Term
| Define primary prevention |
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Definition
| Prevention of 1st cardiovascular event in high risk patients |
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Term
| Define secondary prevention |
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Definition
| Prevention of subsequent cardiovascular events after an initial event. Pt has CHD (MI, angina, CABG, PCI, CVA). |
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Term
| What are the suggested LDL cholesterol ranges? |
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Definition
<100 optimal
100-129 Near optimal
130-159 Borderline high
160-189 High
>190 Very high |
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Term
| What are the suggested total cholesterol ranges? |
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Definition
<200 Desirable
200-239 Borderline high
>240 High |
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Term
| What are the suggested LDL cholesterol ranges? |
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Definition
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Term
| List the 5 major risk factors that modify LDL goals |
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Definition
1. Smoking
2. HTN >140/90
3. Family history of premature CHD
4. Age (men>45, women>55)
5. Low HDL
*HDL>60 subtract risk factor |
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Term
| List Risk Equivalents (risk of having a coronary event is equal to that of established CHD) |
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Definition
1. Peripheral arterial disease
2. Abdominal aortic aneurism
3. Symptomatic carotid artery disease
4. Diabetes
5. Multiple risk factors that confer a 10-year risk for CHD >20% |
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Term
| Define Framingham Risk Assessment |
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Definition
A table that allows assessment of 10-year CHD risk in patients with 2+ risk factors present without CHD or CHD risk equivalent
If >20% this equals a risk equivalent |
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Term
| What is the primary target of cardiovascular event prevention? |
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Definition
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Term
| What is the LDL goal for a person with CHD and CHD risk equivalents? |
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Definition
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Term
| What is the LDL goal for a person with 2+ risk factors? |
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Definition
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Term
| What is the LDL goal for a person with 0-1 risk factor? |
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Definition
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Term
| What is "very high risk"? |
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Definition
| Presence of established CVD plus multiple risk factors (especially poorly controlled, smoking, or metabolic syndromes) or acute coronary syndromes |
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Term
| What are the three levels of 10 year risk on the Framingham Risk Assessment? |
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Definition
>20% is a CHD risk equivalent
10-20%
<10% is low risk |
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Term
| When do you initiate drug therapy in a person with risk? |
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Definition
When their LDL is 30mg/dL higher than their individual goal
(With the exception of 10-20% risk, which should start at 130mg/dL) |
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Term
| What is the LDL goal of a patient with "very high risk"? |
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Definition
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Term
| List major components of Therapeutic Lifestyle Changes |
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Definition
Diet therapy
Weight Control
Increased physical activity
Alcohol/smoking cessation |
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Term
| What is the first line therapy for LDL reduction? |
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Definition
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Term
| What is the MOA of statins? |
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Definition
| Inhibits cholesterol synthesis through inhibition of HMG CoA reductase, the rate limiting step in cholesterol biosynthesis; this results in decreased cholesterol content in the liver, increased LDL receptor activity which removes VLDL, IDL and LDL from the blood |
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Term
| How much will statins typically lower LDL? |
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Definition
18-62%
For every doubling of the dose of a statin, the LDL will lower 6-7% on average |
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Term
| How much will statins typically raise HDL? |
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Definition
5-15% increase
This may actually decrease in patients receiving more potent LDL lowering statins (eg Lipitor or Crestor) |
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Term
| How much will statins typically lower TG? |
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Definition
7-30% reduction
Dose-related effect, greatest with Lipitor. Statins should not be used as monotherapy to lower TG. |
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Term
| List pleiotropic effects of statins |
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Definition
Endothelial cell function (enhanced vasodilation)
Plaque stability ?
