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Cardio Exam 2 > Treatment of Dyslipidemia > Flashcards

Treatment of Dyslipidemia Flashcards

1
Q

Class I

A

Benefits&raquo_space;> Risk

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2
Q

Class IIa

A

Benefits&raquo_space; Risk

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3
Q

Class IIb

A

Benefits >/= Risk

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4
Q

Class III

A

No benefit or harm

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5
Q

Level A-B of Evidence

A 
A = most
C= least
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6
Q

Dietary advice for LDL lowering

A

Intake of veggies, fruits, whole grains, low-fat dairy, pultry, fish, legumes, non-tropical veg oil
Limit sweets, sodas, red meats
5-6% of total calories form saturate fats
Reduce calories from trans fat

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7
Q

Exercise fo Dyslipidemia

A 
Aerobic activity
Decrease LDL and Increase HDL
3-4 sessions, 40 minutes per session
Moderate to vigorous activity
Resistance training may decrease LDL, TG and non HDL
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8
Q

Optimal LDL

A

<100

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9
Q

HDL levels

A

> 41

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10
Q

Desirable TC

A

<200

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11
Q

Total Cholesterol =

A

HDL, LDL, and TGs

So just bc this is high doesn’t mean the bad stuff is high

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12
Q

CK Labs

A

Creatinine Kinase to see if there is muscle breakdown

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13
Q

Who should have CK labs taken?

A 
Personal history of statin intolerance
FH of statin intolerance or muscle disease
Concomitant therapy that make increase risk of interactions
Clinical presentation (not serial)
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14
Q

Secondary causes of elevated LDL

A

saturated or trans fat, weight gain, anorexia
Giuretics, cyclosporine, glucocorticoids, amiodarone
Bilary obstruction, nephrotic syndrome
Hypothyroidism, obesity, pregnancy

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15
Q

Secondary causes of elevated TGs

A

Weight gain, lower fat diet, high intake of refine carbs, alcohol
Oral estrogens, glucocorticoids, BAS, PI, anabolic steroids, BB, thiazides
Nephrotic syndrome, CRF, lipodystrophies
DM, hypothyroidism, obesity, pregnancy

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16
Q

Risk factors for ASCVD

A

Primary relative with LDL >160 or genetic hyperlipidemia
Premature ASCVD in primary relative (men less than 55, women less than65)
Elevated hs-CRP >2
Elevated CAC
Ankle-branchial index less than 0.9

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17
Q

Primary Therapy

A

Statin based

  • Decreases LDL
  • Increases HDL and decreased TGs
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18
Q

Primary prevention =

A

Have NOT had a CV event before

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19
Q

Secondary prevention =

A

Have had a CV event before

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20
Q

High intensity treatment =

A

Needing 50% or more decrease in LDL levels
</=75 yeras without contraindication
No drug-drug interaction
No history of intolerance
— someone who has already had a MI should be on high

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21
Q

Moderate intensity treatment =

A

Needing 30-49% decrease in LDL levels
>75 years
Not able to tolerate high intensity

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22
Q

TG > 500 =

A

Assess underlying causes and target first because it can lead to pancreatitis

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23
Q

Statin Benefit Groups - Clinical ASCVD

A 
ACS (heart attack)
History of MI
Stabel or unstable angina
Coronary or arterial revascularization (stent)
Stroke or TIA
PAD of atherosclerotic origin
High risk of havinga  future ASCVD
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24
Q

