronide?
more than 80%
66
What is the difference between the efficacy of a drug and its active metabolite form?
the active metabolite form has similar effects to those of the parent drug but weaker, although they can still be significant
67
What membrane transporter is inhibited by ezetimibe glucuronide?
NPC1L1

M103 T3 (21 decks)

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