coronary heart disease single largest killer men and women in US, 2500 deaths a day, although has decreased 35% 1999 to 2005 in part bc of drug therapy; risk increases as cholesterol levels increase, atherosclerosis.  Other non-controllable risk ractors: men older than 45, women older than 55, women after menopause, family hx of early heart disease.  Controllable risk factors are diet, weight and inactivity.

Book focused on LDL cholesterol, but what about inflammation in arteries giving cholesterol something to stick to?

Book – main goal of treatment is to lower LDL to reduce risk.  

Hypertension

Prehypertension

Hypertension is SBP above 140 or DBP above 90, or pt using drug to treat hypertension.

Prehypertension is SBP 120-139 or DBP 80-89 – require health promoting lifestyle modifications to prevent CV disease

In persons bt 40-70, q increase of 20 SBP or 10 DBP doubles risk of CV disease

cholesterol and triglycerides, elevation in one of these or both; cholesterol over 240mg/dL and triglycerides over 150mg/dL associated with ATHEROSCLEROSIS, thought to be majoe contributor to heart disease.

Cholesterol and triglcerides are transported through body by LIPOPROTEIN (contains lipid and can bond with above).  Are several lipoproteins, this chapter focuses on LOW-DENSITY LIPOPROTEINS, HIGH-DENSITY LIPOPROTEINS and CHOLESTEROL

LDLs transport cholesterol to peripheral cells.  When these cells have enough, they discard excess to blood which can then penetrate artery walls resulting in plaque.  Target LDL is 130mg/dL

HDLs take cholesterol from peripheral cells and bring to liver where is metabolized and excreted

An HDL abve 40 is good, below bad; considered a MAJOR risk factor.

Triglycerides borderline at 150-190 and may req tx at 190 or more.

TLC = therapeutic lifestyle changes. Recommended is eat less cholesterol (less than 200mg a day), physical activity (30 min brisk walking a day), no smoking, and manage weight

Cholesterol   less than 200 desirable

                  200-239 borderline

                  240 and above high

LDL Cholesterol   less than 100 optimal

                       100-129 near optimal

                       130-159 borderline

                       160-189 High

                       190 and above very high

HDL   less than 40 low

        40-59 borderline (?)

        60 and above high (that’s a good thing)

1. HMG-CoA inhibitors (Statins)
1. atorvastatin (Lipitor)
2. fluveastatin
3. lovastatin
4. pravastatin
5. rosuvastatin (Crestor)
6. simvastatin (Zocor)
2. Bile Acid Resins
1. cholestyramine
2. colestipol
3. colesevelam
3. Fibric Acid Derivatives (Fibrates)
1. Fenofibrate
2. Gemfibrozil
4. Miscellaneous Preparations
1. Ezetimibe
2. Niacin (nicotinic acid) (Niaspan)
5. Combination Drugs
1. amlodipine with atorvastatin (antihypertensive with antihyperlipidemic)
2. niacin with lovastatin
3. ezetimibe with simvastatin

I.      STATINS = HMG-CoA REDUCTASE INHIBITORS

                                                   i.      stands for 3-hydroxy-3-methyglutaryl coenzyme A – it is a catalyst in the manufacture of cholesterol.  Statin prevent manufacture of cholesterol or promote breakdown of it.

                                                  ii.      Reduce serum LDL and truglycerindes

                                                   i.      Treats hyperlipidemia

                                                  ii.      Primary prevention of coronary events , for those without evident CHD

                                                iii.      Secondary prevention of event in pts with evident coronary heart disease

                                                   i.      Well tolerated, when adv rxns do occur are mild and transient and do not require discontinuation, may include

1.        CNS

a.        Headache, dizziness, insomnia

2.        GI

a.        Flatulence, ab pain, cramping, constipation and nausea

                                                   i.      Hypersensitive

                                                  ii.      Those with serious liver disorders

                                                iii.      During pregnancy (cat X!) and lactation

                                                iv.      Use cautiously with hx of alcoholism, acute infection, hypotension, trauma, endocrine disorders, visual disturbances and myopathy

                                                 v.      NURSING ALERT (KNOW THIS) rosuvastatin in high doses linked to risks for serious muscle toxicity (myopathy/rhabdomyolosis) in “certain” populations.  These person may start at a lower dose.  There persons include those taking cyclosporine, macrolides, erythromycin, clarithromycin, amiodaron, niacin, verapamil, Asians and pts with severe renal insufficiency.

