Term
| Who should be screened for hyperlipidemia and how often? |
|
Definition
| all adults 20 or older should be screened every 5 years |
|
|
Term
| When is hereditary hyperlipidemia a possibility? |
|
Definition
| CAD in relatives younger than 50 years |
|
|
Term
| What organ is responsible for fat metabolism? |
|
Definition
|
|
Term
| What organ is responsible for fat metabolism? |
|
Definition
|
|
Term
T/F
The liver is responsible for the synthesis of cholesterol and phospholipids. |
|
Definition
|
|
Term
T/F
The liver is involved in the conversion of carbs and proteins to be stored as fat. |
|
Definition
|
|
Term
| What are 3 treatable risk factors for coronary heart disease? |
|
Definition
| hypertension, smoking, and dyslipidemia |
|
|
Term
| How many people die worldwide from CAD? |
|
Definition
| 7.2 million - more than from cancer or infectious disease |
|
|
Term
| How many Americans over age 20 have cholesterol levels greater than 200 mg/dL? |
|
Definition
|
|
Term
| What proportion of people in the US are unaware that they have hyperlipidemia? |
|
Definition
|
|
Term
| What % of people with hyperlipidemia are on therapy? |
|
Definition
|
|
Term
T/F
cholesterol is synthesized by virtually all cells. |
|
Definition
| True - but especially those of the liver, intestine, adrenal cortex, and reproductive tissues |
|
|
Term
| What is the function of cholesterol? |
|
Definition
structural component of membranes
precursor of bile salts, steroid hormones, and vit. D |
|
|
Term
| What function does cholesterol serve in the membrane? |
|
Definition
makes lipid bilayer less deformable and decreases its permeability to water-soluble molecules
also prevents crystallization of hydrocarbons and phase shifts in the membrane |
|
|
Term
T/F
Liver has a central role in cholesterol balance. |
|
Definition
|
|
Term
| What 3 things does the liver do with cholesterol? |
|
Definition
1. exports it in VLDL particles
2. excretes it as a component in bile
3. converts it to bile salts |
|
|
Term
| What are the 3 sources of liver cholesterol? |
|
Definition
1. diet (chylomicron remnants)
2. local synthesis
3. tissues (via HDL and LDL) |
|
|
Term
| What enzyme catalyzes the rate-limiting step of the pathway in the formation of cholesterol? |
|
Definition
|
|
Term
T/F
Humans can degrade cholesterol to CO2 and H20. |
|
Definition
|
|
Term
| How is cholesterol eliminated? |
|
Definition
| in the feces as unmodified cholesterol or bile acids |
|
|
Term
T/F
Bacteria in the intestine may break down cholesterol. |
|
Definition
| True - the products are not absorbed |
|
|
Term
| Where are chylomicrons synthesized? |
|
Definition
|
|
Term
| What does lipoprotein lipase do? (LDL) |
|
Definition
| in the capillaries of adipose tissue, it degrades TG of chylomicrons to fatty acids and glycerol which enter tissues by diffusion |
|
|
Term
|
Definition
|
|
Term
|
Definition
complexes of proteins and lipids that transport triacylglycerols (Tg) and cholesterol esters in the bood
They are classified as chylomicrons, VLDL, LDL, IDL, and HDL based on density and size |
|
|
Term
| What do chylomicrons and VLDL mainly transport? IDL, LDL, and HDL? |
|
Definition
chylomicrons and VLDL - TG
IDL, LDL, and HDL - CE |
|
|
Term
| Which lipoprotein protein component is found in all plaque forming particles? |
|
Definition
|
|
Term
| Which lipoprotein protein components recognize LDL surface receptor proteins? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| What are VLDL remnants called? |
|
Definition
|
|
Term
| Where does 50% of IDL go? |
|
Definition
|
|
Term
| What % of IDL is converted into LDL? |
|
Definition
|
|
Term
| Where are HDL protein components synthesized? |
|
Definition
|
|
Term
| What activates lipoprotein lipase? |
|
Definition
|
|
Term
| Which apolipoproteins does HDL act as a reservoir for? |
|
Definition
|
|
Term
T/F
HDL cholesterol levels are inversely related to risk of cardiovascular disease. |
|
Definition
|
|
Term
| Why is HDL considered "good cholesterol"? |
|
Definition
| HDL is involved in the reverse cholesterol transport - transport of cholesterol from peripheral cells to the sites of synthesis or excretion |
|
|
Term
| What 5 classes of steroid hormones have cholesterol as their precursor? |
|
Definition
gluccocorticoids
mineralocorticoids
androgens
estrogens
progestins |
|
|
Term
| How are steroid hormones transported in the blood? |
|
Definition
| bound to albumin or specific steroid carrier proteins |
|
|
Term
T/F
High levels of LDL cholesterol are directly correlated with increased risk of cardiovascular disease (atherosclerosis). |
