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Cardio Exam 2: Hyperlipidemia
Cardio Exam 2: Hyperlipidemia
100
Anatomy
Graduate
10/11/2011
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Term
3 of the following 5 criteria are required for dx of metabolic syndrome:
 Definition
- Waist circumference greater than 40 in in men and 35 in in women
- Triglycerides greater than or equal to 150
- Low HDL, less than 40 for men, less than 50 for women
- Raised blood pressure ,greater than or equal to 130/85
- Fasting blood glucose greater than or equal to 110
Term
LDL enters endothelium and intima> oxidized, macrophages and smooth muscle join> foam cells and fatty plaques> grow and grow and grow> plaque becomes unstable and fractures> clot forms> heart attack
 Definition
Term
Endothelial dysfunction: ability for LDL to pass through endothelium as well and stay and be oxidized, affected by bp and high cholesterol, know this definition
 Definition
Term
Most imortant factor influencing endothelial dysfunction and atherosclerotic plaque formation is __.
 Definition
dislipidemia
Term
complications of dislipidema:
 Definition
Cardiovascular Disease

Obesity

HTN

PVD

Cancer

Combined with DM - Increased risk of CHD

Combined with HTN - Increased risk of CHD/CVA
Term
Risk factors for hyperlipidemia:
 Definition
High Fat/High Cholesterol Diet 

Obesity         

Family History/Genetic   

BCP use     

Smoking

Diabetes and Insulin Resistance

Hypertension

Medications  Beta blockers, diuretics, anabolic and corticosteroids, estrogens and progestins, protease inhibitors may elevate lipid levels
Term
Medications that my cause/contribute to hyperlipidemia:
 Definition
- beta blockers
- diuretics
- corticosteroids
- bcps
- protease inhibitors
Term
75-80% of diabetic pts have visceral adiposity.
 Definition
Term
Causes of Hyperlipidemia
Primary
Familial
Genetic
Familial hypercholesterolemia
Familial hyperchylomicronemia

Secondary (most common)
Often a combination of primary and secondary
Obesity
Diabetes
Thyroid Ds.
Sedentary Lifestyle
Medications
Liver and Renal Disease
Cushing's Disease
 Definition
Term
Types of Lipids
Cholesterol
Role in cell wall structure, bile and hormone production
Most associated with atherogenesis and CV disease
Produced in the body in amounts that do not require exogenous sources

Triglycerides
Primary lipid in the body
Primary storage form of lipid
Highest concentration in LDL’s/VLDL
Elevated levels associated with increased CV risk but association not well understood
 Definition
Current theory is that high trigs mask high particle numbers of LDLs> increased cardiovascular diseae.
Term
Lipoproteins
Responsible for lipid transport
As well as composed of lipids but proteins called apoproteins
Classified by density
Chylomicrons Least dense. Formed to carry fats from the gut.
HDL  Most dense and smallest
HDL-C is the most important HDL for CV health
LDL
VLDL --> least dense and largest LDL. Composed mainly of triglycerides
IDL
LDL --> smaller and most cholesterol dense --> most associated with atherogenesis (LDL-c)
Lipoprotein (a)
An LDL like lipoprotein particle also involved in lipid transport. Also contains Apolipoprotein B.
 Definition
Term
The __ and __ the LDL, the more atherogenic it is. ___ __ is the smallest LDL, so it is the most atherogenics.
 Definition
- smaller and denser
- Lipoprotein A
Term
Lipoprotein A has ___ __, which is the driver of all bad cholesterols.
 Definition
apoprotein B
Term
Apolipoproteins
Apolipoproteins are proteins that bind to lipids. They form lipoproteins which transport lipids such as LDL through the bloodstream. These proteins enhance and are involved in controlling lipid transport.

Apolipoproteins also serve as enzyme co-factors, receptor ligands, and lipid transfer carriers that regulate the metabolism of lipoproteins and their uptake in tissues.

