Module 2.2 - Coronary Artery Disease and Hyperlipidemia Flashcards
1
Q
What causes CAD?
A
- It is caused by a partial or complete blockage or narrowing of the coronary arteries, usually a result of atherosclerosis or coronary spasm.
- It refers to the narrowing of the lumen of one of the coronary arteries.
- CAD is the leading cause of ischemic heart disease (IHD). IHD includes angina pectoris, myocardial infarction (MI) and silent myocardial ischemia. IHD accounts for one out of every six deaths in the United States.
- Atherosclerotic lesion formation (atherogenesis) is a complex interaction of risk factors. It is an inflammatory process, initiated by lipid deposition in the coronary arteries followed by atheroma formation.
2
Q
What are 4 non-modifiable risk factors for CAD?
A
- Age – increasing age increases risk
- Gender – Men have a 6-8 time higher risk than premenopausal women
- Race – Caucasian males have a higher mortality rate from CAD than men of other ethnic backgrounds. Women of other ethnic backgrounds have a higher mortality rate than Caucasian women.
- Heredity – FH of premature CAD increases risk
3
Q
What are 8 modifiable risk factors for CAD?
A
1. Smoking
- Causes low density lipoproteins (LDLs) to increase while decreasing high density lipoproteins (HDLs). Smokers have a 2-6 time greater risk of CAD than non-smokers
- Cessation of tobacco use restores the risk of CAD to that of a non-smoker over several years
- Smoking accounts for 36% of the population attributable risks of a first MI
- The risk of a second MI falls by 50% with absolute smoking cessation
- Thorough history of current smoking history is crucial-self reporting may not reflect actual use
2. Hypertension
- risk of CAD is 3 times higher if BP exceeds 160/95 mm/hg
- Is the most common risk factor for premature CAD
- Blood pressure at time of risk assessment may not reflect uncontrolled BP
- 24 hour monitoring may be indicated to capture all readings
- Goal BPs should be set in accordance with JNC guidelines and patients risk factors
3. Diabetes
- Is a CHD risk equivalent with uncontrolled DM increasing that risk
- Insulin resistance, hyperinsulinemia and elevated blood glucoses are associated with atherosclerosis
- Diabetics have a greater incidence of other risk factors including obesity, HTN and HLD
- Morbidity and mortality from T2DM include complications from macrovascular (CAD, stroke, PAD) as well as microvascular complications of retinopathy, nephropathy and neuropathy
4. Obesity
- particularly visceral body fat, BMI > 30 – obesity is overtaking smoking as the leading cause of premature deaths in the U.S.
- BMI goal is 18.5-24.9, waist circumference < 40 inches for men, men, < 35 inches for women
- Obesity contributes to other risk factors including DM and HTN
5. Psychological stress
- Can contribute to increased smoking and self-medicating with food and alcohol
- Non adherence to prescribed medications and treatment plans may occur
6. Oral contraceptive use
- especially in women over 35 years of age
- Can contribute to HTN and thromboembolic events
7. Hyperlipidemia
- CAD is seen with elevated triglyceride level, low density lipoprotein (LDL) and very low density (VLDLs)
- Traditionally, normal LDL without known CAD = <100 mg/dL and normal LDL with known CAD = < 70 mg/dL
- Other risk factors impact goals of therapy
- Low HDL levels are also associated with increased CAD risks
- Normal HDL level + > 35 mg/dL
8. Physical inactivity
- Regular physical activity is recommended from early school years throughout life
- Moderate intensity exercise for 150 minutes per week is the current recommendation
- Adults with limited mobility should strive to remain as physically active as their condition allows
4
Q
When conducting a cholesterol screen on a patient how long should the patient fast for and what labs should be ordered?
A
- Pt. should fast for 9-12 hours prior to lab draw
-
Cholesterol screen = total cholesterol, LDL, HDL and triglyceride levels
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5
Q
What are the indications to order a total cholesterol screen on a patient?
A
- Screening for a familiar lipid disorder (any patient)
- Establishing the risk factor for cardiovascular disease in a patient with no known history of the disease
- Screening any patient for the first time for a lipid disorder.