Decreased inflammation
Decreased lipoprotein oxidation
Decreased coagulation |
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Term
| List side effects of statins |
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Definition
| Myopathy, rhabdomyolysis, GI upset, LFT elevations, HA |
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Term
| List some warnings of statins |
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Definition
| history of myopathy with statin use, Renal insufficiency, LFT’s 3x ULN prior to initiation (need to identify reason for elevation) |
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Term
| List contraindications of statins |
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Definition
| Active or chronic liver disease, pregnancy, CrCl< 30 ml/min for lovastatin, pravastatin & simvastatin; |
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Term
Which statins have shorter half lives?
Does this affect dosing instructions? |
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Definition
Lovastatin, simvastatin, pravastatin, fluvastatin
Dose in PM |
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Term
| Which statins have longer half lives? |
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Definition
Atorvastatin, rosuvastatin, pitavastatin
Dose any time of day |
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Term
| List drugs metabolized by CYP3A4 that should not be taken with statins |
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Definition
| Macrolides, azole antifungals, cyclosporine, protease inhibitors, nefazodone, |
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Term
| List drugs that should not be taken with statins (but for a different reason than CYP3A4) |
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Definition
| Coumadin, Bile Acid Sequesterants, Fibrates and Niacin |
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Term
| Which statin has the least drug interactions? |
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Definition
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Term
| Which statin has the most drug interactions? |
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Definition
| Lovastatin and simvastatin |
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Term
| When can you dose simvastatin 80mg/day? |
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Definition
| Only if the patient has been taking it over a year already without any symptoms |
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Term
| What new contraindications were published in 2011 for simvastatin? |
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Definition
CYP3A4 inhibitors (itraconazole, ketoconazole, posaconazole, HIV protease inhibitors, erythromycin, clarithromycin, telithromycin, and nefazodone)
gemfibrozil, cyclosporine, or danazol |
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Term
| What dosing limitations were published for simvastatin in 2011? |
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Definition
Do not exceed simvastatin 10mg daily if taking verapamil or diltiazem
Do not exceed simvastatin 20mg daily if taking amiodarone, amlodipine, or ranolazine
In Chinese patients, do not use simvastatin >20mg if they are also taking >1g niacin |
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Term
| Did the FDA find that statins change glucose and A1c? |
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Definition
They found small evidence of incidence diabetes, but usually small changes in blood sugar with statins (except pravastatin)
Risks very small, don't stop taking statins |
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Term
| Did the FDA find that statins lead to memory loss and other cognitive adverse effects? |
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Definition
| They found symptoms are not serious and are reversible |
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Term
| Does the FDA suggest LFT with statins? |
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Definition
| Not anymore, just check at baseline and as clinically indicated |
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Term
| What monitoring should be done with statins? |
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Definition
FLP- baseline, 6-12 weeks
LFT- baseline, then if clinically indicated
CPK- baseline, then if symptomatic |
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Term
| List the statins from most potent to least potent |
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Definition
Rosuvastatin
Atorvastatin
Simvastatin (/pitavastatin)
Pravastatin/Lovastatin
Fluvastatin |
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Term
| What should a patient be dosed with if they need LDL lowered by 27% ? |
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Definition
10mg Simvastatin
20mg Pravastatin/Lovastatin
40mg Fluvastatin |
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Term
| What should a patient be dosed with if they need LDL lowered by 34% ? |
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Definition
10mg Atorvastatin
20mg Simvastatin
40mg Pravastatin/Lovastatin |
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Term
| What should a patient be dosed with if they need LDL lowered by 41% ? |
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Definition
20mg Atorvastatin
40mg Simvastatin
80mg Pravastatin/Lovastatin |
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Term
| What should a patient be dosed with if they need LDL lowered by 48% ? |
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Definition
10mg Rosuvastatin
40mg Atorvastatin
80mg Simvastatin |
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Term
| What should a patient be dosed with if they need LDL lowered by 55% ? |
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Definition
