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Class 9
Cardiovascular Hyperlipidemia HTN Obesity
| Question | Answer |
|---|---|
| Identify cardiovascular risk factors for hyperlipidemia (Slide #31 & Cecil Page 87 Table 8-1, ATPIII Step3) | Cigarette smoking Hypertension--BP>140/90 or on medication Low HDL cholesterol--<40 mg/dL Family history of premature CHD CHD in male first degree relative <55 years CHD in female first degree relative <65 years Men > 45 years Women > 55 years |
| Describe epidemiology, of hyperlipidemia. (Slide #3) | CAD risk increased by 5 if cholesterol >209 For every 10mg/dL elevation in cholesterol there is a 10% increase in heart disease For every 5 mg/dL increase in HDL, heart disease risk decreased by 10% Fewer than 10% of women with heart disease utilize |
| Describe pathophysiology of hyperlipidemia. (Slide 5, 6, | - Serum elevations of the lower density particles are correlated with cardiovascular disease LDL lipoprotein is most strongly correlated with INCREASED CV disease - VLDL -increase cardiovascular risk. Mostly triglyceride - HDL -elevations are corre |
| Describe clinical findings of hyperlipidemia (Slide 12-16) | - Xanthomas (Tendinous, Tuberous, Eruptive, Planar) - Opthalmologic (Corneal arcus <40y, lipemia retina,) - Cardiovascular (Atherosclerosis, Aortic Stenosis-genetic) - Gastrointestinal (Pancreatitis-elevated triglycerides, cholelithiasis) - Musculosk |
| *** Describe methods of diagnosing hyperlipidemia | Fasting total cholesterol, triglyceride and lipoprotein assessments are required for diagnosis, page 691 Cecil. |
| Classification of LDL cholesterol (Slide 27) | <100 -Optimal 100-129 -Near or above optimal 130-159 -Boderline high 169-189 -High >/=190 -Very high |
| Classification of total cholesterol (Slide 27) | <200 -Desirable 200-239 -Boderline high >/=240 -High |
| Classification of HDL cholesterol (Slide 27) | <40 -Low (associated with increased risk) >/=60 -High (associated with less risk) |
| *** Construct a treatment plan for different clients with hyperlipidemia (Slide 28) | Risk Assessment Primary Prevention Secondary Prevention LDL-Lowering Therapy Therapeutic Lifestyle Changes (TLC) |
| Risk Assessment (Slide 29) | All adults age > 20 need fasting lipoprotein profile once every 5 years Total cholesterol LDL cholesterol HDL cholesterol Triglyceride |
| Pediatric Risk Assessment (Slide 30) | Children and adolescents who have a family history of elevated cholesterol and/or heart disease Children whose family history is unknown Children who have risk factors-such as DM, obesity, htn (Nelson Essential of Pediatrics, 6th ed., pg. 27) |
| Primary Prevention (Slide 40) | Clients without established CHD - Reduce intake of saturated fat and cholesterol - Increased physical activity - Weight control - Drug therapy in some selected clients All patients with elevated LDL cholesterol or other form of |
| Secondary Prevention (Slide 42) | - Clients with established CHD or CHD equivalents - Goal of therapy is < 100 mg/dL with < 70 mg/dL as an option - Therapeutic lifestyle changes - Drug therapy |
| LDL Lowering Therapy (Slide 43) | Two modalities of LDL-lowering therapy TLC--therapeutic lifestyle changes Drug therapy |
| Update ACC/AHA Guidelines, 2013. NIH 2011 screening recommendations Major changes (Slide 44) | For very high risk -LDL goal of < 70 mg/dL is an option. For moderately high risk -LDL goal is 130, but < 100 mg/dL is an option Drug therapy in high risk/moderately high risk -Try to achieve 30-40% reduction in baseline LDL levels No changes for l |
| Therapeutic Lifestyle Change (TLC) (Slide 45) | Nutrition Weight reduction Physical activity |
| Role of nutrition (Slide 45) | Transfatty acids (saturated fats)-reduce/eliminate Role of omega-3 oils (cold H20 fish/fish oil)-add to diet Soy protein-add to diet Plant stanol/sterol margarines (Benecol) –add to diet Viscous fiber sources (soluble fiber)-add to diet |
| CHD risk equivalents (know these!) (Slide 34) | Other forms of atherosclerotic disease - peripheral vascular disease - abdominal aortic aneurysm - symptomatic carotid artery disease Diabetes |
