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Class 9

Cardiovascular Hyperlipidemia HTN Obesity

QuestionAnswer
Identify cardiovascular risk factors for hyperlipidemia (Slide #31 & Cecil Page 87 Table 8-1, ATPIII Step3) Cigarette smoking Hypertension--BP>140/90 or on medication Low HDL cholesterol--<40 mg/dL Family history of premature CHD CHD in male first degree relative <55 years CHD in female first degree relative <65 years Men > 45 years Women > 55 years
Describe epidemiology, of hyperlipidemia. (Slide #3) CAD risk increased by 5 if cholesterol >209 For every 10mg/dL elevation in cholesterol there is a 10% increase in heart disease For every 5 mg/dL increase in HDL, heart disease risk decreased by 10% Fewer than 10% of women with heart disease utilize
Describe pathophysiology of hyperlipidemia. (Slide 5, 6, - Serum elevations of the lower density particles are correlated with cardiovascular disease LDL lipoprotein is most strongly correlated with INCREASED CV disease - VLDL -increase cardiovascular risk. Mostly triglyceride - HDL -elevations are corre
Describe clinical findings of hyperlipidemia (Slide 12-16) - Xanthomas (Tendinous, Tuberous, Eruptive, Planar) - Opthalmologic (Corneal arcus <40y, lipemia retina,) - Cardiovascular (Atherosclerosis, Aortic Stenosis-genetic) - Gastrointestinal (Pancreatitis-elevated triglycerides, cholelithiasis) - Musculosk
*** Describe methods of diagnosing hyperlipidemia Fasting total cholesterol, triglyceride and lipoprotein assessments are required for diagnosis, page 691 Cecil.
Classification of LDL cholesterol (Slide 27) <100 -Optimal 100-129 -Near or above optimal 130-159 -Boderline high 169-189 -High >/=190 -Very high
Classification of total cholesterol (Slide 27) <200 -Desirable 200-239 -Boderline high >/=240 -High
Classification of HDL cholesterol (Slide 27) <40 -Low (associated with increased risk) >/=60 -High (associated with less risk)
*** Construct a treatment plan for different clients with hyperlipidemia (Slide 28) Risk Assessment Primary Prevention Secondary Prevention LDL-Lowering Therapy Therapeutic Lifestyle Changes (TLC)
Risk Assessment (Slide 29) All adults age > 20 need fasting lipoprotein profile once every 5 years Total cholesterol LDL cholesterol HDL cholesterol Triglyceride
Pediatric Risk Assessment (Slide 30) Children and adolescents who have a family history of elevated cholesterol and/or heart disease Children whose family history is unknown Children who have risk factors-such as DM, obesity, htn (Nelson Essential of Pediatrics, 6th ed., pg. 27)
Primary Prevention (Slide 40) Clients without established CHD - Reduce intake of saturated fat and cholesterol - Increased physical activity - Weight control - Drug therapy in some selected clients All patients with elevated LDL cholesterol or other form of
Secondary Prevention (Slide 42) - Clients with established CHD or CHD equivalents - Goal of therapy is < 100 mg/dL with < 70 mg/dL as an option - Therapeutic lifestyle changes - Drug therapy
LDL Lowering Therapy (Slide 43) Two modalities of LDL-lowering therapy TLC--therapeutic lifestyle changes Drug therapy
Update ACC/AHA Guidelines, 2013. NIH 2011 screening recommendations Major changes (Slide 44) For very high risk -LDL goal of < 70 mg/dL is an option. For moderately high risk -LDL goal is 130, but < 100 mg/dL is an option Drug therapy in high risk/moderately high risk -Try to achieve 30-40% reduction in baseline LDL levels No changes for l
Therapeutic Lifestyle Change (TLC) (Slide 45) Nutrition Weight reduction Physical activity
Role of nutrition (Slide 45) Transfatty acids (saturated fats)-reduce/eliminate Role of omega-3 oils (cold H20 fish/fish oil)-add to diet Soy protein-add to diet Plant stanol/sterol margarines (Benecol) –add to diet Viscous fiber sources (soluble fiber)-add to diet
CHD risk equivalents (know these!) (Slide 34) Other forms of atherosclerotic disease - peripheral vascular disease - abdominal aortic aneurysm - symptomatic carotid artery disease Diabetes
Name major drugs for treating hyperlipidemia Statins (non-statins are not recommended in most cases) Bile acid sequestrants Nicotinic acid Fibric acid derivatives Adjunctive agent that acts of brush border of gut (Zetia)
High dose Statin (average LDL reduction about 50% or higher) (retrieved from Guidelines prescriber's letter) - Atorvastatin 80 mg once daily (40 mg if 80 mg not tolerated). - Rosuvastatin 20 mg to 40 mg once daily.
