Term
| Cardiovascular Disease types |
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Definition
• Coronary artery disease
- Acute coronary syndrome • Unstable angina • Myocardial infarction - ST-segment elevation - Non-ST
• Cerebrovascular
• Peripheral artery disease
• Aortic/thoracic disorders |
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Term
| coronary artery disease components |
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Definition
- Arterial vessel circulation • Oxygen rich
• High shear stress
- Plaque rupture
• Exposes vessel collagen • Triggers platelet cascade
- Thrombus formation
• Platelet rich “white” clot • Thin fibrous cap |
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Term
| lipid profile goals ATP III guidelin4es in 2002 |
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Definition
| total cholesterol <200. LDL cholesterol <100, Triglycerides <150, HDL cholesterol >/= 60 |
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Term
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Definition
•-2013 ACC/AHA Blood Cholesterol Guidelines replaced ATP III Guidelines
• No longer treat to LDL cholesterol targets
• Non-statin therapy discouraged in most cases
• Lifestyle modification recommended for all patients
• 10-year ASCVD risk calculator |
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Term
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Definition
• Cardiovascular disease is most common cause of death in patients with chronic kidney disease (CKD)
• Recommend statins for adults with CKD who are 50 years or older and not on hemodialysis |
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Term
| lifestyle modificstions for cad |
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Definition
• Heart healthy diet
• Regular exercise
• Smoking cessation
• Maintenance of healthy weight |
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Term
statin benefit groups
[image] |
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Definition
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Term
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Definition
• Validated in non-Hispanic Caucasian and African-American women and men aged 40-79 with and without DM and LDL-C 70- 189 mg/dL
• Use non-Hispanic Caucasian equation for other ethnic groups
• Do not calculate 10-year risk in patients with clinical ASCVD or LDL-C ≥ 190 mg/dL |
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Term
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Definition
-Atherosclerotic cardiovascular disease (ASCVD)
• Coronary death
• Nonfatal myocardial infarction • Fatal or nonfatal stroke
-in individuals not receiving cholesterol-lowering drug therapy recalculate estimated 10 y ASCVD risk every 4-6 y in individuals aged 40-75 w/o clinical ASCVD or diabetes and w LDL-C 70-189 mg/dl |
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Term
| risks that outweigh statin benefit |
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Definition
• NYHA Class II-IV heart failure
• Maintenance hemodialysis
• LDL-C <70 mg/dL |
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Term
| initial evaluation for statins |
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Definition
• Fasting lipid panel: to assess adherence and predicted response
- LDL-D >190 mg/dL, should assess for secondary causes or screen family for familial hyperlipidemia
- TG >500 mg/dL should be treated
- Repeat at 4–12 weeks, then every 3–12 months
• ALT: result > 3x ULN is a contraindication to statin therapy
• CK (if indicated)
• HbA1c: screen for diabetes mellitus
• Obtain history of prior or current muscle symptoms |
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Term
| pharmacological and non-pharmacologic therapy for cad |
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Definition
• HMG-CoA reductase inhibitors = statins • Fibrates
• Bile acid sequestrants
• Sterol absorption inhibitor
• Nicotinic acid
• Omega-3 ethyl esters
• Plant sterols/stanols
• Red yeast Chinese rice |
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Term
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Definition
• Coronary artery calcium screening (CAC) can reclassify as much as 50% of statin eligible patients.
• CAC testing may be cost-effective for intermediate-risk patients.
• Risk-benefit profile may be stronger for moderate-intensity compared to high- intensity statin treatment. |
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Term
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Definition
[image]
• 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors or “statins”
• Inhibit HMG-CoA reductase, reduce cholesterol synthesis, upregulate LDL receptors on hepatocytes
• Adverse effects: altered mental status or memory impairment, hepatic dysfunction, myopathy, rhabdomyolysis, diabetes mellitus, hemorrhagic stroke
• Contraindicated during pregnancy and lactation
• Avoid in severe hepatic impairment
• Some agents more effective when given in the evening when most cholesterol synthesis occurs |
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Term
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Definition
• Multiple comorbidities including renal or hepatic impairment
• History of statin intolerance or muscle disorders
• Unexplained ALT > 3x ULN
• Age >75 years
• Genetic polymorphisms or concomitant drugs which decrease statin metabolism or clearance |
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Term
| statin-induced myopathy recommendations |
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Definition
• Obtain history of prior and current muscle symptoms at baseline and every visit
• Discontinue statin, evaluate factors that may predispose patient to muscle symptoms, rule out other causes
• Severe symptoms
- Check CK, creatinine, urinalysis for myoglobinuria
• Consider re-challenge
- Less potent statin
- More hydrophilic statin
- Alternate day dosing
• Mild-moderatesymptoms
- Resolve and no contraindications: restart same statin as same or lower dose
- Resolve, statin established as cause: use low dose of different statin then increase as tolerated
- Symptoms unresolved after two months: consider other causes, if other cause identified, restart original statin at original dose |
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Term
| High intensity statins anticipated response and agents w enzymes |
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Definition
Anticipated response: decrease LDL-C ≥50%
Atorvastatin (Lipitor)- CYP3A4
Rosuvastatin (Crestor)- CYP2C9 substrate, reduce dose in renal impairment |
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Term
| Moderate-Intensity statin anticipated response and agents w comments |
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Definition
Anticipated response: decrease LDL-C 30–50%
Atorvastatin (Lipitor)- CYP3A4 substrate
Rosuvastatin (Crestor) CYP2C9 substrate, reduce dose in renal impairment
Pravastatin (Pravachol)- low potential for drug interactions, low potency