| Name major drugs for treating hyperlipidemia | Statins (non-statins are not recommended in most cases) Bile acid sequestrants Nicotinic acid Fibric acid derivatives Adjunctive agent that acts of brush border of gut (Zetia) |
| High dose Statin (average LDL reduction about 50% or higher) (retrieved from Guidelines prescriber's letter) | - Atorvastatin 80 mg once daily (40 mg if 80 mg not tolerated). - Rosuvastatin 20 mg to 40 mg once daily. |
| Moderate-dose Statin (average LDL reduction about 30 to <50%): | - Atorvastatin 10 to 20 mg once daily.b - Fluvastatin 40 mg twice daily or 80 mg (XL) once daily. - Lovastatin 40 mg once daily. - Pitavastatin 2 to 4 mg once daily.b - Pravastatin 40 to 80 mg once daily.b - Rosuvastatin 5 to 10 mg once daily.b - S |
| Low-dose Statin (average LDL reduction <30%): | - Fluvastatin 20 to 40 mg once daily. - Lovastatin 20 mg once daily. - Pitavastatin 1 mg once daily. - Pravastatin 10 to 20 mg once daily. - Simvastatin 10 mg once daily. |
| Indication for high-dose statin (retrieved from Guidelines prescriber's letter) | - Secondary prevention in adults 75 years of age and younger. (Level A) - Primary prevention in adults with LDL 190 mg/dL (5 mmol/L) or higher. (Level A) - Primary prevention in adults 40 to 75 years of age with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L |
| Indication for moderate-dose statin (retrieved from Guidelines prescriber's letter | - Secondary prevention in adults older than 75 years. (Level A) - Patients who cannot tolerate a high-dose statin. - Primary prevention in adults 40 to 75 years of age with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L) and an estimated 10-year risk of ather |
| Indication for Nonstatin | - Triglycerides 500 mg/dL or higher (use omega-3 fatty acids [e.g., fish oil], niacin, or fenofibrate). - Patients who cannot tolerate the recommended statin dose or do not achieve the expected statin response and are high-risk (i.e., patient with LDL |
| What to do before initiating nonstatin | - Reinforce statin adherence and lifestyle changes, and check for secondary causes before adding a non statin. ** Do not add gemfibrozil to statin therapy. **No proof adding a non statin to a statin further reduces cardiovascular risk. |
| What is the side effect of statins (retrieved from ATP III Guideline) | Myopathy Increased liver enzymes |
| What is the side effect of bile acid sequestrants (Cholestyramine, Colestipol, Colesevelam) | Gastrointestinal distress Constipation Decreased absorption of other drugs |
| What is the side effect of nicotinic acid (Crystalline, Niaspan) | Flushing Hyperglycemia Hyperuricemia (gout) Upper GI distress Hepatotoxicity |
| Side effect of fibric acids (Gemfibrozil, Fenofibrate, Clofibrate) | Dyspepsia Gallstones Myopathy |
| Define Obesity | Excess of adipose tissue Manifested by body weight in excess of 20% or a BMI of 30 or higher. Two types: Upper body (apple-shaped-greater risk for DM2, CAD, CVA, early death; lower body (pear-shaped) In pediatric obesity is equal to or greater than 9 |
| Morbidity associated with obesity (Obesity slide 5) | National Health and Nutrition Exam Survey III reports 59.4% of men are overweight 49.9% of women are overweight Almost 20% of men and 25.1% of women are obese Incidence of obesity is higher in lower socioeconomic classes Higher incidence in African A |
| Mortality associated with obesity | |
| Risk factors associated with obesity | Type 2 DM CAD CVA Early deathcd |
| Prevention, treatment and teaching related to obesity | |
| Pneumonic for secondary HTN causes (ABCDE) | Accuracy, aldosteronism, apnea Bruits, bad kidneys Catecholamines, Cushing’s, Coarct Drugs, diet Endocrine, erythropoeitin |
| Meds that can elevate BP | Oral contraceptives Cyclosporine Tricyclic antidepressants Sympathomimetic decongestants Appetite suppressants Corticosteroids NSAIDs Erythropoietin Anabolic steroids / corticosteroids MAOI Norepineprine reuptake inhibitors Stop drugs if can be |
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