High intensity drugs

A

Atorvastatin (Lipitor) 40-80 mg

Rosuvastatin (Crestor) 20-40 mg

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25
Other groups that benefit from statin therapy
Primary elevations in adults greater than 21 with greater than 190 mg/dL Primary prevention Diabetes age 40-75 with LDL 70-189 mg/dL Primary prevention with LDL 70-189 mg/dL
26
Primary elevations in adults >21 with > 190 mg/dL
At high risk bc of genetic causes (FH) Should receive high intensity and should intensify until at least greater than 50% LDL reduction After max on statin, can add other drugs to help Need to screen family members
27
Primary Prevention Diabetes age 40-75 with LDL 70-189 mg/dL
At least moderate therapy If 10 year risk is greater than 7.5% consider high If less than 40 or greater than 75 weigh risks and benefits
28
Primary prevention with LDL 70-189 mg/dL
Pool Cohort Equation: Estimate 10 year and lifetime risk Greater than 7.5 moderate to high 5-75 moderate
29
Statin Cholesterol Effects
Decrease LDL 18-63% Decrease TG 7-30% Increase HDL 5-15%
30
Moderate Intensity Drugs
``` Atorvastatin 10 mg Rosuvastatin 10 mg Simvastatin 20-40 mg Pravastatin 40 mg Lovastatin 40 mg ```
31
Low Intensity Drugs
Pravastatin 10-20 mg | Lovastatin 20 mg
32
QPM Drugs
Lovastatin Pravastatin Simvastatin
33
Statin AE
Increased LFTs (baseline --> 6-12 wks later --> annually) Myotoxicity (myalgia, myopathy) Rhabdomyolysis Increased risk with Fibric acid derivatives Pain, tenderness, stiffness, cramping, weakness, or fatigue New onset diabetes
34
Define myalgia
Muscle aches, soreness or weakness with minimal or no elevation in CK
35
Define myopathy
Muscle symptoms associated with elevation in CK >10X ULN
36
Define Rhabdomyolysis
A CK > 10,000 IU/L or 10X ULN with an elevation in serum creatinine or requiring IV hydration therapy - Dark brown pee (dehydrated)
37
Treatment of Muscle pain
D/C until it goes away, restart with a low dose of same statin If it comes back d/c and let resolve and start a low dose different statin If not the statins fault, restart statin at original dose
38
Statin contrindications
Liver disease Unexplained LFTs Pregnancy
39
Statin Drug interactions
Warfarin 3A4 Inhibitors Grapfruit juice Anything with an increase risk of myopathy
40
Statin Monitoring
Recheck FLP in 4-12 weeks Assess every 3-12 months after Reinforce adherence at each visit
41
Fibric Acid Derivatives
Primarily for hyperTGs
42
Fibric Acid Derivatives Cholesterol effects
Decreased TGs 20-50% Increased HDL 10-20% Decrease LDL 5-20% (may increase with gemifibrozil)
43
Gemfibrozil Outcomes
Primary prevention of CHD and secondary prevention of cardiac events in men with low HDL 600 mg BID
44
Fenofibrate Outcomes
Prevent CHD in T2DM Fenofibrate + simvastatin in T2DM pts 40-200 mg QD
45
Fibric Acid Derivatives AE and Monitoring
GI, rash, hepatoxicity, myalgias Drug interactions: warfarin, concurrent use with statins Renal function at baseline, 3 months then Q 6 months
46
Fibric Acid Derivatives Clinical Pearls
First line for hyperTG Fenofibrate preffered with statins Monitor renal esp with feno
47
Bile Acid Sequestrants
Primarily LDL lower
48
Bile Acid Sequestrants Cholesterol Effects
Decrease LDL 15-30% Increase HDL 3-5% TG +/- or Increased
49
Bile Acid Sequestrants Outcomes
Primary prevent in men | Secondary prevention in men
50
Cholestyramine resin
4 g 1-2 times/day up to 16-34 g/day Mixed with water Taken with meals
51
Micronized Colestipol
2-16 g/day in 2-4 doses
52
Colesevelam
2 tablets or 1.875 g packet BID
53
Bile Acid Sequestrants AE and Monitoring
GI Contraindicated in complete bowel obstruction Not absorbed Some contain phenylalanine Avoid if TG >300 and caution if 250-299 Check FLP baseline, 3 months and 6-12 months
54
Bile Acid Sequestrants Drug Interactions
Decrease absorption of other medications Take other meds 1 hour before or 4 hours after Supplement with vitamin ADEK, folic acid and Fe
55
Bile Acid Sequestrants Clinical pearls
Limited use due to tolerability and outcome data | Option for patients with contraindications due to liver impairment or another
56
Niacin Cholesterol effects
Decreased LDL 5-25% Decreased TG 20-50% Increased HDL 15-35%
57
Niacin Outcome
Inconsistent demonstrating benefits
58
Laropiprant
Decreased niacin induced flushing
59
Niacin IR
Usual dose 2 g/day doses up to 6 g/day
60
Niacin SR
1000 mg BID max of 2 g
61
Niacin ER
500 mg QHS x 4 weeks, increase to 100 mg QHS | Max 2 g
62
Niacin AE and monitoring
Flushing and itching secondary to PG-mediated vasodilation 325 mg aspirin 30 minutes before dose may decrease reaction Avoid spicy foods, alcohol, hot beverages, hot baths, to avoid flushing May increase uric acid and blood glc Hepatotoxicity GI
63
Niacin Labs
ALT, glc, hgb, A1c, uric acid | During titration and 6 months after stable
64
Do not use Niacin if:
ALTs >2-3 x ULN Persistent cutaneous symptoms Persistent hyperglycemia, acute gout or unexplained ab pain or GI symptoms
65
Niacin Drug interactions
Statins (myopathy) | Cholestyramine (Decrease absorption)
66
Niacin Clinical Pearls
Most potent to increase HDL Limited use due to lack of data and tolerability Do not use "no flush niacin" - inostilhexalicainate or nicotinamide (increased risk of hepatotoxicity)
67
Ezetimibe cholesterol effects
Decreased LDL 19% Decreased TG 8% HDL +/-
68
Ezetimibe AE and Monitoring
Generally well tolerated | With adn w/o statin: increase myopathy and LFTS
69
Ezetimibe Drug Interactions
Increased warfarin Decreased BAS Increase conc with cyclosporine
70
Ezetimibe Clinical Pearls
Do see modest reduction | Expensive
71
FA Cholesterol effects for Lovaza
Decreased TG 44% Increased HDL 9% Increased LDL 45%
72
FA Cholesterol effects for Vascepa
Decreased TG 27% Decreased HDL 4% Decreased LDL 5%
73
FA Outcome data
Lacking | Secondary prevention
74
FA Adverse reaction
GI | Taste perversion
75
Lovaza dosing
4 g daily
76
Icosapent dosing
4 g daily
77
FA Clinical Pearls
May consider in patient with high TG Decreased risk for hepatotoxicity and CYP450 interactions Icospanent (V) dose not decrease LDL Icospanent is NOT as effect at lower TGs
78
Statin + BAS
Improved LDL reduction
79
Statin + Ezetimibe
Improved LDL reduction
80
Statin + Fibric acid derivative
Decreased TGs and likely LDL
81
Statin + niacin
Improved LDL and TGs
82
Naicin + BAS
Improved LDL

Cardio Exam 2 (10 decks)

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