Treatment of Hyperlipidaemia

Question 1

What is atherosclerosis?

Answer 1

response to injury - as you accumulate risk factors you damage your vascular internal and inevitably you end up with some form of atherosclerosis -

risk factors:

smoking, diabetes etc

Question 2

what are some modifiable risk factors for cardiovascular disease?

Answer 2

•Modifiable

–Smoking

–Dyslipidaemia

• raised LDL cholesterol
• low HDL cholesterol
• raised triglycerides

–Raised blood pressure

–Diabetes mellitus

–Obesity

–Dietary factors

–Lack of exercise

–Excess alcohol consumption

Question 3

what is the single greatest predictor of cardiovscular disease?

Answer 3

family history

Question 4

what are the good/bad types of lipids?

Answer 4

low density lipoprotein = bad

high density lipoprotein?= good

Question 5

describe the process of atherosclerosis and it’s association with hyperlipidemia

Answer 5

As you damage the endothelium – monocytes attack to the endothelium = oxidized LDLs are taken up by monocytes which then migrate into the subendothelium and then plaque developments form

Question 6

how are lipoproteins classified?

Answer 6

by density

Based on density:

• Chylomicrons (non-atherogenic)
• Very low-density lipoprotein (VLDL)

•

•Intermediate-density lipoprotein (IDL)

•

•Low-density lipoprotein (LDL)

•

•High-density lipoprotein (HDL).

Question 7

how do you raise your good cholesterol?

Answer 7

you raise your HDL cholesterol - by consistently exercising - it’s one of the reasons that exercise works

Question 8

Why is HDL good for you?

Answer 8

Mechanism may be

due to reverse cholesterol

transport (Probably other mechanisms e.g. antiinflammatory, antioxidative.)

Question 9

what is the difference between primary prevention and secondary prevention in CVD?

Answer 9

primary = stop heart attack from occuring in the first place

secondary = stop heart attack from occuring again with drug therapy

Question 10

the more risk factors….?

Answer 10

the more aggressive the treatment

Question 11

obesity raises the risk of morbidity from… ?

Answer 11

• Hypertension
• Dyslipidemia
• Type II diabetes mellitus
• Coronary heart disease
• Stroke
• Gallbladder disease
• Osteoarthritis
• Sleep apnea
• Cancer

Question 12

are triglycerides bad for you?

Answer 12

yes. rarely you’ll find isolated raised triglycerides - it’s usually involved with other condiitons

Question 13

a 65 year old diabetic, hypothyroidetic, obese, boozy, and he is on the pill, presents to the clinic with a raised cholesterol… what do you do?

Answer 13

if you have a primary reason for high cholesterol - treat it - find the cause and stomp on it

Question 14

how do statins work?

Answer 14

• The statins are the most effective and best-tolerated agents for treating dyslipidemia.
• These drugs are competitive inhibitors of HMG-CoA reductase

Question 15

what do you use to lower triglycerides?

Answer 15

with a fibrate

Question 16

what is the effect of statins?

Answer 16

lower LDL

raise HDL

lower Triglycerides

Question 17

why might you use a different statin?

Answer 17

people have differences in metabolism - so if you have side effects on one, use a different one

Question 18

what are some proven adverse effects of statins?

Answer 18

•Myopathy

• defined as muscle pain or weakness combined with large increases in blood concentrations of creatinine kinase
• Diabetes you will cause in some people
• It is likely that the risk of haemorrhagic stroke is increased
• the net benefit of the drug far outweighs the side effects

Question 19

what are some myths about statins ?

Answer 19

nocebo - if you tell someone about the side effects, they’ll start to feel like they have them- it’s the opposite of the placebo

muscle pain?- muscle pain on a placebo is the same as muscle pain on statins

memory loss?- nope

cataracts? nope

erectile dysfunciton? Nope

Will you find evidece of this in literature? Yes. Do the statins cuase this? No.

Question 20

risk of myopathy with statins increases with what?

Answer 20

increases with concentration

Question 21

what factors may increase statin risk?

Answer 21

drugs that effect the catabolism of statins - increase risk of myopathy

measure a CK before prescribing a Statin in the following situations.

• Renal impairment
• Hypothyroidism
• Personal or family history of hereditary muscular disorders
• Previous history of muscular toxicity with a statin or fibrate
• Alcohol abuse
• Elderly patient
• Clinical monitoring is essential in these patients
• If CK levels are significantly elevated do not use a Statin

Question 22

how do fibrates work?

Answer 22

we don’re really know - invovles interaction with the nuclear transcription factor PPAR that regulates several genes invovled in lipid metabolism

Question 23

What are Bile-Acid binding sequestrants?

Answer 23

bile-acid binding resins stop absorption of bile - they are very effective drugs - they are not absorbed by the body so they are super safe!

Question 24

the benefits of statin therapy depends on what?

Answer 24

depends on the individuals absolute risk

• Lowering LDL by 2 mmol/L for 5 years in 10,000 patients would typically prevent major vascular events from occurring in about 1000 patients (10% absolute benefit) with pre-existing occlusive vascular disease (secondary prevention).
• And in 500 patients (5% absolute benefit) who are at increased risk but have not yet had a vascular event (primary prevention)

Question 25

What is the biggest concern with statins? What increases this risk?

Answer 25

myopathy = biggest risk

• increase risk of this with concentration of statins or drugs that effect statin catabolism

Question 26

is it true to say that statins are extremely beneficial for a small subgroup of the population and not effective for a larger group?

Answer 26

that’s a fair statement - you cannot measure individual risk. You cannot prove that someone ‘would have’ had a heart attack if not on statins