Six Classes of Apolipoproteins  A, B, C, D, E, H

Apolipoprotein B is found in all lipoproteins especially chylomicrons, VLDL, IDL, and LDL.
Apo B-100 specific for all LDL particles
 Definition
Term
___ is a key tool to understanding lipid risks in pts.
 Definition
Apoprotein B
Term
__ _ is closely associated with HDL.
 Definition
Apoprotein A
Term
Lipid panel:
 Definition
- TC (total cholesterol)
- HDL
- LDL
- TGY
- Total cholesterol/HDL ratio
- Non-HDL cholesterol
- Apoprotein A/B
- Lipoprotein A
- Lipoprotein lipase
- Fractionated LDL
Term
The non-HDL is now becoming commonly placed in lipid panels.Determined by subtracting HDL from the TC= non-HDL number. Tends to give better understanding of atherogenic burden of LDL in body. Primarily applied with trigs are above 200
 Definition
non-HDL= TC-HDL
Term
More precise measure of LDL?
 Definition
Apo-B
Term
Total Cholesterol
High > 240 mg/dl
High Normal 200-239 mg/dl
Normal < 200 mg/dl
HDL
Normal > 40 mg/dl
Low < 40 mg/dl
LDL
High >160 mg/dl
Borderline High 130 - 159 mg/dl
Normal <130 mg/dl
Optimal <100 mg/dl (< 70 high risk)
Triglycerides
Normal < 150mg/dl
High Normal 150 – 199mg/dl
High 200 – 499mg/dl
Very High > 500mg/dl
Non-HDL Cholesterol
Normal < 160mg/dl
Optimal < 130 mg/dl
High Risk < 100 mg/dl
Total Cholesterol/HDL Ratio
Normal < 5:1
Optimal < 3.5:1
Apolipoprotein B
Normal <100mg/dl
High Risk <80-90mg/dl
 Definition
Term
normal total cholesterol:
 Definition
less than 200 mg/dl
Term
high normal total cholesterol:
 Definition
200-239 mg/dL
Term
High total cholesterol:
 Definition
greater than or equal to 240 mg/dl
Term
HDL normal:
 Definition
greater than or equal to 40
Term
low HDL:
 Definition
less than 40
Term
optimal LDL:
 Definition
less than 100 mg/dL
Term
optimal LDL for high risk pts?
 Definition
less than 70 mg/dL
Term
Normal LDL:
 Definition
less than 130 mg/dl
Term
Borderline high LDL:
 Definition
130-159
Term
High LDL:
 Definition
greater than or equal to 160 mg/dl
Term
Normal Triglycerides:
 Definition
less than 150 mg/dl
Term
High normal triglycerides:
 Definition
150-199 mg/dl
Term
High triglycerides:
 Definition
200-499 mg/dl
Term
Very high triglycerides:
 Definition
greater than 500 mg/dl
Term
normal Non-HDL cholesterol:
 Definition
less than 160 mg/dL
Term
Optimal non-HDL cholesterol?
 Definition
less than 130mg/dl
Term
High risk non-HDL:
 Definition
less than 100
Term
Normal total cholesterol: HDL ratio:
 Definition
less than 5:1
Term
Optimal total cholesterol: HDL ratio:
 Definition
less than 3.5:1
Term
Normal apolipoprotein B:
 Definition
less than 100 mg/dl
Term
Optimal apolipoprotein B:
 Definition
less than 80-90 mg/dl
Term
bottom line essential targets:
 Definition
TC  < 200 mg/dl

HDL 
Men > 45 mg/dl
Women > 50 mg/dl

LDL
Everyone  < 160 mg/dl
2+ Risk/<20%  < 130 mg/dl
CHD/CHD Equivalent  < 100 mg/dl
CHD/CHD Equivalent (High Risk)  < 70 mg/dl

Triglycerides
Everyone  < 200 mg/dl
CM Risk Factors  < 150 mg/dl

Non-HDL (Primarily those with hypertriglyceride)
Everyone  < 130 mg/dl
CM Risk Factors  < 90 mg/dl

TC/HDL Ratio
Everyone  < 4:1
Term
Age 20 or older pts, should have lipid panel at least every 5 years.
 Definition
Term
The U.S. Preventive Services Task Force (USPSTF) recommends that:

>All men aged 35 and older and all women aged 45 and older should be screened routinely for lipid disorders. (“A” Recommendation)

>Younger adults—men aged 20-35 and women aged 20-45—should be screened if they have other risk factors for heart disease. These risk factors include tobacco use, diabetes, a family history of heart disease, high cholesterol, or high blood pressure. (“B” Recommendation)

> Recommended screening tools: HDL and Total Cholesterol. There is insufficient evidence to recommend for or against measuring triglycerides.
 Definition
Term
Once 35 or 40, should routinely screen lipids (every year).
 Definition
Term
LDL lowering is important for all patients, but especially important for Diabetics. Primary target always LDL. Secondary target HDL.
 Definition
Term
ATP III Guidelines
(Assessment and Therapeutic Approach)