Simvastatin (Zocor)- CYP3A4 substrate, increased of myopathy at 80 mg/day
Lovostatin (Mevacor)- CYP3A4 substrate
Fluvastatin (Lescol XL)- CYP2C9 inhibitor
Pitavastatin (Livalo) |
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Term
| Low-Intensity statin anticipated response and agents w comments |
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Definition
Anticipated response: decrease LDL-C <30%
Pravastatin (pravachol)- low potential for drug interactions, low potency
Simvastatin (Zocor)- CYP3A4 substrate, increased of myopathy at 80 mg/day
Lovastatin (Mevacor)- CYP3A4 substrate
Fluvastatin (Lescol XL)- CYP2C9 inhibitor
Pitavastatin (Livalo) |
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Term
| Fibrates non-statin therapy MOA |
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Definition
| • MOA: peroxisome proliferator-activated receptor-alpha agonists, ↓ secretion of VLDL, ↑ lipoprotein lipase activity, increase HDL |
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Term
• Adverse effects: dyspepsia, rash, hypokalemia, myopathy, hepatic dysfunction, gallstones, rare blood dyscrasias, rhabdomyolysis
• Use caution with obese, females, Native Americans due to ↑ risk of gallstones
• Avoid in renal or hepatic impairment
• Avoid concurrent use with statins due to ↑ risk of myopathy and rhabdomyolysis
• May consider adding fenofibrate to a low or moderate-intensity statin in select cases if benefits are greater than risks (e.g. TG > 500 mg/dL) |
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Definition
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Term
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Definition
Gemfibrozil (Lopid)= CYP2C9 and CYP2C19 inhibitor
Fenofibrate (Tricor) |
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Term
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Definition
[image]
• MOA:sterol absorption inhibitor,in bile inhibits reabsorption of cholesterol, decreases LDL |
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Term
| • Adverse effects:rare hepatic dysfunction, myositis |
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Definition
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Term
• Monitoring:baselineLFTs,discontinueif persistent ALT > 3x ULN
• GenerallyusedincombinationwithHMG-CoA reductase inhibitors
• Contraindicated during pregnancy and lactation |
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Definition
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Term
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Definition
• ADA 2016 guidelines recommend to consider adding ezetimibe to moderate-intensity statin therapy in
selected patients with diabetes |
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Term
| bile acid sequestrants MOA |
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Definition
[image]
• MOA: prevent reabsorption of bile acids by binding them in the intestinal lumen, ↑ cholesterol catabolism, upregulates LDL receptors |
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Term
• Adverse effects: constipation, bloating, heartburn, diarrhea, increased VLDL
• Monitoring: fasting lipid panel at baseline, 3 months, then every 6–12 months
• Avoid in diverticulitis, TG ≥ 250 mg/dL (C/I >400), type III hyperlipoproteinemia
• May impair vitamin K and folic acid absorption
• Must take with food to be effective
• Administer other medications one hour prior, or two hours after to limit interactions |
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Definition
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Term
| Bile acid sequestrant agents |
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Definition
Colestipol (Colestid)
Cholestyramine (Questran)
Colesevelam (Welchol) |
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Term
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Definition
[image]
• aka Vitamin B3
• MOA: ↓ VLDL hepatic secretion and catabolism of apoAI; ↑ HDL, ↓ LDL and TG |
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Term
• Initiate at low dose, then titrate as tolerated over weeks
• Monitoring: fasting BG or HbA1c, LFTs, uric acid at baseline, when dose ↑ and every six months
• Flushing can be prevented by pre-medication with aspirin 325 mg 30 minutes prior to nicotinic acid dose
• Contraindicated during pregnancy and lactation |
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Definition
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Term
| • Adverse effects: flushing, pruritis, rash, dry skin, nausea, abdominal discomfort, hyperuricemia, hyperglycemia, rare hepatotoxicity, arrhythmias, macular edema |
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Definition
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Term
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Definition
• Persistent severe cutaneous symptoms
• Persistent hyperglycemia
• Acute gout
• Unexplained abdominal pain or gastrointestinal symptoms
• New-onset atrial fibrillation
• New-onset weight loss |
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Term
| omega-3 fatty acids prescription or OTC and MOA |
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Definition
• Lovaza by prescription or over-the-counter fish oil capsules; 3-4 gm docosahexaenoic and eicosapentaenoic acids/day
• MOA: reduce hepatic synthesis of triglycerides, increase plasma lipoprotein lipase activity |
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Term
• Adverse effects: pruritis, rash, dysgeusia, dyspepsia, constipation, LFT abnormalities, may increase LDL levels
• Monitoring: gastrointestinal disturbances, skin changes, bleeding
• May consider when TG > 500 mg/dL |
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Definition
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Term
| PCSK9 inhibitors use and moa |
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Definition
• Adjunct treatment for patients with inadequate LDL reduction on statins and lifestyle modifications
• MOA: proprotein convertase subtilisin kexin type 9 (PCSK9), inhibitor facilitates LDL clearance from plasma |
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Term
• Adverse effects: rash, itching, swelling, pain, or bruising at injection site, nasopharyngitis, flu, allergic reactions
• Injection q2–4 weeks depending on agent and indication
• Cost
• Very effective in lowering LDL
• Impact on cardiovascular outcomes seemingly positive
• Long-term neurologic consequences of low LDL not known |
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Definition
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Term
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Definition
Alirocumab (Praluent)
Evolocumab (Repatha) |
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Term
| medications and affects on LDL |
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Definition
statins dec 18-55%
bile acid sequestrants dec 15-30%
nicotinic acid dec 5-25%
fibric acids dec 5-20% |
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