Moderate-dose Statin (average LDL reduction about 30 to <50%): - Atorvastatin 10 to 20 mg once daily.b - Fluvastatin 40 mg twice daily or 80 mg (XL) once daily. - Lovastatin 40 mg once daily. - Pitavastatin 2 to 4 mg once daily.b - Pravastatin 40 to 80 mg once daily.b - Rosuvastatin 5 to 10 mg once daily.b - S
Low-dose Statin (average LDL reduction <30%): - Fluvastatin 20 to 40 mg once daily. - Lovastatin 20 mg once daily. - Pitavastatin 1 mg once daily. - Pravastatin 10 to 20 mg once daily. - Simvastatin 10 mg once daily.
Indication for high-dose statin (retrieved from Guidelines prescriber's letter) - Secondary prevention in adults 75 years of age and younger. (Level A) - Primary prevention in adults with LDL 190 mg/dL (5 mmol/L) or higher. (Level A) - Primary prevention in adults 40 to 75 years of age with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L
Indication for moderate-dose statin (retrieved from Guidelines prescriber's letter - Secondary prevention in adults older than 75 years. (Level A) - Patients who cannot tolerate a high-dose statin. - Primary prevention in adults 40 to 75 years of age with LDL 70 to 189 mg/dL (1.8 to 4.9 mmol/L) and an estimated 10-year risk of ather
Indication for Nonstatin - Triglycerides 500 mg/dL or higher (use omega-3 fatty acids [e.g., fish oil], niacin, or fenofibrate). - Patients who cannot tolerate the recommended statin dose or do not achieve the expected statin response and are high-risk (i.e., patient with LDL
What to do before initiating nonstatin - Reinforce statin adherence and lifestyle changes, and check for secondary causes before adding a non statin. ** Do not add gemfibrozil to statin therapy. **No proof adding a non statin to a statin further reduces cardiovascular risk.
What is the side effect of statins (retrieved from ATP III Guideline) Myopathy Increased liver enzymes
What is the side effect of bile acid sequestrants (Cholestyramine, Colestipol, Colesevelam) Gastrointestinal distress Constipation Decreased absorption of other drugs
What is the side effect of nicotinic acid (Crystalline, Niaspan) Flushing Hyperglycemia Hyperuricemia (gout) Upper GI distress Hepatotoxicity
Side effect of fibric acids (Gemfibrozil, Fenofibrate, Clofibrate) Dyspepsia Gallstones Myopathy
Define Obesity Excess of adipose tissue Manifested by body weight in excess of 20% or a BMI of 30 or higher. Two types: Upper body (apple-shaped-greater risk for DM2, CAD, CVA, early death; lower body (pear-shaped) In pediatric obesity is equal to or greater than 9
Morbidity associated with obesity (Obesity slide 5) National Health and Nutrition Exam Survey III reports 59.4% of men are overweight 49.9% of women are overweight Almost 20% of men and 25.1% of women are obese Incidence of obesity is higher in lower socioeconomic classes Higher incidence in African A
Mortality associated with obesity
Risk factors associated with obesity Type 2 DM CAD CVA Early deathcd
Prevention, treatment and teaching related to obesity
Pneumonic for secondary HTN causes (ABCDE) Accuracy, aldosteronism, apnea Bruits, bad kidneys Catecholamines, Cushing’s, Coarct Drugs, diet Endocrine, erythropoeitin
Meds that can elevate BP Oral contraceptives Cyclosporine Tricyclic antidepressants Sympathomimetic decongestants Appetite suppressants Corticosteroids NSAIDs Erythropoietin Anabolic steroids / corticosteroids MAOI Norepineprine reuptake inhibitors Stop drugs if can be