|
Definition
|
|
Term
T/F
LDL is known as the "bad" cholesterol. |
|
Definition
|
|
Term
| How does a fatty streak form? |
|
Definition
1. LDL cholesterol penetrates the endothelium and is oxidized.
2. This induces the conversion of monocytes into macrophages, which engulf LDL and enlarge into foam cells.
3. macrophages secrete paracrines, causing smooth muscle cells to begin to migrate into tunica intima.
4. Lesion composed of foam cells and LDL is called a fatty streak. |
|
|
Term
| How does an atherosclerotic plaque form? |
|
Definition
1. Lipid layer forms
2. smooth muscle cells divide, thickening arterial wall
3. fatty streak grows into a plaque that protrudes into the artery lumen. Connective tissue forms over area forming a fibrous cap. This may calcify. |
|
|
Term
| What is a plaque with an intact cap called? |
|
Definition
|
|
Term
| What is a plaque with a dissolving cap called? |
|
Definition
|
|
Term
| What causes a plaque to become vulnerable? |
|
Definition
| macrophages in the plaque may release enzymes that dissolve collagen in fibrous cap. |
|
|
Term
| What is the danger of a ruptured plaque? |
|
Definition
| exposed collagen in tunica intima |
|
|
Term
T/F
Collagen exposure initiates blood clotting. |
|
Definition
|
|
Term
T/F
Angiography is lumenography and therefore tells us nothing about the arterial wall itself. |
|
Definition
|
|
Term
| Exercise (increases/decreases) the HDL in your blood. |
|
Definition
|
|
Term
| Which gender generally has more HDL? |
|
Definition
|
|
Term
| How do antioxidants help prevent atherosclerosis? |
|
Definition
| They prevent LDL from being oxidized which prevents formation of fatty streak. |
|
|
Term
T/F
CRP is a better predictor of atherosclerotic heart disease than LDL. |
|
Definition
| Don't know - it is debated |
|
|
Term
|
Definition
| vit. C, vit. E, beta-carotene |
|
|
Term
| What is the goal for total cholesterol after treatment? What is unacceptable? |
|
Definition
goal: < 200 total
unacceptable: > 240 |
|
|
Term
| What is the goal for LDL cholesterol after treatment? What is unacceptable? What is high risk? |
|
Definition
goal: < 100
unacceptable: > 160
high risk: > 190 |
|
|
Term
| What is the goal for HDL cholesterol after treatment? What is too low? |
|
Definition
goal: >/= 60
too low: < 40 |
|
|
Term
| What is the goal for triglycerides after treatment? What is unacceptable? What is high risk? |
|
Definition
goal: < 150
unacceptable: > 200
high risk: >500 |
|
|
Term
| For high risk CVD pt, what is the goal for LDL cholesterol? |
|
Definition
|
|
Term
| At what point do LDL levels and Triglyceride levels become a +1 risk factor for CAD? |
|
Definition
LDL > 190
Triglycerides > 500 |
|
|
Term
| What are 5 secondary causes of dyslipidemia? |
|
Definition
| diabetes, hypthyroidism, obesity, liver disease, nephrotic syndrome |
|
|
Term
|
Definition
a metabolic disorder
increased weight circumference
elevated triglycerides
decreased HDL
blood pressure above 130/85
glucose levels above 100 or diabetes
proinflammatory/prothrombic state that may include elevate CRP |
|
|
Term
| What is primary prevention? Secondary prevention? |
|
Definition
primary - prevention before cardiovascular or cerebrovascular event
secondary - prevention after event |
|
|
Term
| When is it important to consider hereditary hyperlipidemia? |
|
Definition
|
|
Term
| Name 3 hereditary lipid disorders. |
|
Definition
