Module 6 cardiac Flashcards
What are the risk factors for CV disease?
gender, age cigarette smoking, DM, HTN, dyslipidemia
Which lipoproteins are associated with hyperlipidemia?
Decreased amount of High-density lipoproteins (HDL-C)
At which point in the cholesterol synthesis pathway do the statins intervene?
HMG CoA- inhibits this step to decrease the amount of endogenous cholesterol in our body
What does the LDL-C do? And what are the important aspects to remember?
“Bad” cholesterol
60% of total cholesterol in body
transports cholesterol to peripheral cells
excess initiates atherosclerosis
predictor for CV disease
Primary target of cholesterol lowering therapy
What is HDL-C and what does it do?
“Good” cholesterol
20-30% of cholesterol in body
transports cholesterol from peripheral tissues and vessels to liver and kidneys for removal
What is VLDL-C and what is its purpose?
Made up of triglycerides
produced by liver
precursor to LDL
There are primary and secondary causes of hyperlipidemia. What are the primary causes?
genetics
There are primary and secondary causes of hyperlipidemia. What are the secondary causes?
Diet (high fat)
Underlying disease (DM, Liver disease, CRF, alcoholism)
Medications (estrogens, protease inhibitors, steroids, thiazides, beta blockers)
What effect does estrogen have on cholesterol?
decreases LDL
increases HDL
but increases triglycerides
What determines the patient’s LDL goal?
Coronary hear disease risk assessment
Risk factor status
What are the determinants of the CHD risk assessment?
MI Myocardial ischemia angina coronary angioplasty coronary artery surgery DM Peripheral arterial disease AAA Carotid artery disease
What are the risk factors to count after the CHD risk assessment is complete?
Cigarette smoking
Hypertension (140/90)
Low HDL (45, women =/> 55)
After completing the Framingham scoring, your patient has a 10year risk of >20%, what is their LDL-C goal?
<100mg/dl
After completing the Framingham scoring, your patient has a 10year risk of </= 20%, what is their LDL-C goal?
<130 mg/dl
For those patients with 0-1 risk factor and no need for further risk factor assessment, what would their LDL-C goal be?
<160 mg/dl
What are the items to score in the Framingham risk assessment?
Age Total cholesterol Smoking status HDL level Systolic blood pressure
What is the normal/accepted HDL range?
40-60 mg/dl
What is the accepted/normal level for total cholesterol?
<200 mg/dl
What does a lipoprotein analysis include?
total cholesterol
LDL-C
HDL-C
triglycerides
What is the accepted/normal for triglycerides?
<150 mg/dl
What is considered the “cornerstone” in LDL-lowering therapy?
Lifestyle changes
What are the 4 lifestyle modifications encouraged in lowering LDL levels?
Reduce intake of cholesterol
soluble fiber intake of 10-25g/d
Weight reduction
Increased physical activity
Describe the progression of drug therapy in primary prevention of hyperlipidemia.
- Initiate statin or bile acid sequestrant or nicotinic acid
- In 6 weeks, if goal not acheived, intensify same medications
- In 6 weeks, if goal acheived, treat other lipid risk factors. If goal not acheived, refer to specialist.
- Monitor Q4-6 months
What is the main concern in increasing the lipid lowering medications?
rhabdomyolosis
What are the four drug classifications used in treatment of dyslipidemia?
HMG CoA Reductase Inhibitors (Statins)
Bile acid sequestrants
nicotinic acid (Niacin)
Fibric acids
What are the contraindications in using HMG CoA Reductase inhibitors?
Liver disease (absolutely do not use)
CYP450meds
Antifungals
macrolides
Name the HMG CoA Reductase inhibitors.
lovastatin (Mevacor) pravastatin (Pravachol) simvastatin (Zocor) fluvastatin (Lescol) atorvastatin (Lipitor) rosuvastatin (Crestor) newest
When do the HMG CoA Reductase inhibitors work best?
when taken before bed
What are the major side effects of HMG CoA reductase inhibitors?
Myopathy
increased liver enzymes
Are bile acid sequestrants systemic acting?
No
What effect do bile acid sequestrants have on triglycerides?
increases triglyceride levels
What are the side effects of bile acid sequestrants?
GI distress/constipation
decreased absorption of other drugs (HCTZ, warfarin, digoxin, thyroid meds, BBs, statins)
When is the use of bile acid sequestrants contraindicated?
TG level of more than 400
dysbetalipoproteinemia (increases TG = acute pancreatitis)
What are the common bile acid sequestrants used?
cholestyramine (Questran)
colestipol (Colestid)
colesevelam (Welchol)
Which medication is used to raise the HDL level once the LDL goal has been reached?
Nicotinic acid
What does nicotinic acid do?
decreases the production of VLDL which eventually becomes LDL and raises HDL
What are the side effects of nicotinic acid?
flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity
When is nicotinic acid contraindicated?
liver disease
severe gout
peptic ulcer
What is an important aspect in patient education regarding nictonic acid?
Side effects lessen over time
What is the major drug interaction in using fibric acids?
Warfarin - more warfarin is available in blood, increasing anticoagulant effect
What do fibric acids do?
decreases hepatic TG production and VLDL synthesis
Name the 2 fibric acids used.
gemfibrozil (Lopid)
fenofibrate (Tricor)
What does ezetimibe (Zetia) do?
inhibits the absorption of cholesterol by the small intestine
What drug interactions are of concern in using ezetimibe (Zetia)?
fibric acids and cyclosporines block the absorption of Zetia
What is the purpose of taking fish oil (omega-3 fatty acids)?
decreases TG/VLDL
What are the main risks associated with a triglyceride level > 500?
pancreatitis, increased risk for atherosclerosis
What is the treatment for hypertriglyceridemia?
dietary fat restriction ETOH restriction weight reduction treat coexisting conditions medications: fibric acids, niacin, fish oil, statins
What are the four types of medications used in treating Coronary Artery Disease?
Nitrates
Beta Blockers
Calcium Channel Blockers
What do nitrates do?
Reduce cardiac preload
Dilate coronary arteries
What are the 3 nitrates commonly prescribed?
Nitroglycerin
isosorbide dinitrate
isosorbide mononitrate
What is the timeframe that a patient being treated with nitrates should be nitrate FREE?
8-12 hours
What is the first line nitroglycerin agent?
Sublingual nitroglycerin