20mg Rosuvastatin
80mg Atorvastatin |
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Term
| What should a patient be dosed with if they need LDL lowered by 62% ? |
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Definition
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Term
| What is the MOA of bile acid sequesterants? |
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Definition
Binds bile acid in the GI tract
The positive charge on the BAS binds to the negative charge on the bile acids in the gastrointestinal tract; this reduces enterohepatic recirculation of bile acids which increases hepatic bile acid synthesis |
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Term
| How do bile acid sequesterants influence lipoproteins? |
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Definition
They could raise TG
Lower LDL |
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Term
| How much do bile acid sequesterants change lipoproteins? |
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Definition
LDL 15-30% reduction (dose dependent)
HDL 3-5% increase
TG no effect or increase |
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Term
| List side effects of bile acid seuqesterants |
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Definition
| GI upset, fecal impaction, TG elevations, transient LFT elevations (occurs ~4-6 weeks) |
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Term
| List warnings of bile acid sequesterants |
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Definition
TG > 200 mg/dL, constipation
Always take with a full glass of water |
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Term
| List contraindications of bile acid sequesterants |
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Definition
| familial dysbetalipoproteinemia, TG > 400 mg/dL, chronic constipation, preexisting biliary obstruction |
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Term
| What monitoring needs to be done with bile acid sequesterants? |
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Definition
| FLP- baseline and after 6 weeks at target dose |
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Term
| Describe drug interactions of bile acid sequesterants |
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Definition
Numerous because of binding; separate administration of other medications by 1 hour before or 4-6 hours after
E.g.: HCTZ, loop diuretics, warfarin, propranolol (other beta blockers), digoxin, fat soluble vitamins |
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Term
| List the available forms of niacin |
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Definition
Crystalline nicotinic acid (Niacin)- available OTC
Extended release nicotinic acid (Niaspan)- requires Rx
Sustained Release nicotinic acid- OTC (not recommended) |
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Term
| What pathways have they proposed to explain the MOA of niacin? |
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Definition
Adipose tissue- inhibits lipolysis
Liver- inhibits fatty acid synthesis
LPL- enhances activity
Altered composition of LDL |
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Term
| List side effects of niacin |
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Definition
LFT elevations, hyperuricemia, hyperglycemia, GI upset/dyspepsia, flushing (occurs b/c of prostaglandin release therefore causing vasodilation), myopathy, HA (occurs b/c of prostaglandin (PG) release therefore causing vasodilation)
Warning: mild to moderate gout |
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Term
| How can one avoid flushing with niacin? |
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Definition
Take aspirin 30min prior
Be compliant
Titrate up
Avoid hot beverages, hot temperatures, and alcohol |
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Term
| List contraindications of niacin |
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Definition
| chronic and active liver disease, severe gout, active PUD |
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Term
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Definition
| moderate to mild gout/hyperuricemia, DM, hx PUD, diabetes |
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Term
| How should niacin be monitored |
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Definition
FLP- baseline and 6 weeks
LFTs- baseline and 6-12 weeks
CPK- baseline and if symptomatic
BG- only if have diabetes
Uric acid- if hx of gout |
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Term
| What is the mechanism of action of fibrates? |
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Definition
Unclear:
Binds to peroxisome proliferation-activated receptor-alpha (PPARα) in the liver and brown adipose tissue, this stimulates increased fatty acid oxidation and increased LPL synthesis
Stimulates ApoA1 and AII
Antithrombic effect |
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Term
| How do fibrates affect lipoproteins? |
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Definition
LDL 5-20% reduction (nonhypertriglyeridemic pts;if hypertriglyeridemic may increase)
HDL 10-20% increase (greater in severe hypertriglyceridemia)
TG 20-50% reduction |
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Term
| List contraindications of fibrates |
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Definition
| Severe renal or hepatic impairment, preexisting gall bladder disease |
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Term
| List warnings of fibrates |
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Definition
| Use caution in combination with other drugs that may cause myopathy or LFT elevations (statins or niacin) |
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Term
| List adverse effects of fibrates |