1. Familial lipoprotein lipase deficiency
2. Familial hypercholesterolemia
3. Familial combined hyperlipidemia |
|
|
Term
| What features are seen with familial lipoprotein lipase deficiency? |
|
Definition
Homozygous - elevated TG
Heterozygous - high TG and low HDL |
|
|
Term
| What features are seen with familial hypercholesterolemia? |
|
Definition
homozygous - elevated LDL (> 300), Xanthomas, vascular disease by age 20
heterozygous - elevated LDL |
|
|
Term
| What features are seen with familial combined hyperlipidemia? |
|
Definition
|
|
Term
| What are the causes of hypertriglyceridemia? |
|
Definition
genetic
OR
alcoholism
hypthyroidism
nephrotic syndrome/end-stage renal disease
HIV infection |
|
|
Term
T/F
Patients with TG > 2,000 almost always have a genetic and a secondary cause for their hypertriglyceridemia. |
|
Definition
|
|
Term
| What are the non-pharmacologic treatments for hyperlipedemia? |
|
Definition
achieve normal BMI
diet - reduce cholesterol, reduce sat. fats, no trans fats, high fiber |
|
|
Term
| How long should patients be given a trial of diet therapy before using pharmacologic therapy for hyperlipidemia? |
|
Definition
|
|
Term
| How do statins work to lower cholesterol? |
|
Definition
| They inhibit HMG-CoA reductase (which is the rate limiting step in cholesterol synthesis) |
|
|
Term
T/F
Statins prevent the liver from manufacturing VLDL. |
|
Definition
|
|
Term
| Why are statins dosed at night? |
|
Definition
| because that is when the liver makes cholesterol |
|
|
Term
|
Definition
statin for treating hyperlipidemia
Crestor
10 mg start QPM
Max 40 mg |
|
|
Term
|
Definition
statin
Lipitor
> 6 years of age
10 mg start QPM
max 80 mg
may be the best agent for lowering triglycerides |
|
|
Term
|
Definition
statin
Zocor
> 13 years of age
20 mg start QPM
Max 80 mg
raises HDL too |
|
|
Term
|
Definition
statin
Mevacor, Altoprev
$4 formulary
less potent |
|
|
Term
|
Definition
statin
Lescol XL
most tolerable |
|
|
Term
|
Definition
statin
Pravachol
most tolerable
metabolized by isomerization in the gut instead of using Cytochrome P-450, so it has a lower side effect profile |
|
|
Term
T/F
Statins decrea the risk of adverse cardiac events even when not at treatment goal. |
|
Definition
True
Why? plaque stability and decrease in CRP |
|
|
Term
T/F
Statins are effective in diabetics. |
|
Definition
|
|
Term
| Which of the statins must especially be taken at night and why? |
|
Definition
| simvastatin because half life is only 4 hours |
|
|
Term
| What 2 things do you advise patients to do when they take their statin? |
|
Definition
| Take it with food and take it at night |
|
|
Term
| What are 2 possible serious side effects for statins? |
|
Definition
rhabdomyolysis or myopathy
elevated serum transaminates |
|
|
Term
| How do you monitor for rhabdomyolysis? |
|
Definition
| serum creatine kinase and watch for bilateral muscle pain in major muscles |
|
|
Term
| How do you monitor serum transaminases? How often? What is the cut-off? |
|
Definition
Check *ALT* and AST
get a baseline and check every 3 months for 1 year and ever 6 months thereafter
cut off is < 3x normal |
|
|
Term
| What are some counterindications to statin therapy? |
|
Definition
liver disease
pregnancy
nursing mothers
elevated liver enzymes for any reason
children < 10 years
history of rhabdomyolysis from statin |
|
|
Term
| What pregnancy category are statins? |
|
Definition
|
|
Term
T/F