                                                   i.      With macrolides, erythromycin or clarithromycin for infections increases risk of severe myopathy or rhabdomyolosis

                                                  ii.      With amiodaron for CV problems increases risk of myopathy

                                                iii.      With niacin infections increases risk of severe myopathy or rhabdomyolosis

                                                iv.      With protease inhibitors elevates levels of statins

                                                 v.      With verapamil increases risk of myopathy

                                                vi.      With warfarin increases anticoagulant effect (increases bleeding risk)

                                              vii.      With bile acid resins, have additive effect providing benefit of treating hypercholesterolemia if not responsing to singe drug for this condition

                                             viii.      Always ask about herbal/complementary remedies because are possible interactions with St. John’s wort causeing a decrease in effectiveness of statin

                                                   i.      Bile  ismade/secreted by liver, stored in gallbladder, emulsifies fat/lipids in order to be absorbed by intestine.  Once fats are absorbed, the bile acid resins bind to bile acids and form an insoluble substance that cannot be absorbed so is secreted in feces.  With an increased loss of bile acids, the liver uses more cholesterol to form more bile, thus decreasing serum cholesterol.

                                                   i.      Hyperlipidemia in pts who do not have adequate response to TLC

                                                  ii.      For pruritus assoc. with partial biliary obstruction (cholestyramine only)

                                                   i.      Constipation, can be sever leading to impaction, aggravation of hemorrhoids, abd cramps, flatulence and nausea

                                                  ii.      Increased bleeding tendency related to vit K malabsorption and vit A and D deficiencies

                                                   i.      Contra in those with knjown hypersensitivities

                                                  ii.      Contra in those with complete biliary obstruction

                                                iii.      Used cautioslu in lever and kidbney disease

                                                iv.      Caution in pregnancy (cat C) and lactation (decreases absorption of vitamins that many affect the infant)               

                                                   i.      Cholestyramine with anticoagulants decrease effect of anticoagulant

                                                  ii.      With thyroid hormone assoc with loss of efficacy of thyroid hormone and also hypothyroidism (esp. cholestyramine)

                                                iii.      With vitamins A, D, E, K and Folic Acid reduces absorption of these nutrients

                                                iv.      With the following, can cause decreased absorption of the following:

1.        NSAIDS

2.        penicillin G and tetracycline

3.        clofibrate and niacin

4.        digitalis glycosides

5.        furosemide and thiazide diuretics for edema

6.        glipizide for diabetes

7.        hydrocortisone for inflammation

8.        methyldopa and propranalol (hypertension and CV problems respectively)

                                                 v.      All bile acid resins and cholestyramine in particular, can decrease absorption of numerous drugs, so should be admined alone and other drugs given 1 hour before or 4 hours after admin of bile acids

                                                   i.      Clofibrate works by stimulating liver to increase breakdown of very-low-density lipoproteins (VLDLs) to LDLs,  somehow inhibiting cholesterol formation….

                                                  ii.      Fenofibrate acts by reducing VLDL and stimulating catabolism of triglyceride-rich lipoproteins resulting in a decrease in plasma triglycerides and cholesterol

                                                iii.      Gemfibozil increases excretion of cholesterol in feces and reduces production of triglycerides byt liver lowering serum lipids

                                                   i.      Use varies by drug

                                                  ii.      Clofibrate and gemfirozil for very high triglyucerides and at risk for abdominal pain and pancreatitis and who do not have response to dietary modifications

                                                iii.      Clofibrate NOT used for other types of hyperlipidemia and no thought to prevent coronary heart disease (then what is the point?  The ab pain and pancreatitis I guess…)

                                                   i.      N/V and GI upset

                                                  ii.      Diarrhea

                                                iii.      Cholelithiasis (gallstones) or cholecytitis (gall bladder inflammation) – this may cause PCP to stop drug

                                                   i.      Contra with known hypersensitivities

                                                  ii.      Contra in pts with significant hepatic/renal dysfunction

                                                iii.      Contra in primary biliary cirrhosis b/c these drugs may increase already increased cholesterol (huh?)