Primary Target Lower LDL

Secondary Target  HDL/TGY

If elevated TGY the Secondary Target is Non-HDL then HDL/TGY

If Metabolic Syndrome/Diabetes/CV Ds the secondary target is  Non-HDL, HDL, TGY, ApoB.
 Definition
Term
with 0-1 risk factor for CHD, LDL goal should be less than __. Drug therapy should be initiated when greater than or equal to __.
 Definition
160
190
Term
With 2+ risk factors for CHD or 10 year risk of 20%, LDL goal should be less than __. If 10 year risk is between 10 and 20% initiate drug tmt at __. If 10 year risk is less than 10% initiate drug therapy at __.
 Definition
- 130
- 130
- 160
Term
With CHD or CHD risk equivalents, the LDL goal should be less than __ and drug tmt should begin at __.
 Definition
100
130
Term
Atherogenic dislipidemia primary, secondary, and tertiary goals:
 Definition
- target elevated LDL
- target elevated non-HDL
- reduce Apo-B, increase HDL
Term
Non–HDL-C is a stronger predictor of CHD risk than LDL-C
 Definition
Term
TLM Diet
Saturated fat < 7 % of calories, No Trans Fats
Increase fiber (Oatmeal)
Fruits, vegetables, nuts, legumes
Fish, poultry
Less red meat, less fried/processed foods
Add breakfast
Small portions

Weight management
Target BMI < 30

Increased physical activity
(Daily aerobic activity at a minimum/at least 150 minutes weekly)

Wellness/Disease Screening
 Definition
Term
TLM Diet
Saturated fat < 7 % of calories, No Trans Fats
Increase fiber (Oatmeal)
Fruits, vegetables, nuts, legumes
Fish, poultry
Less red meat, less fried/processed foods
Add breakfast
Small portions

Weight management
Target BMI < 30

Increased physical activity
(Daily aerobic activity at a minimum/at least 150 minutes weekly)

Wellness/Disease Screening
 Definition
Term
Always consider drug simultaneously with TLC for CHD and CHD equivalents

In general, consider adding drug to TLM after 3 months for other risk categories.
Individualize.

There are now lipid lowering drug combinations
 Definition
Term
Initiate LDL lowering drug (statin), see pt back in __ __. If not at goal then, increase dose for another __ _. If still not at goal, treat other __ __ __. Then still not at goal, monitor adherence.
 Definition
- 6 weeks
- 6 weeks
- other lipid risk factor
Term
If LDL over 200, TLC is not going to be enough> start on medication initially.
Statins are best lipid lowering drugs (LDL). Statins are very effective at getting LDL down.

Simvastatin is strongest, then Atorvastatin.
 Definition
Term
__ __ __ __ are the DOC of choice for elevated LDL and Total Cholesterol. These are the most commonly prescribed meds for dyslipidemia. The decrease LDL by __%, increase HDL by __, and decrease TGY by ___.
 Definition
- HMG-CoA reductase inhibitors
- 18-55%
- 5-15%
- 7-30%

Lovastatin, Pravastatin, Simvastatin, Fluvastatin, Atorvastatin, Rosuvastatin, Pitavastatin
Term
Side effects of HMG-CoA reductase Inhibitors:
 Definition
- myopathy/rhabdomyolysis (CPK monitoring)
- Increased liver enzymes (AST/ALT monitoring)
Term
2 HMG-CoA reductase inhibitors that help increase HDL and decrease TGY:
 Definition
Simvastatin
Rosuvastatin
Term
Contraindications to HMG-CoA Reductase Inhibitors:
 Definition
ABSOLUTE: active liver diseaes
Relative: use of certain drugs like (CMAC)
- cyclosporine
- macrolide
- anti-fungal
- CYP-450 inhibitors
- fibrates and niacin with caution
Term
EVIDENCE THAT LOW VITAMIN D LEVELS ATTRIBUTE TO STATIN RESISTANCE> SO CHECK VITAMIN D, so if increase vitamin D, then maybe not statin resistant.
 Definition
Term
Niacin side effects;
 Definition
- flushing
- hyperglycemia
- hyperuricemia (gout)
- upper GI distress
- hepatotoxicity
Term
CI to niacin:
 Definition
Absolute: chronic liver disease, severe gout
Relative: Diabetes, Hyperuricemia, PUD
Term
Niacin clinical trial results:
 Definition
reduced major coronary events and possibly total mortality
Term
Niacin is mainly used to boost HDL, but it also decreases LDL and TGYs a little bit.
 Definition
Term
Bile acid sequestrants decrease __ and increase __, but have no effect on __.
 Definition
- LDL
- HDL
- TGY
Term
Fibrates decrease __ and __, while increasing __.
 Definition
LDL and TGY
HDL
Term
Fibrates mainly used for high __.
 Definition
TGY
Term
Bile acid sequestrant side effects:
 Definition
- GI distress
- constipation
- decreased absorption of other drugs
Term
If pt has high TGY, do NOT use __ __ __, these make high TGY worse.
 Definition
bile acid sequestrant
Term
Bile acid sequestrant CI;
 Definition
Absolute: dysbetalipoproteinemia, TG> 400
Relative: TG> 200
Term
Bile acid sequestrants clinical trial results:
 Definition
- reduced major coronary events
- reduced CAD deaths
Term
Fibrates side effects:
 Definition
- dyspepsia
- gall stones
- myopathy
- unexplained non-CAD death
Term
Fibrates side effects:
 Definition
- dyspepsia
- gall stones
- myopathy
- unexplained non-CAD death
Term
Fibrate CI:
 Definition
- severe renal disease
- severe hepatic disease
Term
FIBRATES CLAIM TO FAME IS TRIG LOWERING. ALSO MODESTLY RAISE HDL.
 Definition
Term
Bile acid sequestrants aka __. Name the drugs in this class.
 Definition
- Resins
- Cholestyramine
- Colestipol
- Colesevelam
Term
Only lipid lowering class of drugs approved during pregnancy:
 Definition
bile acid sequestrants
Term
class of lipid lowering drugs that may actually increase TGY?
 Definition
bile acid sequestrants
Term
main effects of niacin:
 Definition
- increase HDL and decrease TGY