Risk of myopathy is low and rhabdomyolysis is rare with statin therapy. |
|
Definition
| True - and risk is equal between different statins |
|
|
Term
T/F
If myopathy is a side effect, you can no longer use statins. |
|
Definition
| False - wait one month, swtich to another statin and start at 1/2 starting dose |
|
|
Term
| What % reductions in MI and CVA are there with intensive statin therapy? |
|
Definition
|
|
Term
|
Definition
cholesterol absorption inhibitor
Zetia
inhibits cholesterol absorption in the brush border of the intestines by up to 50% |
|
|
Term
| What are the side effects of ezetimbe? |
|
Definition
diarrhea
abdominal bloating
back pain |
|
|
Term
| What pregnancy category is ezetimbe? |
|
Definition
|
|
Term
T/F
Ezetimbe may used with any statin (usually you reduce the statin dose to less than 1/2 the max dose). |
|
Definition
|
|
Term
T/F
There is no increase in myopathy or rhabdomyolysis when combo use of statin and ezetimbe is used. |
|
Definition
|
|
Term
T/F
The risk for a pt with an LDL of 100 and an HDL of 25 is greater than the risk of a patient with an LDL of 220 and an HDL of 45. |
|
Definition
|
|
Term
|
Definition
|
|
Term
| What does nicotinic acid do? |
|
Definition
reduces VLDL synthesis in the liver
decreases TG levels
increases HDL levels
minimal effect on LDL |
|
|
Term
| What is the most effective medication for raising HDL? |
|
Definition
|
|
Term
| Who is a good candidate for nicotinic acid treatment? |
|
Definition
| someone with low HDL and slightly elevated LDL |
|
|
Term
| What problem is associated with nicotinic acid? |
|
Definition
|
|
Term
| How do you prevent the flushing reaction caused by nicotinic acid? |
|
Definition
take 1/2 hour after aspirin and 1/2 hour before bed
low starting dose and titrate to dose |
|
|
Term
T/F
Time released nicotinic acid products require liver enzyme monitoring. |
|
Definition
|
|
Term
| What pregnancy category is nicotinic acid? |
|
Definition
|
|
Term
|
Definition
|
|
Term
T/F
For patients with CHD lowering the target for LDL to 70 does decrease risk. |
|
Definition
|
|
Term
T/F
For patients with an LDL of 70, there is a substantial risk reduction in patients meeting the target goal of 150 for TG levels. |
|
Definition
|
|
Term
| What is the mechanism of action of fibrates? |
|
Definition
increase activity of lipoprotein lipase
decrease TG (more effectively than nicotinic acid)
lower VLDL
increase HDL (less effectively than nicotinic acid) |
|
|
Term
| Fibrates are the DOC for what condition? |
|
Definition
| isolated hypertriglyceremia - to prevent pancreatitis with TG > 1,000 |
|
|
Term
| What drug has a drug-drug interaction with fibrates? What does it cause? |
|
Definition
statins
increase serum levels of statins |
|
|
Term
|
Definition
fibrate
Tricor, Lofibra, Antara, Fibricor, Lipofen, Fenoglide, Triglide, Trilipix
145 mg po QD |
|
|
Term
|
Definition
fibrate - biggest drug-drug interaction with statins
Lopid |
|
|
Term
|
Definition
fibrate
no longer on the market
caused chest pain |
|
|
Term
T/F
You must monitor liver enzymes with fibrate treatment. |
|
Definition
| True - especially if combined with statins |
|
|
Term
| What are the possible side effects of fibrates? |
|
Definition
GI complaints
skin rashes
cholelithiasis
potentiates the action of coumadin |
|
|
Term
|
Definition
Bile Sequestering agent
Questran, Questran light, Prevalite |
|
|
Term
|
Definition
bile sequestering agent