                                                iv.      Used cautiously with pregnancy (cat C)

                                                 v.      Not used during lactation

                                                vi.      Not used in pts with peptic ulcer

                                              vii.      Not used with diabetics

                                                   i.      With anticoagulants, enhances anticoagulation

                                                  ii.      With cyclosporine for immunosupression after transplant organ, decreases effect of cyclosporine (immune system no as suppressed, more risk of organ rejection) – especially with gemfibrozil

                                                iii.      With HMG-CoA reductase inhibitors (statins) increases risk of rhabdomyolosis

                                                iv.      With sulfonyloreas for treatment of diabetes increases hypoglycemic effects – especially with gemfibrozil

                                                   i.      How niacin lowers lipds in not fully understood

                                                  ii.      Ezetimibe inhibits absorption of cholesterol in small intesitine, decreasing cholesterol in liver

                                                   i.      Niacin an adjuctive therapy for loweing very  high tryiglycerides in pts at risk ofr pancreatitis and whose response to dietary measures inadequate; typically used along with other antihyperlipidemics

                                                   i.      GI

1.        N/V ab pain

2.        Diarrhea

                                                  ii.      Other

1.        Severe, generalized flushing of skin, warmth everywhere

2.        severe itching or tingling

                                                   i.      Known hypersensitivities

                                                  ii.      Niacin contra in active peptic ulcer, hepatic dysfunction, and arterial bleeding

                                                iii.      Niacin used cautiously in high alcohol consumption, unstable angina, gout and pregnancy (cat C)

                                                iv.      Enzetimibe contra in pregnant and lactating women

– benefits for CV health, lowers cholesterol and triglycerides, lowers BP and helps to prevent atherosclerosis; mild stomach upset/irritation, sodon’t take alone.  Increased risk of bleeding when taken with warfarin.  No serious reactions during pregnancy, but not recommended.  Garlic excreted in breast milk, so can cause colic.  PCP should know if taking.

                                                   i.      Preadmin

1.        many have no sxs, often given outpt.  Lipid panel and liver function test (LFT) obtained before admined.

2.        take dietary hx, focus on regularly consumed food

3.        Vitals and weight

4.        Skind and eyelids inspected for xanthomas (flat or elevated yellowish deposits) may be seen in more severe hyperlipidemia

                                                  ii.      Ongoing

1.        Usually outpatient and PCP monitors lipid levels periodically, liver 6 and 12 wks after initiation, and  6 months intervals afterwards.  Nurse monitors these levels, any increases reported to PCP. 

2.        If aminotransferase (AST) increases to 3X normal, pCP may discontinue drug

3.        Max effects are within 4 weeks, lipid profiles will be ordered to determine efficacy; PCP may alter dose accordingly, or add another drud, discontinue, etc

4.        NURSING ALERT – sometimes an INCREASE in blood lipids occurs!!  If happens, notify PCP bc may need to change drug (obviously!)

5.        Ckeck vitals

6.        Assess bowel fnxg bc adv rxn is constipation and can be severe without treatment

                                                   i.      Promoting Optimal Response to Therapy

1.        Explain regimen (usually outpt) and adv rxns.  Emphasize following dietary guidelines.  Drug will be dced (usually) if not effective after 3 months

                                                  ii.      Monitoring and Managing Pt Needs

1.        Constipation

a.        All can cause constipation, esp. bile acid resins.  Can worsen, and severely worsen existing constipation.  Instruct pt to increase fluid, high fiber, exercise daily.  If persists or worsens, contact PCP.  May req reduced dosage or dc.

b.       LIFESPAN ALERT – older adults prone to constipation when taking bile acid resins.  Monitor for hard, dry stools, difficulty and complaints.  Keep accurate records of this.

2.        Risk for Imbalances Nutrition: Less Than Body Reqs

a.        Bile acid resins interfere with digestion of fats and prevent absorption of fat-souble vitamins ADEK and folic acid.  If long term drug therapy, then may give A and D in a water soluble form or given parenterally

3.        Risk for Impaired Skin Integrity

a.        Pts taking nicotinic acid flushing, itching, tingling.  Usually at higher doses, but even at smaller.  May frighten the patient.

b.       NURSING ALERT – advise pt on Niaspan to contact PCP if skin reaction is severe or cause great discomforr.  Aspirin may be recommended to take before niacin to reduce the reactions.