(modest effect on LDL)
Term
__ taken 30 min before Niacin can decrease flushing. Or can tell pt to eat a __ __ __ like applesauce with the Niacin to decrease flushing.
 Definition
- Aspirin
- pectin-containing food
Term
__ __ are the __ for lowering TGY (especially when over 500), or this class of drugs can also be used with statins.
 Definition
Fibric acids
Term
3 Fibrate/Fibric Acid drugs;
 Definition
- Gemfibrozil
- Fenofibrate
- Clofibrate
Term
Fibric acid drugs:
 Definition
Lipid Effects:
Decrease LDL 5-20% (may increase in pts with high TG)
Increase HDL 10-20%
Decrease TG 20-50%
Term
Cholesterol Absorption Inhibitors like __ are usually used in combo with a statino reach LDL goal, but can be used alone for mild LDL goals.
 Definition
Ezetimibe
Term
Cholesterol Absorption Inhibitor actions:
 Definition
- decrease LDL
- decrease ApoB
- decrease total cholesterol
Term
Side effects of cholesterol aborption inhibitors (Ezetimibe):
 Definition
- Arthralgias
- Back pain
- Abdominal pain
- Diarrhea
- Cough
Term
Precautions of using cholesterol absorption inhibitors (Ezetimibe)
 Definition
- elevated liver enzymes, especially when used with fibrate
- caution use with cyclosporine
Term
contraindications to cholesterol absorption inhibitors (Ezetimibe)
 Definition
severe hepatic disease
Term
Lovaza is __ __ __ __ or __ __.
 Definition
omega 3 fatty acid or fish oil
Term
Fish oil (lovaza) is used primarily to lower __, it may also __ __.
 Definition
- lower triglycerides
- increase HDL
Term
Lovaza (fish oil) side effects:
 Definition
- eructation
- infection
- flu like syndrome
- dyspepsia
- taste changes
- back pain
Term
fish oil can interact with many meds.
 Definition
Term
3 options for treating non-HDL:
 Definition
fibrates
niacin
combo therapy
Term
If TGY are greater than or equal to 500 mg/dl, first lower the __ to prevent __.
 Definition
TGY
pancreatitis
Term
TGY greater than or equal to 500 managment:
 Definition
First lower TG to prevent pancreatitis
Very low-fat diet ( 15% calories from fat)
Weight management and exercise
Fibrate, nicotinic acid, Omega 3FA
When TG < 500, turn to LDL lowering tx
Term
tmt of low HDL:
 Definition
First reach LDL Goal
Intensify weight management and increase physical activity
If TG 200-499 mg/dl, achieve non-HDL goal
If TG < 200 mg/dl (isolated low HDL) in CHD or equivalent, consider fibrate and/or nicotinic acid
ETOH and Omega-3 FA’s elevate HDL
Term
__ are good at lowering CRP and other inflammatory agents.
 Definition
Statins
Term
in order from weakest to strongest of statins:

Simvastatin..Atorvastain...Rosuvastatin

(Rosuvastatin is the strongest)
 Definition
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