- Establish patient’s presence of or risks for CAD, carotid artery disease, PAD, AAA and DM
6
Q
What are the reference values for total cholesterol levels? (Desirable, borderline, & high cholesterol levels)
A
- Desirable is less than 200 mg/dl
- Borderline high 200-239 mg/dl
- high > 240 mg/dl
7
Q
What are the reference values for LDL levels?
A
- Optimal = less than 100 mg/dl
- Borderline = 130-159 mg/dl
- High = 160-189 mg/dl
- Very high = > 190 mg/dl
- With known CAD, goal is < 70 mg/dl
8
Q
What are the reference values for HDL levels?
A
- High = less than 40 mg/dl
- Boderline high = 40-49
- Desirable = > 50 mg/dl
9
Q
What are the reference values for Triglyceride levels?
A
- Desirable = < 150 mg/dl
- Borderline high = 150-199 mg/dl
- High = 200-499 mg/dl
- Very high = > 500 mg/dl
10
Q
What are 8 modifiable lifestyle changes to reduce risks of CAD and HLD?
A
1. Dietary Changes
- Reduce saturated fats
- Increase soluble fiber intake
- Add plant sterols
- Exercise and weight management to avoid metabolic syndrome
2. Smoking cessation
- Consider smoking cessation assistance with pharmacological help
- Complete cessation is the goal, decrease in smoking can improve risks slightly
3. BP control
- The lifetime risk for all forms of cardiovascular disease increase with uncontrolled HTN
- Beta blockers are first-line antihypertensives for patients with known CAD. If tolerated, they are also indicated for patients that do NOT have hypertension for beta blockade effects. Angina can be improved as well as exercise tolerance.
- Calcium channel blockers can be used alternatively
- Angiotensin-converting enzyme (ACE) inhibitors should be used in patients with CAD, DM or those with left ventricular dysfunction OR ARBs
4. Diabetes control
- Studies show higher glucose levels and Hemoglobin A1Cs correlated with increased atherosclerotic disease
- Diabetes + other risk factors increase the risk for CAD and recurrent myocardial infarctions
5. Antiplatelet Therapy
- Prevention of platelet aggregation. All patients with known CAD should be prescribed ASA (81 mg) unless contraindicated or Plavix 75 mg daily for secondary prevention of further events
- The use of antiplatelet therapy for primary prevention is not supported
6. Stress management
- Studies have shown a link between myocardial infarctions and sudden cardiac death
7. Oral contraceptive use discontinued
- Concerns about thromboembolic events have decreased with a decrease in both estrogen and progestin content
- Age limit for women who smoke is 35, unlimited for healthy nonsmoking women
8. Review need for Hormone replacement therapy
- The use of HRT after menopause is a major issue and remains unresolved
- Use of HRT strictly to reduce cardiovascular events is not recommended
11
Q
When should statins be initiated on patients to help lower cholesterol levels?
A
- Use an atherosclerotic cardiovascular disease calculator and if their risk is greater than 7.5% begin the patient on a high-intensity or moderate-intensity statin regimen.
- High-intensity statin therapy should be initiated as first-line therapy in both women and men < 75 years of age who have clinical atherosclerotic disease unless contraindicated.
- Patients > 75 years of age, the risks and benefits should be considered along with patient preference
- Adults 21 years of age or older with primary LDL-C of 190 mg/dl or greater should be initiated on a high-intensity statin therapy
12
Q
What are some High-Intensity statins?
A
These drugs lower cholesterol _>_50%
- Atorvastatin 40-80 mg
- Rosuvastatin 20-40 mg
13
Q
What are some moderate intensity statins?
A
These medications lower cholesterol by 30-50%:
- Atorvastatin 10-20 mg
- Rosuvastatin 5-10 mg
- Simvastatin 20-40 mg
- Pravastatin 40-80 mg
- Lovastatin 40 mg
- Fluvastatin 80 mg
- Pitavastatin 2-4 mg
14
Q
How do -statin medications work and what are some common adverse effects?
A
- MOA: Statins limit the synthesis of cholesterol and increase the catabolism of low-density lipoprotein (LDL) cholesterol (aka decreases LDL)
- S/X: Myopathy/myositis, interacts with many drugs
First line preferred therapy for lowering cholesterol
Obtain Baseline liver function tests prior to beginning drug therapy