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Definition
Its typically well tolerated
LFT elevations, myopathy, GI upset, increased gallstone |
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Term
| List drug interactions with fibrates |
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Definition
| Niacin, statins, Coumadin, BAS |
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Term
| List monitoring to be done with fibrates |
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Definition
FLP- baseline and 6-12weeks
LFTs- baseline and 6-12 weeks, then 3-6mo after
CPK- baseline and if symptomatic
Renal function- baseline and as needed |
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Term
| What is the MOA of Zetia? |
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Definition
| Acts on the brush border of the small intestine and inhibits the absorption of cholesterol, therefore decreasing the delivery of dietary cholesterol to the liver which will decrease cholesterol stores and increase clearance of cholesterol from the blood |
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Term
| How does Zetia affect lipoproteins? |
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Definition
Lowers LDL 18%, 25% if with statin
HDL and TG not clinically significant |
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Term
| List adverse effects, warnings, and contraindications of Zetia |
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Definition
Adverse effects: fatigue, arthralgias, GI upset
Warnings: moderate to severe hepatic insufficiency
Contraindications: hypersensitivity |
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Term
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Definition
| 10 mg QD (most beneficial when utilized with statins, minimal clinical benefit when used with other lipid lowering agents) |
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Term
| List monitoring to be done with Zetia |
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Definition
FLP- baseline and 6-12 weeks
LFT- baseline and as directed for statin
CPK- baseline and as directed for statin |
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Term
| What Omega-3 Fatty Acid medications are on the market? |
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Definition
Fish Oil capsules- available OTC
Lovaza- requires Rx (indicated for TG >500mg/dL) |
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Term
| Describe the MOA of Omega-3 Fatty Acid |
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Definition
Omega-3 fatty acids are poor substrates for the enzymes responsible for TG synthesis and they inhibit esterification of other fatty acids; also increase hepatic beta-oxidation
May lower thromboxane-A2 |
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Term
| What effects do Omega-3 Fatty Acids have on lipoproteins? |
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Definition
LDL- may increase
HDL- only small increases (less than fibrates); inconsistent
TG- primary effect to lower TG, but likely modest result |
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Term
| List adverse effects of Omega-3 Fatty Acids |
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Definition
| dyspepsia, possible diarrhea with higher doses, possible prolonged bleeding time |
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Term
| List warnings and cautions of Omega-3 Fatty Acids |
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Definition
Warnings:
Use caution in patients with known fish allergy
Due to possible prolongation of bleeding time, use caution in those using anticoagulants
Safety and efficacy not established in children or pregnancy
Contraindicated: hypersensitivity |
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Term
| List drug interactions of Omega-3 Fatty Acids |
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Definition
| Anti-coagulants, drugs that may increase TG |
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Term
| How is fish oi OTC dosed? |
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Definition
Typical daily dose- 1g BID or TID
Potentially effective dose is 10-18g/day |
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Term
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Definition
1g QD or BID
Typical daily dose 4g (??) |
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Term
| Describe monitoring to be done with Omega-3 Fatty Acids |
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Definition
FLP- baseline and 6-12 weeks
LFT- baseline and 6-12 weeks |
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Term
| List the clinical identification of metabolic symdrome in men |
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Definition
Waist >40in
TG >150
HDL <40
BP >130/85
Fasting glucose >100 |
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Term
| List the clinical identification of metabolic symdrome in women |
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Definition
Waist >35in
TG >150
HDL <50
BP >130/85
Fasting glucose >100 |
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Term
| How many clinical IDs must someone have to have metabolic syndrome? |
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Definition
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Term
| List the ranges of TG level classification |
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Definition
Normal triglycerides: <150 mg/dL
Borderline-high triglycerides:150-199 mg/dL
High triglycerides:200-499 mg/dL
Very high triglycerides:>500 mg/dL |
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Term
| If TG are > 200mg/dL after LDL is reached, what is the new goal? |
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Definition
| Treat Non-HDL cholesterol (total cholesterol – HDL) |
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