4.        Nausea

a.        Some cause nausea.  If so, take with food.  Also, can provide relaxed environment with no unpleasant odors or sounds (huh?)  Nurse can also provide several small mealsinstead of three large.  If severe or vomiting occurs, notify PCP.

5.        Risk for Injury

a.        Some cause dizziness, fibrates and statins.  Monitor hospitalized pt carefully, assist with ambulation, place call light near.  Especially important with first doses to see how responds

6.        Potential Medical Complications

a.        Vit K Deficiency

                                                                                                                           i.      Check for bruises over whole body.  Encourage eating food high in K like green vegetable, beef liver, green tea. 

                                                                                                                          ii.      If see bruising or bleeding occurs, report to PCP.  Parenteral may be prescribed, or oral to prevent further deficiency.

b.       Rhabdomyolosis

                                                                                                                           i.      Statins especially are associated with skeletal muscle effects leading to rhabdomyolosis which is a rare condition where muscles are damaged releasing muscle cells into bloodstream, possibly leading to renal dysfunction or acure renal failure. 

                                                                                                                          ii.      Nurse should be alert for muscle pain, tenderness, weakness, especially with malaise and/or fever. 

                                                                                                                        iii.      More likely in Asians

                                                                                                                        iv.      Report to PCP bc drug may need dc

1.        General

a.        Stress importance of following diet bc drug therapy alone won’t significantly lower lipids.  Provide copy of diet and review.  Can refer to dietician, websites, etc. 

b.       Framingham Heart Study used to predict heart attack risk – pt can enter in information to predict risk for next 10 years – on various web sites.  If the risk is lowered over time, pt compliance may increase.

2.        Statins

a.        Lovastatin usually taken once daily preferably with evening meal

b.       Fluvastatin, simvastatin and pravastatin taken qid evening or bedtime

c.        Do not drink lots of grapefruit juice while taking

d.       With rosuvastatin advise qid evening.  If taking actacids, take at least 2 hrs after rosuvastatin

e.        If fluvastatin or pravastatin prescribed with bile acid resin, the statin should be taken 2 hours after the BAR or at least 4 hours after.

f.         Statins may cause photosensitivity, so avoid exposure and take precautions

g.       Cannot be used during pregnancy (cat X) so explain must use contraception.  If wants to become pregnanat, tell PCP first

h.       Advise contact PCP ASAP if muscle pain, tenderness, weakness

3.        Bile Acid Resins

a.        Take before meal unless PCP says otherwise. 

b.       For cholestyramine powder, must be mixed vigorously with water 2-6 ounces.  Can also be mixed with liquidy soups or crushed fruits (applesauce eg); do not injest in dry form; take other drigs 1 hour before, or 4-6 hours after cholestyramine

c.        Cholestyramine is available in a light form (with splenda) for diabetics etc

d.       For colestipol granules, mix in liquids, soup, oatmeal, applesauce, etc, after mixing with water. Granules will not dissolve.  Once drink, add more water and drink to get the rest stuck on cup.

e.        For colestipol tablets, swallow whole one at a time with full glass fluid.  Do not chew, cut, etc.

f.         Sipping or holding preparations in mouth can cause tooth discoloration or enamel decay

g.       Constipation, nausea, ab pain, distension may occur and may subside after time.  Notify PCP if bnothersome

h.       Notify PCP if unusual bleeding or bruising occurs

4.        Fibric Acide Derivitives

a.        For gemfibrozil, explain dizziness/blurred vision may occur.  Be cautious driving, etc

b.       Notify PCP if epigastric pain, diarrhea, N/V occurs with gemfibrozil.

5.        Miscellaneous antihyperlipidemics

a.        For nicotinic acid advise to take with meals.  Advise of flushing, warmth, severe itching, headache may occur.  Will usually subside with time, but contact PCP ASAP if severe.  The PCP can prescribe aspirin taken 30 min before niacin to decrease flushing.  If dizzy, avoid sudden change in posture.

b.       For ezetimibe explain should not be taken at least 2 hrs before or 4 hours after bile acid sequestrant (what is that?) and to report unusual pain, weakness, tenderness, severe diarrhea, or respiratory infections (okay….)