Colestid |
|
|
Term
|
Definition
bile sequestering agent
Welchol |
|
|
Term
| What is the mechanism of action of bile sequestering agents? |
|
Definition
| bind bile acids in the intestines which causes shunting of cholesterol to bile acid pathways and causes an increased uptake of LDL by the liver |
|
|
Term
| When are bile sequestering agents ineffective? |
|
Definition
| homozygous familial hypercholesterolemia |
|
|
Term
| What are the possible side effects of bile sequestering agents? |
|
Definition
| constipation, bloating, flatulence, dry flaking skin, decrease absorption of fat-soluble vitamins, decrease absorption of acidic drugs - warfarin and digoxin |
|
|
Term
|
Definition
| omega-3 fatty acid ehtyl esters (Lovaza, Omacor) |
|
|
Term
| How does fish oil work to treat hyperlipidemia? |
|
Definition
exact mechanism unknown
reduces synthesis of triglycerides by the liver
reduces VLDL, LDL, cholesterol, and triglycerides
increases HDL |
|
|
Term
| What pregnancy category is fish oil? |
|
Definition
|
|
Term
| What things must you monitor when a patient is on fish oil? |
|
Definition
|
|
Term
|
Definition
| nicotinic acid + lovastatin |
|
|
Term
|
Definition
| amlodopine + atorvastatin |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
T/F
1% reduction in LDL = 1% reduction in CHD event rates. |
|
Definition
|
|
Term
T/F
2% increase in HDL = 1% reduction in CHD event rates. |
|
Definition
|
|
Term
| What are the most effective agents in lowering LDL? |
|
Definition
|
|
Term
| What is the order of effectiveness of the statins? |
|
Definition
| rosuvastatin > atorvastatin > simvastatin |
|
|
Term
T/F
All statins raise the HDL. |
|
Definition
|
|
Term
| Which statin is most effective at reducing TG? |
|
Definition
|
|
Term
| What is the most effective agent at raising HDL? |
|
Definition
nicotinic acid
secondary effects on lowering TG |
|
|
Term
| What are the most effective agents for TG? |
|
Definition
fibrates
secondary effects on HDL |
|
|
Term
| What is the most effective agent for preventing cholesterol absorption? |
|
Definition
|
|
Term
| What drug is used if LDL is elevated above 110? |
|
Definition
|
|
Term
| What drug is used if LDL is above 160? |
|
Definition
|
|
Term
| What drug is used if LDL is > 110 and TG > 300? |
|
Definition
|
|
Term
| What drug is used if LDL is > 110 and HDL < 35? |
|
Definition
|
|
Term
| What drug is used if LDL < 110 and TG > 500? |
|
Definition
|
|
Term
| What drug is used if LDL > 110 and HDL < 30? |
|
Definition
|
|
Term
| If after treatment, the pt is not at goal, what drug do you use to target LDL? |
|
Definition
| raise statin dose or add ezetimbe |
|
|
Term
| If after treatment, the pt is not at goal, what drug do you use to target TG? |
|
Definition
|
|
Term
| If after treatment, the pt is not at goal, what drug do you use to target HDL? |
|
Definition
|
|
Term
| What qualifies hyperlipidemia in children? |
|
Definition
total cholesterol > 200
LDL > 130 |
|
|
Term
| How long should you try diet therapy in children? |
|
Definition
| 6 months or more - no rush to fix it and need consistently high numbers to justify medical therapy |
|
|
Term
| What drugs are used to treat hyperlipidemia in pediatrics? |
|
Definition
|
|
Term
| For pediatric patients with elevated triglycerides > 500, how do you treat? |
|
Definition
fish oil 2 g/day
nicotinic acid
fibrates only if at high risk for pancreatitis |
|
|
