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what is primary prevention
- patients at risk but no CV event
- treat less aggressively
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when should adults get lipoprotein profile screening
every 5 years
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what are secondary causes of dyslipidemia
- DM
- hypothyroidism
- nephrotic synrome
- obstructive liver disease
- drug induced (thiazides, BBs, OC, iotretinoin)
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organizations who created dyslipidemia guidelines
- adult treatment panel
- national cholesterol education program (NCEP)
- National Heart Lung and Blood Institute
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when were the ATP III guidelines published and updated
- published 2001
- updated 2004
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optimal, borderline high, high, very high TG level
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causes of low HDL
- elevated triglycerides
- obesity
- physical inactivity
- type 2 DM
- smoking
- beta blockers, anabolic steroids, progestational agents
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borderline high TC
200-239
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what can elevated TGs be treated with
fibrates, niacin, omega-3 fatty acids
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what disease can lead to TGs >500
acute pancreatitis
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How do you treat elevated TGs (from diet)
treat with very low-fat diets (<15% of daily calories)
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name the positive risk factors for
- cigarette smoke
- HTN
- low HDL
- age (male >45 female >55)
- FH of premature CHD
- -CHD in male < 55
- -CHD in female < 65
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CHD risk equivalents
- DM
- symptomatic carotid artery disease
- peripheral arterial disease
- abdominal aortic aneurysm
- 10 yr risk of CHD > 20%
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what is the underlying risk factor for metabolic syndrome
insulin resistance
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LDL goals for 0-1 risk factors
<160
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LDL goal for 2 or more risk factors
<130
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target to treat is whos principle?
NCEP principle
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according to the NCEP principle what percentage reduction in LDL levels are used to establish an initial dose
30-40%
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if LDL < 70 is not achievable, aim to decrease LDL by how much? (according to the NCEP)
>50%
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in a tailored treatment approach how do you treat patients with a moderate risk
- moderate dose statin (simvastatin 40)
- -reduction of 35-45%
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according to the tailored treatment approach how do you treat high risk patients?
- with high dose statins (lipitor 40mg)
- -55-60% reduction
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what type of therapy should be initiated in patients with acute coronary syndrome?
high dose statin therapy
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what type of therapy should be used in primary prevention of cardiovascular events in high risk patients?
statin therapy
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therapeutic drug classes that do not change patient-oriented outcomes
ezetimibe, bile acid binding resins, niacin, fibrates
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doses for rosuvastatin
5, 10, 20, 40
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doses for simvastatin
10, 20, 40, 80
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doses for atorvastatin
10, 20, 40, 80
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doses for pravastatin
10, 20, 40, 80
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doses for pitavastatin
1, 2, 4
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doses for fluvastatin
20, 40
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doses for lovastatin
10, 20, 40
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statin most effective when given at night
lovastatin w/ evening meals
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which statin can be used in HIV pts
- Pravastatin
- Crestor
- Lipitor (low doses)
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side effects of statins
- HA
- diarrhea
- GI upset
- myopathy
- rhabdomyolysis
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what do we monitor in pts taking statins
lipids, LFTs, CPK at baseline
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drug interactions with statins
- macrolides
- anti fungals
- amiodarone
- warfarin
- gemfibrozil
- niacin
- protease inhibitors
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how long until therapeutic effects seen in pts taking statins
- 2-4 wks
- optimal effects in 6 wks
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which drug class is teratogenic
statins
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HPS
- -heart protection study
- -used simva 40
- -concluded statin therapy efficacious in pts with DM (even without CHD and with low LDL lvs)
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PROSPER trials
- prospective study of pravastatin in the elderly at risk
- pravastatin 40mg
- decreased non fatal MI and CHD death and fatal and non fatal stroke
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ASCOT-LLA
- -anglo-scandinavian cardiac outcomes trial-lipid lowering arm
- -atorvastatin 10
- -treated pts with HTN and >=3 CV risk factors
- -stopped early bc of compelling evidence supporting the fact that there was a decrease in total CV events by 21% in pts treated with lipitor
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JUPITER
- -Justification for the Use of statins in Prevention: an Intervention Trial Evaluation Rosuvastatin
- -no prior CAD or DM with LDL less than 130 and high C-reactive protein
- -rosuvastatin
- -significantly reduced levels of MI, stroke revascularization, angina, and combined endpoint including death
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lipid effects of fibrates
- LDL- no effect
- HDL- 10-15
- TG- 20-50
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side effects of fibrates
- myopathy
- GI upset
- gallstones
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what to do with an interaction with fibrates and OA
adjust the dose of OA
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Fibrates place in therapy
TGs (effective in DM pts)
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if you add a fibrate to a statin what must you adjust in the pts regimen
you must decrease the statin dose in half
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ACCORD lipid therapy
- -action to control cardiovascular risk in diabetes
- -type 2 pts
- -adding a fenofibrate did not appear to reduce risk of fatal CV events, non fatal MI and non-fatal stroke as compared to statin therapy
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lipid effects from bile acid sequestrants
- LDL 10-30
- HDL 3-5
- TG - no effect
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side effects of Bile acid sequestrants
- constipation
- bloating
- abdominal pain
- gallstones
- myopathy
- decreased absorption of many medications and fat soluble vitamins
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clinical pearls of Bile Acid Sequestrants
- must take with food and liquid for decrease GI side effects
- fruits, fiberl and a stool softener may help with constipation
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Bile Acid sequestrants place in therapy
- reduces coronary events
- effective added to statin therapy
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Bile acid sequestrants may increase TGs in pts with?
TG >300
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Best Bile Acid Sequestrant in class
welchol
welchol
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dosing for welchol
3 tablets BID or 6 tablets once
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cholestyramine dosing/class
- bile acid sequestrant
- 4g 1-2 times per day
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cholesterol absorption inhibitor has no effect on
TGs
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cholesterol absorption inhibitor lipid effects
- LDL 15-20
- HDL 3
- no effect on TGs
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TLC
- reduce intake of sat fats by <7%
- reduce intake of dietary cholesterol <200
- moderate increase in polyunsat fats
- dietary fiber 10-25 g per day
- exercise
- smoking cessation
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what is the OTC niacin formulation and dosage strengths
IR 50, 100 (dietary supplement)
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Niacin lipid effects
- LDL 2-25
- HDL 15-35
- TG 20-50
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best drug for raising HDL
Niacin 15-35
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side effects of niacin
- flusing
- HA
- GI upset (take with food)
- hyperglycemia
- hyperuricemia
- hepatotoxicity
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niacin is contraindicated in
liver disease and gout
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clinical pearls for niacin
- take with food to avoid GI upset
- take ASA for flushing (so min prior)
- take at bedtime with food
- avoid hot beverages, food, showers around time of administration
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Niacin works best for
raising HDL 15-35%
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AIM-HIGH
- -atherothrombosis intervention in metabolic syndrome with low HDL/high triglycerides: impact on global health
- -found no incremental benefit from the addition of niacin to statin therapy
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Omega 3 fatty acids lipid effect
TGs 30-50
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side effects of lovaza
- fishy taste
- GI upset
- flu-like symptoms
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Omega-3 place in therapy
- pts with TG >=500
- 4g per day in 1 or 2 doses
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ORIGIN
- -outcome reduction with an initial glargine intervention
- -1g of n-3 fatty acids
- -did not reduce the rage of CV events in pts at high risk for CV events
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